Chapter 05 The LPNLVN and the Nursing Process

Chapter 05 The LPNLVN and the Nursing Process

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.1)A nurse is preparing to administer three medications to a client. The client was admitted two daysago with deep vein thrombophlebitis, is on bed rest, and has oxygen per nasal cannula. The nurseverifies the client’s identity and elevates the head of the bed. What is the most appropriate nextnursing action that promotes the client’s physiological safety?1)A)Remove the nasal cannula.B)Ask the client if he would like to take the medications one at a time or all together.C)Have the client take several sips of water.D)Assess the client’s gag reflex.Answer:CExplanation:A)Oxygen is drying to the mucous membranes. People receiving oxygen by nasalcannula tend to be mouth breathers and this increases the dryness. To facilitateswallowing medications (whether one by one or all at the same time), have theclient first moisten the mucous membranes of the mouth and pharynx. The nursecan ascertain the client’s preference for the order in which to take the medications,but it is more important to address the oral dryness to promote safety for the client.There is no indication that the gag reflex is absent or diminished. This is moreimportant with a new postoperative client or someone with swallowingdifficulties. An advantage of a nasal cannula is that it does not need to be removedfor the client to eat or take oral medications.PlanningPhysiological Integrity-Reduction of Risk PotentialAnalysisB)Oxygen is drying to the mucous membranes. People receiving oxygen by nasalcannula tend to be mouth breathers and this increases the dryness. To facilitateswallowing medications (whether one by one or all at the same time), have theclient first moisten the mucous membranes of the mouth and pharynx. The nursecan ascertain the client’s preference for the order in which to take the medications,but it is more important to address the oral dryness to promote safety for the client.There is no indication that the gag reflex is absent or diminished. This is moreimportant with a new postoperative client or someone with swallowingdifficulties. An advantage of a nasal cannula is that it does not need to be removedfor the client to eat or take oral medications.PlanningPhysiological Integrity-Reduction of Risk PotentialAnalysisC)Oxygen is drying to the mucous membranes. People receiving oxygen by nasalcannula tend to be mouth breathers and this increases the dryness. To facilitateswallowing medications (whether one by one or all at the same time), have theclient first moisten the mucous membranes of the mouth and pharynx. The nursecan ascertain the client’s preference for the order in which to take the medications,but it is more important to address the oral dryness to promote safety for the client.There is no indication that the gag reflex is absent or diminished. This is moreimportant with a new postoperative client or someone with swallowingdifficulties. An advantage of a nasal cannula is that it does not need to be removedfor the client to eat or take oral medications.PlanningPhysiological Integrity-Reduction of Risk PotentialAnalysis1
D)Oxygen is drying to the mucous membranes. People receiving oxygen by nasalcannula tend to be mouth breathers and this increases the dryness. To facilitateswallowing medications (whether one by one or all at the same time), have theclient first moisten the mucous membranes of the mouth and pharynx. The nursecan ascertain the client’s preference for the order in which to take the medications,but it is more important to address the oral dryness to promote safety for the client.There is no indication that the gag reflex is absent or diminished. This is moreimportant with a new postoperative client or someone with swallowingdifficulties. An advantage of a nasal cannula is that it does not need to be removedfor the client to eat or take oral medications.PlanningPhysiological Integrity-Reduction of Risk PotentialAnalysis2)A home care client with rheumatoid arthritis is seen by the home health nurse. The client is takingnaproxen (Naprosyn) 500 milligrams orally twice a day for pain control. As part of the nursingassessment for this client, it is essential that the nurse:2)A)Assess if the client has had any weight loss since the last nursing visit.B)Determine if the client is taking the medication 30 minutes before meals.C)Reinforce the necessity for range of motion exercises to all joints at least twice a day.D)Ask the client about the color of her stools.Answer:DExplanation:A)The client is taking a large dose of a nonsteroidal antiinflammatory medication thatcan cause gastrointestinal bleeding. The color of the stools can be an indicator ofbleeding. The medication should be taken with food, not on an empty stomach. Aclient with rheumatoid arthritis who is overweight is encouraged to lose weight;but this is not the focus of this question. Range of motion exercises need to betailored to the individual client and the status of the arthritis.AssessmentPhysiological Integrity — Pharmacological TherapiesApplicationB)The client is taking a large dose of a nonsteroidal antiinflammatory medication thatcan cause gastrointestinal bleeding. The color of the stools can be an indicator ofbleeding. The medication should be taken with food, not on an empty stomach. Aclient with rheumatoid arthritis who is overweight is encouraged to lose weight;but this is not the focus of this question. Range of motion exercises need to betailored to the individual client and the status of the arthritis.AssessmentPhysiological Integrity — Pharmacological TherapiesApplicationC)The client is taking a large dose of a nonsteroidal antiinflammatory medication thatcan cause gastrointestinal bleeding. The color of the stools can be an indicator ofbleeding. The medication should be taken with food, not on an empty stomach. Aclient with rheumatoid arthritis who is overweight is encouraged to lose weight;but this is not the focus of this question. Range of motion exercises need to betailored to the individual client and the status of the arthritis.AssessmentPhysiological Integrity — Pharmacological TherapiesApplication2
