Question

Patient's data.

Answer 1

Correct Answers:

Allergy history

Rationale :

🚫A severe penicillin allergy is a contraindication to administering cefazolin, a first-generation cephalosporin, because of potential cross-reactivity within the β-lactam class.

🚫When the history suggests IgE-mediated reactions (e.g., anaphylaxis, angioedema, bronchospasm, immediate urticaria), the risk of a serious repeat reaction is clinically unacceptable.

🚫Before giving any β-lactam, the nurse should clarify the allergy details, verify reaction type and timing, and notify the provider to select a non-β-lactam alternative for perioperative prophylaxis if the allergy is severe.

🚫Medication safety requires checking the MAR/allergy band and reconciling allergies with new orders—especially for antibiotics—prior to first dose.

🚫Documenting the reaction and communicating it to the surgical and anesthesia teams helps prevent perioperative anaphylaxis and supports safe antibiotic stewardship.

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Answer 2

Correct Answers:

"I will wrap my affected ankle with an elastic bandage."

Rationale :

🦶Compression with an elastic bandage is a core part of RICE therapy for a grade 2 (moderate) ankle sprain, helping limit swelling and provide external support to partially torn ligaments.

🦶When applied correctly—snug but not tight—compression maintains circulatory flow (watch for numbness, tingling, or color change) while reducing edema and pain.

🦶Compression should be paired with rest, intermittent ice (15–20 min on/off for the first 24–48 hr), and elevation above heart level to optimize recovery.

🦶Early management also includes protected weight-bearing (e.g., crutches or brace) and a guided functional rehab program (range of motion → strengthening → proprioception) to prevent chronic instability.

🦶Consistent use of compression during the acute phase improves comfort, facilitates a faster return to activity, and lowers the risk of reinjury.

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Answer 3

Correct Answers:

Hoarseness
Blood-tinged sputum
Dysphagia

Rationale :

Hoarseness

💎Persistent hoarseness (>2 weeks) is the most common early sign of laryngeal (especially glottic) cancer because even small lesions disrupt vocal fold vibration and mucosal wave.

💎Tumor infiltration or edema limits cord approximation and increases airflow turbulence, producing a rough, raspy, or breathy voice that does not improve with typical upper-respiratory care.

💎Involvement of the recurrent laryngeal nerve or impaired cord mobility can further degrade phonation, making voice fatigue and reduced projection notable findings.

💎Hoarseness from laryngeal cancer is typically progressive, reflecting tumor growth rather than fluctuating inflammation.

💎Early recognition of voice change as a red flag prompts laryngoscopy and imaging, which enables earlier staging and better oncologic outcomes.

Blood-tinged sputum

💎Hemoptysis (blood-streaked sputum) arises when friable tumor mucosa or submucosal vessels erode and bleed, especially with coughing or throat clearing.

💎Even small, bright-red streaks are clinically meaningful in the context of throat symptoms and warrant urgent laryngoscopic evaluation.

💎Ongoing microbleeding reflects mucosal ulceration and local inflammation, often accompanying odynophagia or foreign-body throat sensation.

💎While massive bleeding is uncommon early, recurrent minor bleeding suggests an exposed, vascular tumor surface.

💎Identifying hemoptysis early helps stratify risk for airway compromise and guides the need for oncology and ENT co-management.

Dysphagia

💎Dysphagia occurs as supraglottic or transglottic tumors encroach on the pharyngo-laryngeal lumen, impeding bolus passage and triggering throat pain (odynophagia).

💎Patients often progress from difficulty with solids to liquids, signaling mechanical obstruction rather than purely functional dysmotility.

💎Tumor-related edema and impaired laryngeal elevation increase aspiration risk, provoking cough during meals and post-prandial throat clearing.

💎Referred otalgia (ear pain) via glossopharyngeal/vagal pathways may accompany dysphagia and further points to upper aerodigestive tract malignancy.

💎Early acknowledgment of swallowing difficulty prompts swallow assessment, airway safety planning, and definitive visualization to stage and treat the lesion.

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Answer 4

Correct Answers:

Vomiting

Rationale :

🟢Vomiting during or after a transfusion indicates a septic transfusion reaction, which occurs when the transfused blood is contaminated with bacteria.

🟢This reaction is characterized by nausea, vomiting, fever, chills, and hypotension, which can progress to septic shock if untreated.

🟢The onset is usually rapid, often occurring within minutes of starting the transfusion.

🟢Nurses must stop the transfusion immediately, maintain IV access with normal saline, and notify the provider.

🟢Early recognition prevents life-threatening complications such as multi-organ failure.

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Answer 5

Correct Answers:

Abdominal wound dry, without redness

Rationale :

♦Objective documentation is critical in nursing practice, and stating that the abdominal wound is dry and without redness provides measurable, factual data.

♦This information reflects the current status of wound healing and helps track potential complications like infection or dehiscence.

