Question

The nurse prepares to establish intravenous access for a client diagnosed with breast cancer. Which question is most important for the nurse to ask before inserting the access?

Answer 1

Correct Answers:

"Have you had a mastectomy or lymph node dissection on either side?"

Rationale :

♦ Mastectomy or lymph node dissection impairs lymphatic drainage, which greatly increases the risk for lymphedema and infection if IVs or blood pressures are performed on the affected side.

♦ Asking this question ensures the nurse avoids the affected arm, thereby protecting circulation and reducing complications.

♦ This is priority over anticoagulant use, allergies, or client preference because it prevents long-term harm.

♦ Standard of care: Use the opposite arm or a central line if needed.

♦ This aligns with oncology nursing guidelines for safe vascular access.

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Answer 2

Correct Answers:

Records specific dates and times of late arrivals using objective language
Reports factual observations to the RN supervisor using the facility's communication channels

Rationale :

♦ LPNs can record objective, factual data such as dates, times, and observations without judgment.

♦ LPNs appropriately report to the RN supervisor using established communication channels.

♦ Conducting evaluations and initiating discipline are managerial roles, not LPN duties.

♦ Documenting break duration is unnecessary unless specifically instructed—focus is on late arrivals.

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Answer 3

Correct Answers:

The extremes are 100 and 1.

Rationale :

♦ In proportions, the extremes are the first and last terms (here 2:100 :: 1:50 → extremes are 100 and 1).

♦ The means are the two middle terms (2 and 50).

♦ Recognizing extremes vs. means is fundamental to ratio/proportion problem-solving in dosage calculations.

♦ The ratios are proportional because 2:100 = 1:50 simplifies to the same value.

♦ This knowledge is used directly in nursing drug math calculations.

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Answer 4

Correct Answers:

Reporting diseases based on the healthcare provider's judgment of severity and significance

Rationale :

♦ Nurses are legally required to follow public health reporting laws, not personal judgment.

♦ Diseases like TB, hepatitis, and measles are reported to local/state health departments, which then notify the CDC if necessary.

♦ This ensures surveillance, prevention, and outbreak control.

♦ Reporting only highly contagious diseases or relying on provider judgment is incomplete and unsafe.

♦ Facility infection control may be part of the process, but law requires external reporting.

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Answer 5

Correct Answers:

Measure and document drainage amount from collection chamber

Rationale :

♦ After placement and residual checks are confirmed by the RN, the LPN’s role is to monitor ongoing function, which includes measuring and documenting drainage.

♦ Checking tube placement with air bolus is outdated and not reliable—placement is verified by RN with pH or X-ray.

♦ Repositioning or advancing the tube is outside the LPN role and requires provider/RN involvement.

♦ Adjusting feeding rates is not within LPN scope unless specifically delegated.

♦ Measuring drainage helps monitor GI function, fluid balance, and effectiveness of suction.

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Answer 6

Correct Answers:

12 gtt/min
25 gtt/min
40 gtt/min
120 gtt/min

Rationale :

♦ Correct calculation: 75 mL/hr × (20 gtts/mL) ÷ 60 = 25 gtt/min.

♦ (2 gtt/min) is far too slow, client at risk for inadequate hydration.

♦ (12 gtt/min) is low, infusion is under the ordered rate.

♦ (25 gtt/min) is correct → does NOT require attention.

♦ (40 gtt/min) is too fast, client at risk for fluid overload.

♦ (120 gtt/min) is dangerously fast, needs immediate correction.

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Answer 7

Correct Answers:

Document daily weights before breakfast
Report weight gains of 2 pounds or more in 24 hours
Ensure clients wear similar clothing for each weighing

Rationale :

♦ Daily weights before breakfast are the best indicator of fluid balance.

♦ Report 2 lbs or more in 24 hrs—sign of fluid retention, especially in CHF/renal clients.

♦ Same clothing ensures accurate, consistent measurements.

♦ Posting protocols is an RN/administrative role.

♦ Adjusting fluid restrictions requires provider/RN input, not LPN role.

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Answer 8

Correct Answers:

“I have been having some trouble swallowing lately."

Rationale :

♦ Dysphagia (difficulty swallowing) is a red-flag symptom for esophageal stricture or cancer.

♦ Pantoprazole timing, sour taste in mouth, or eating pizza frequently indicate poor management, but not urgent danger.

♦ Dysphagia signals progression and potential obstruction, requiring provider notification.

♦ Early recognition prevents aspiration and further complications.

♦ Nurses prioritize symptoms that indicate airway or obstruction risk.

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Answer 9

Correct Answers:

A client who states to the nurse, "You must be in the wrong room. My name is not Ann.”

Rationale :

♦ Identity disorder (dissociative identity disorder) involves disruption of self-identity, where the person may present as different identities or deny their true self.

♦ Refusal of identity or claiming another name is classic.