D)The client is taking a large dose of a nonsteroidal antiinflammatory medication thatcan cause gastrointestinal bleeding. The color of the stools can be an indicator ofbleeding. The medication should be taken with food, not on an empty stomach. Aclient with rheumatoid arthritis who is overweight is encouraged to lose weight;but this is not the focus of this question. Range of motion exercises need to betailored to the individual client and the status of the arthritis.AssessmentPhysiological Integrity — Pharmacological TherapiesApplication3)A nurse turns a client to the side, and notes that the client has several lightly reddened areas overthe back and hips. The skin is intact. What is an appropriate independent nursing action for thenurse to perform at this time?3)A)Massage the client’s back with lotion using circular motions around the reddened areas.B)Place small pillows under the shoulders and coccyx.C)Order an air mattress for the client.D)Document the observation and inform the nurse in charge.Answer:AExplanation:A)An independent decision and action that can be made by the nurse at this time is tostimulate circulation by providing a back massage. Reddened areas are not directlymassaged, because this may promote tissue damage in an already compromisedarea. It cannot be determined from the information in the scenario whether theclient is at risk for skin breakdown. There is none at this time. Although theobservation will be documented and the charge nurse will be informed, these twoactions are expected responses to observations, not independent nursing actions.Ordering an air mattress will require a collaborative (rather than independent)decision to identify the most appropriate nursing interventions for the client.Placing small pillows under the shoulder and coccyx is not correct and will lead tofurther pressure on these areas.ImplementationPhysiological Integrity-Basic Care and ComfortApplicationB)An independent decision and action that can be made by the nurse at this time is tostimulate circulation by providing a back massage. Reddened areas are not directlymassaged, because this may promote tissue damage in an already compromisedarea. It cannot be determined from the information in the scenario whether theclient is at risk for skin breakdown. There is none at this time. Although theobservation will be documented and the charge nurse will be informed, these twoactions are expected responses to observations, not independent nursing actions.Ordering an air mattress will require a collaborative (rather than independent)decision to identify the most appropriate nursing interventions for the client.Placing small pillows under the shoulder and coccyx is not correct and will lead tofurther pressure on these areas.ImplementationPhysiological Integrity-Basic Care and ComfortApplication3
C)An independent decision and action that can be made by the nurse at this time is tostimulate circulation by providing a back massage. Reddened areas are not directlymassaged, because this may promote tissue damage in an already compromisedarea. It cannot be determined from the information in the scenario whether theclient is at risk for skin breakdown. There is none at this time. Although theobservation will be documented and the charge nurse will be informed, these twoactions are expected responses to observations, not independent nursing actions.Ordering an air mattress will require a collaborative (rather than independent)decision to identify the most appropriate nursing interventions for the client.Placing small pillows under the shoulder and coccyx is not correct and will lead tofurther pressure on these areas.ImplementationPhysiological Integrity-Basic Care and ComfortApplicationD)An independent decision and action that can be made by the nurse at this time is tostimulate circulation by providing a back massage. Reddened areas are not directlymassaged, because this may promote tissue damage in an already compromisedarea. It cannot be determined from the information in the scenario whether theclient is at risk for skin breakdown. There is none at this time. Although theobservation will be documented and the charge nurse will be informed, these twoactions are expected responses to observations, not independent nursing actions.Ordering an air mattress will require a collaborative (rather than independent)decision to identify the most appropriate nursing interventions for the client.Placing small pillows under the shoulder and coccyx is not correct and will lead tofurther pressure on these areas.ImplementationPhysiological Integrity-Basic Care and ComfortApplication