A client with limited mobility is at risk for pressure ulcers. Which action should the LPN take first?
A. Apply a moisture barrier cream
B. Reposition the client every 2 hours
C. Massage reddened areas
D. Increase protein in diet
B. Reposition the client every 2 hours
Rationale: Repositioning reduces pressure on vulnerable areas, which is the most immediate and effective preventative measure.
A client is prescribed furosemide. What should the LPN monitor?
A. Blood glucose
B. Potassium level
C. Respiratory rate
D. Heart rate
B. Potassium level
Rationale: Furosemide is a loop diuretic and can cause hypokalemia. Monitoring potassium is essential.
A pregnant client reports leg cramps at night. What should the LPN recommend?
A. Increase sodium intake
B. Decrease fluids
C. Elevate legs before bed
D. Perform calf stretching
D. Perform calf stretching
Rationale: Calf stretches can help relieve or prevent pregnancy-related muscle cramps, especially in the lower legs. Increasing sodium or decreasing fluids is not appropriate
A child has a high fever and a seizure. What is the nurse's priority?
A. Call the provider
B. Restrain the child
C. Place the child on their side
D. Give antipyretics
C. Place the child on their side
Rationale: This protects the airway during a seizure. Safety is the priority before calling for help or administering meds.
A post-op client reports sudden chest pain and shortness of breath. What does the nurse suspect?
A. Atelectasis
B. Pneumonia
C. Pulmonary embolism
D. Pleural effusion
C. Pulmonary embolism
Rationale: Sudden chest pain and dyspnea in a post-op client are classic signs of a pulmonary embolism—a medical emergency.
The LPN is reinforcing teaching about hand hygiene. Which statement indicates understanding?
A. "I will wash my hands for at least 10 seconds."
B. "Alcohol-based hand rub can replace handwashing always."
C. "I should use hand sanitizer after removing gloves."
D. "I only need to wash hands if I see visible dirt."
C. "I should use hand sanitizer after removing gloves."
Rationale: Gloves can have microscopic tears. Hand hygiene is required after glove removal to prevent cross-contamination.
A client is allergic to penicillin. Which medication should be questioned?
A. Azithromycin
B. Cephalexin
C. Doxycycline
D. Erythromycin
B. Cephalexin
Rationale: Cephalosporins like cephalexin are chemically related to penicillins; there is a risk of cross-reactivity.
A postpartum client is at risk for hemorrhage. What is the nurse’s priority?
A. Check the baby’s temperature
B. Assess uterine firmness
C. Encourage breastfeeding
D. Measure urine output
B. Assess uterine firmness
Rationale: A boggy (soft) uterus indicates uterine atony, a leading cause of postpartum hemorrhage. It should be firm and contracted.
The LPN is caring for a child with asthma. Which sign indicates respiratory distress?
A. Regular breathing
B. Nasal flaring
C. Sleeping through the night
D. Pink lips
B. Nasal flaring
Rationale: Nasal flaring is a key sign of increased work of breathing and respiratory distress in pediatric clients.
Which lab value should be monitored for a client on warfarin?
A. BUN
B. INR
C. Potassium
D. Creatinine
B. INR
Rationale: The INR (International Normalized Ratio) indicates blood clotting time and is monitored to manage warfarin therapy.
A nurse finds a client on the floor. What is the first action?
A. Document the incident
B. Call the physician
C. Assess the client for injury
D. Notify the family
C.Assess the client for injury
Rationale: Always assess before taking further action to determine if there are injuries that require immediate intervention.
When administering digoxin, which assessment is most important?
A. Bowel sounds
B. Apical pulse
C. Skin color
D. Respiratory rate
B. Apical pulse
Rationale: Digoxin can slow the heart rate. The apical pulse must be checked before administration, typically withheld if <60 bpm.
Which finding in a newborn should be reported?
A. Moro reflex present
B. Respirations 50/min
C. Yellow skin on day 1
D. Weight loss of 5%
C. Yellow skin on day 1
Rationale: Jaundice in the first 24 hours may indicate pathologic jaundice and requires further evaluation. Normal weight loss is up to 10%.