♦Unlike subjective terms such as "healing well," this entry can be clearly understood by all providers and supports continuity of care.

♦Documentation must be precise, descriptive, and accurate to meet professional standards and legal requirements.

♦Clear wound documentation is also essential for monitoring postoperative progress and guiding interventions if needed.

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Answer 6

Correct Answers:

Occupational therapist

Rationale :

💠An occupational therapist helps clients regain independence in activities of daily living (ADLs) after immobility caused by disuse syndrome.

💠After cast removal, clients often experience muscle weakness, stiffness, and decreased functional ability that requires rehabilitation.

💠Occupational therapy focuses on strengthening, coordination, and adaptive techniques to restore functional use of the limb.

💠The referral supports both physical recovery and improved quality of life by promoting safe reintegration into daily routines.

💠This intervention is key in preventing long-term disability following prolonged immobilization.

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Answer 7

Correct Answers:

Adhere to a high-protein diet.

Rationale :

⭐A high-protein diet supports respiratory muscle strength and overall energy in clients with COPD.

⭐COPD increases the body’s metabolic demand due to the extra work of breathing, so protein intake prevents muscle wasting.

⭐Adequate protein also helps maintain immune function, reducing risk of infections that can exacerbate COPD.

⭐Clients with COPD often have reduced appetite, so nutrient-dense meals are essential.

⭐Teaching must emphasize protein while still balancing carbohydrate and fat intake for overall energy.

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Answer 8

Correct Answers:

1 cup cooked peas

Rationale :

🔴Cooked peas contain the highest fiber content among the listed foods, with around 8.8 grams per cup.

🔴Fiber supports bowel health, lowers cholesterol, and regulates blood glucose.

🔴High-fiber foods are emphasized in health promotion and chronic disease prevention education.

🔴Fruits like bananas and beverages like tomato juice provide some fiber, but not nearly as much as legumes.

🔴Recommending peas highlights the importance of plant-based fiber sources for optimal nutrition.

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Answer 9

Correct Answers:

Physical inactivity
Family history of colorectal cancer
Age over 50 years
History of diabetes mellitus

Rationale :

Physical inactivity

🔶Physical inactivity increases colorectal cancer risk by slowing colonic transit, which prolongs mucosal exposure to carcinogens formed during digestion.

🔶 Reduced activity contributes to central adiposity and insulin resistance, both of which drive pro-inflammatory and pro-mitogenic signaling in the colon.

🔶 Lower levels of myokines and higher systemic inflammation (e.g., CRP) associated with sedentariness promote a microenvironment favorable to tumor initiation and progression.

🔶 Regular moderate-to-vigorous exercise improves insulin sensitivity and decreases IGF-1 signaling, which can reduce adenoma formation and growth.

🔶 Incorporating routine physical activity is a modifiable prevention strategy that complements age-appropriate screening to lower disease incidence.

Family history of colorectal cancer

🔶 A family history, particularly in a first-degree relative, substantially increases the lifetime risk of colorectal cancer due to shared genetic and environmental factors.

🔶 Hereditary syndromes such as Lynch syndrome (MMR gene defects) and familial adenomatous polyposis (APC mutations) markedly elevate risk and lead to earlier onset disease.

🔶 Even outside classic syndromes, clustering of CRC in families suggests polygenic susceptibility and warrants earlier and more frequent screening.

🔶 Family history often correlates with accelerated adenoma–carcinoma sequence, shortening the time from polyp to malignancy.

🔶 A clear pedigree assessment guides personalized surveillance, genetic counseling, and risk-reducing strategies.

Age over 50 years

🔶 Advancing age is one of the strongest predictors of colorectal cancer, reflecting cumulative DNA damage, epigenetic changes, and prolonged carcinogen exposure.

🔶 The majority of historical CRC cases occurred after age 50, aligning screening recommendations to begin in midlife (with many guidelines now initiating at 45 based on rising early-onset trends).

🔶 Age-related declines in immune surveillance and increased prevalence of adenomatous polyps facilitate malignant transformation.

🔶 With increasing age, coexisting metabolic and inflammatory conditions amplify pro-tumor pathways in the colon.

🔶 Diligent, guideline-based screening in older adults is a cornerstone of early detection and mortality reduction.

History of diabetes mellitus

🔶 Type 2 diabetes mellitus elevates colorectal cancer risk through hyperinsulinemia and increased IGF-1 activity, which stimulate cell proliferation and inhibit apoptosis in colonic epithelium.

🔶 Chronic low-grade inflammation, oxidative stress, and altered gut microbiota in diabetes create a pro-carcinogenic milieu.

🔶 Shared risk factors—obesity, sedentary behavior, and poor diet quality—compound the association between diabetes and CRC.

🔶 Diabetes-related dyslipidemia and endothelial dysfunction may further promote tumorigenesis and progression.

🔶 Tight glycemic control, weight management, and adherence to screening can mitigate risk among individuals with diabetes.