♦ Crying/isolating → depression.

♦ Repeated showers → OCD behavior.

♦ Talking to self → hallucinations (schizophrenia/psychosis).

♦ Identity confusion or multiple identities define the disorder.

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Answer 10

Correct Answers:

The liver converts glycogen into glucose.
The heart rate Increases.
Salivation and digestion decrease or stop.

Rationale :

♦ The sympathetic nervous system is activated.

♦ The liver converts glycogen into glucose → increases energy availability.

♦ The heart rate increases → improves blood/oxygen supply.

♦ Salivation and digestion decrease → blood redirected to muscles/brain.

♦ (ciliary relaxation) = not sympathetic response.

♦ (airway constriction) is incorrect; in fight-or-flight, bronchioles dilate, not constrict.

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QLexNursing

1 :
The nurse prepares to establish intravenous access for a client diagnosed with breast cancer. Which question is most important for the nurse to ask before inserting the access?

2 :
LPN/LVN works on a medical unit and notes a unlicensed assistive personnel consistently arriving 15 minutes late for shifts and taking extended breaks. The RN supervisor asks the LPN/LVN to document observations. Which actions does the LPN/LVN implement? Select all that apply.

3 :
The nurse understands the solutions for proportionality when looking at ratio and proportion shows as of 2: 100 and the other, 1:50 respectively. Which statement indicates the nurse's of calculating both components?

4 :
The nurse cares for a client with a communicable disease. Which action aligns with the reporting for a communicable disease?

5 :
A nurse provides care to a client with a nasogastric (NG) tube. The RN has verified proper tube and residual checks. Which action does the nurse should provide for continued care

7 :
The LPN/LVN assists with the weight monitoring protocol for clients. Which actions does the LPN/LVN implement regarding this task? Select all that apply.

8 :
The nurse cares for an older adult client with a diagnosis of gastroesophageal reflux disease. Which statement is most concerning to the nurse?

9 :
The nurse is making rounds for 4 clients in a mental health unit. Which client shows symptoms of identity disorder?

10 :
A person is hiking through the, woods and they see a black bear walking toward them. Which the person’s body make? Select all that apply.

QLexNursing

1 : The nurse prepares to establish intravenous access for a client diagnosed with breast cancer. Which question is most important for the nurse to ask before inserting the access?

2 : LPN/LVN works on a medical unit and notes a unlicensed assistive personnel consistently arriving 15 minutes late for shifts and taking extended breaks. The RN supervisor asks the LPN/LVN to document observations. Which actions does the LPN/LVN implement? Select all that apply.

3 : The nurse understands the solutions for proportionality when looking at ratio and proportion shows as of 2: 100 and the other, 1:50 respectively. Which statement indicates the nurse's of calculating both components?

4 : The nurse cares for a client with a communicable disease. Which action aligns with the reporting for a communicable disease?

5 : A nurse provides care to a client with a nasogastric (NG) tube. The RN has verified proper tube and residual checks. Which action does the nurse should provide for continued care

7 : The LPN/LVN assists with the weight monitoring protocol for clients. Which actions does the LPN/LVN implement regarding this task? Select all that apply.

8 : The nurse cares for an older adult client with a diagnosis of gastroesophageal reflux disease. Which statement is most concerning to the nurse?

9 : The nurse is making rounds for 4 clients in a mental health unit. Which client shows symptoms of identity disorder?

10 : A person is hiking through the, woods and they see a black bear walking toward them. Which the person’s body make? Select all that apply.

1 :
The nurse prepares to establish intravenous access for a client diagnosed with breast cancer. Which question is most important for the nurse to ask before inserting the access?

2 :
LPN/LVN works on a medical unit and notes a unlicensed assistive personnel consistently arriving 15 minutes late for shifts and taking extended breaks. The RN supervisor asks the LPN/LVN to document observations. Which actions does the LPN/LVN implement? Select all that apply.

3 :
The nurse understands the solutions for proportionality when looking at ratio and proportion shows as of 2: 100 and the other, 1:50 respectively. Which statement indicates the nurse's of calculating both components?

4 :
The nurse cares for a client with a communicable disease. Which action aligns with the reporting for a communicable disease?

5 :
A nurse provides care to a client with a nasogastric (NG) tube. The RN has verified proper tube and residual checks. Which action does the nurse should provide for continued care

7 :
The LPN/LVN assists with the weight monitoring protocol for clients. Which actions does the LPN/LVN implement regarding this task? Select all that apply.

8 :
The nurse cares for an older adult client with a diagnosis of gastroesophageal reflux disease. Which statement is most concerning to the nurse?

9 :
The nurse is making rounds for 4 clients in a mental health unit. Which client shows symptoms of identity disorder?

10 :
A person is hiking through the, woods and they see a black bear walking toward them. Which the person’s body make? Select all that apply.