A 4-month-old arrives for vaccination. Which is appropriate?
A. MMR
B. Varicella
C. DTaP
D. HPV
C. DTaP
Rationale: DTaP is recommended starting at 2 months of age. MMR and varicella are given at 12–15 months; HPV at 11–12 years.
A diabetic client has cool, clammy skin and confusion. What should the LPN do first?
A. Give insulin
B. Call the provider
C. Give 15g of carbohydrates
D. Recheck blood glucose in 30 minutes
C. Give 15g of carbohydrates
Rationale: These are signs of hypoglycemia. The nurse should immediately provide a fast-acting carbohydrate like juice or glucose gel.
Which action is appropriate when taking an apical pulse?
A. Place stethoscope over the carotid artery
B. Count for 15 seconds and multiply by 4
C. Count for a full minute
D. Ask the client to take a deep breath
C. Count for a full minute
Rationale: An apical pulse should be counted for a full minute, especially in clients with irregular rhythms or those on cardiac meds.
The LPN gives a medication and the client develops hives and shortness of breath. What is the first action?
A. Notify the physician
B. Stop the medication
C. Document the reaction
D. Administer an antihistamine
B. Stop the medication
Rationale: Stopping the medication prevents further exposure. This is the first action before further steps are taken.
A woman at 36 weeks gestation reports headache and swelling. What is the concern?
A. Labor
B. Dehydration
C. Preeclampsia
D. Gestational diabetes
C. Preeclampsia
Rationale: Headache, swelling, and hypertension are signs of preeclampsia, a potentially serious pregnancy complication.
A child with strep throat is prescribed amoxicillin. Which teaching is correct?
A. Stop the antibiotic if symptoms improve
B. Give medication until finished
C. Avoid fluids during treatment
D. Expect a rash as a normal side effect
B. Give medication until finished
Rationale: Completing the full course of antibiotics prevents complications like rheumatic fever and antibiotic resistance.
A client with COPD is receiving oxygen. Which finding requires immediate attention?
A. O2 sat of 90%
B. Confusion and lethargy
C. Increased respiratory rate
D. Productive cough
B. Confusion and lethargy
Rationale: These symptoms can indicate CO₂ retention, especially in COPD clients who are sensitive to oxygen levels.
The LPN is caring for a client with hearing loss. Which communication method is best?
A. Speak loudly and slowly
B. Turn away while speaking
C. Use written communication or gestures
D. Avoid using facial expressions
C. Use written communication or gestures
Rationale: Clear written communication or visual cues help overcome hearing barriers more effectively than shouting.
Which statement indicates correct use of a metered-dose inhaler?
A. “I will inhale before pressing the canister.”
B. “I will shake the inhaler before each use.”
C. “I will exhale deeply after pressing the inhaler.”
D. “I will skip doses if I feel fine.”
B. “I will shake the inhaler before each use.”
Rationale: Shaking the inhaler mixes the medication properly for full dosing.
A client is breastfeeding. Which sign suggests proper latch?
A. Clicking sound
B. Sore nipples
C. Cheeks rounded, no dimpling
D. Baby feeding for under 2 minutes
C. Cheeks rounded, no dimpling
Rationale: A good latch is indicated by full cheeks and no dimpling, suggesting effective suction and feeding.
The nurse observes a toddler with a tracheostomy. Which action requires intervention?
A. Suctioning for 10 seconds
B. Using sterile gloves to change trach ties
C. Feeding the child while laying flat
D. Providing humidified air
C. Feeding the child while laying flat
Rationale: This poses an aspiration risk. The child should be positioned upright during feeding.
The LPN reinforces teaching on wound care. Which statement shows understanding?
A. “I will remove the old dressing with sterile gloves.”
B. “I will clean from the outer wound to the center.”
C. “I will wash my hands before and after dressing changes.”
D. “I will reuse dressings to save supplies.”
C. “I will wash my hands before and after dressing changes.”
Rationale: Hand hygiene is the most effective way to prevent infection during wound care