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Answer 10

Correct Answers:

Swiss cheese

Rationale :

🟣Swiss cheese is high in saturated fats, which elevate LDL cholesterol and increase cardiovascular risk.

🟣Dietary teaching for high LDL focuses on limiting saturated and trans fats, while encouraging unsaturated fat sources.

🟣Foods like avocados, walnuts, and canola oil provide heart-healthy unsaturated fats that help lower LDL.

🟣High LDL contributes to atherosclerosis, coronary artery disease, and stroke risk, so diet management is critical.

🟣Education should focus on moderation and replacing unhealthy fats with beneficial alternatives.

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LPN Specialty Med-surg Final~2025

No.

1 :
Patient's data.

Answer Options

2 :
A nurse is reinforcing teaching with a client who has a grade 2 ankle sprain. Which of the following statements by the client indicates an understanding of the teaching?

3 :
A nurse is collecting data from a client who has laryngeal cancer. Which of the following findings should the nurse expect? (Select all that apply)

4 :
A nurse is assisting with the care of a postoperative client who is receiving a unit of packed RBCs. Which of the following manifestations should the nurse recognize as an indication of a septic reaction to the blood transfusion?

5 :
A nurse is caring for a client who is postoperative following an appendectomy. Which of the following information should the nurse include when documenting in the electronic medical record?

6 :
A nurse is contributing to the plan of care for a client who has disuse syndrome following cast removal from a lower extremity. Which of the following referrals should the nurse include in the plan of care?

7 :
A nurse is reinforcing dietary teaching with a client who has COPD. Which of the following instructions should the nurse include in the teaching?

8 :
A nurse is reinforcing teaching about high-fiber foods with a client at a health fair. Which of the following foods should the nurse recommend as having the highest fiber content?

9 :
A nurse is reinforcing teaching about risk factors for colorectal cancer with a client. Which of the following risk factors should the nurse include in the teaching? (Select all that apply.)

10 :
A nurse is reinforcing dietary teaching with an older adult client who has an increased LDL level. Which of the following foods should the nurse encourage the client to limit?

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LPN Specialty Med-surg Final~2025

No.

1 : Patient's data.

Answer Options

2 : A nurse is reinforcing teaching with a client who has a grade 2 ankle sprain. Which of the following statements by the client indicates an understanding of the teaching?

3 : A nurse is collecting data from a client who has laryngeal cancer. Which of the following findings should the nurse expect? (Select all that apply)

4 : A nurse is assisting with the care of a postoperative client who is receiving a unit of packed RBCs. Which of the following manifestations should the nurse recognize as an indication of a septic reaction to the blood transfusion?

5 : A nurse is caring for a client who is postoperative following an appendectomy. Which of the following information should the nurse include when documenting in the electronic medical record?

6 : A nurse is contributing to the plan of care for a client who has disuse syndrome following cast removal from a lower extremity. Which of the following referrals should the nurse include in the plan of care?

7 : A nurse is reinforcing dietary teaching with a client who has COPD. Which of the following instructions should the nurse include in the teaching?

8 : A nurse is reinforcing teaching about high-fiber foods with a client at a health fair. Which of the following foods should the nurse recommend as having the highest fiber content?

9 : A nurse is reinforcing teaching about risk factors for colorectal cancer with a client. Which of the following risk factors should the nurse include in the teaching? (Select all that apply.)

10 : A nurse is reinforcing dietary teaching with an older adult client who has an increased LDL level. Which of the following foods should the nurse encourage the client to limit?

1 :
Patient's data.

2 :
A nurse is reinforcing teaching with a client who has a grade 2 ankle sprain. Which of the following statements by the client indicates an understanding of the teaching?

3 :
A nurse is collecting data from a client who has laryngeal cancer. Which of the following findings should the nurse expect? (Select all that apply)

4 :
A nurse is assisting with the care of a postoperative client who is receiving a unit of packed RBCs. Which of the following manifestations should the nurse recognize as an indication of a septic reaction to the blood transfusion?

5 :
A nurse is caring for a client who is postoperative following an appendectomy. Which of the following information should the nurse include when documenting in the electronic medical record?

6 :
A nurse is contributing to the plan of care for a client who has disuse syndrome following cast removal from a lower extremity. Which of the following referrals should the nurse include in the plan of care?

7 :
A nurse is reinforcing dietary teaching with a client who has COPD. Which of the following instructions should the nurse include in the teaching?

8 :
A nurse is reinforcing teaching about high-fiber foods with a client at a health fair. Which of the following foods should the nurse recommend as having the highest fiber content?

9 :
A nurse is reinforcing teaching about risk factors for colorectal cancer with a client. Which of the following risk factors should the nurse include in the teaching? (Select all that apply.)

10 :
A nurse is reinforcing dietary teaching with an older adult client who has an increased LDL level. Which of the following foods should the nurse encourage the client to limit?