Ch.1 Critical Thinking
An emergency department nurse is collecting information from a client who has stable vital signs when their other client begins to report chest pain. Which of the following should be the nurse's priority?
Ask another nurse to assess the client who reports chest pain.
Call for a code blue.
Alert the RN to assess the client reporting chest pain
Call the client's home for someone to pick up the client.
what is Alert the RN to assess the client reporting chest pain
Chest pain is an indicator of cardiovascular problems and should be reported immediately.
Which type of white blood cell is primarily responsible for producing antibodies?
A. Neutrophils
B. Eosinophils
C. B lymphocytes
D. T lymphocytes
What is
B lymphocytes
Rationale:
B cells are part of the adaptive immune system and are responsible for producing antibodies to neutralize antigens. Neutrophils and eosinophils are more involved in innate responses, and T cells are responsible for cell-mediated immunity.
A nurse is reviewing the arterial blood gas (ABG) results of a client. The client’s ABGs are:pH: 7.6PaCO2: 40 mm HgHCO3: 32 mEq/L.Which of the following acid base conditions should the nurse identify the client is experiencing?
What is: Metabolic alkalosis
Rationale: The nurse should identify that the client is experiencing metabolic alkalosis. The client’s pH is above 7.45, the PaCO2 is within the expected reference range and the HCO3 is above 26 mEq/L.
What is the primary purpose of a wound dressing?
A. To improve circulation
B. To prevent scarring
C. To protect the wound from infection
D. To stop wound drainage completely
What is C. To protect the wound from infection
Rationale: Dressings act as a barrier to external contaminants, helping prevent infection while promoting healing.
A client diagnosed with Clostridioides difficile (C. diff) infection is placed on contact precautions. Which action by the LVN requires immediate correction?
A. Wearing gloves and a gown before entering the room
B. Using alcohol-based hand sanitizer after removing gloves
C. Placing a dedicated stethoscope in the client’s room
D. Disposing of PPE inside the client’s room
What is B. Using alcohol-based hand sanitizer after removing gloves
Rationale: C. diff spores are resistant to alcohol. The LVN must wash hands with soap and water after glove removal. The other actions are appropriate for contact precautions.
All of the following patients have been admitted to the acute care setting. On admission, which patient should receive a focused assessment?
a. 53-year-old admitted with a perforated ulcer
b. 5-year-old admitted for the implant of grommets in the middle ear
c. 76-year-old admitted for a knee replacement
d. 40-year-old admitted for possible bowel obstruction
What is
a. 53-year-old admitted with a perforated ulcer
The LVN is reviewing lab results for a client with suspected infection. Which finding best indicates activation of the immune system?
A. Hemoglobin 12.2 g/dL
B. Platelets 180,000/mm³
C. White blood cell count 15,000/mm³
D. Sodium 140 mEq/L
What is
C. White blood cell count 15,000/mm³
Rationale:
An elevated WBC count is a common sign of infection and immune activation. The other values are within normal limits and not specific indicators of immune response.
A nurse is caring for a client who has respiratory acidosis. Which of the following pH levels should the nurse expect?
What is pH 7.31
Rationale: A client who has respiratory acidosis will have a pH level less than 7.35 and a PaCO2 greater than 45 mm Hg.
The LVN is caring for a surgical client with a wound closed using staples. Which finding should the LVN report to the RN or provider?
A. Pink tissue along the edges
B. Clear, small amount of drainage
C. Staples intact with mild tenderness
D. Redness and warmth spreading beyond the incision site
What is D. Redness and warmth spreading beyond the incision site
Rationale: These are signs of infection that require prompt assessment and possible intervention by the RN or provider.
The LVN is caring for a client with systemic lupus erythematosus (SLE). Which client report should the LVN recognize as most concerning?
A. “I’ve had some joint stiffness this week.”
B. “I’m more tired than usual lately.”
C. “I’ve noticed blood in my urine today.”
D. “I have a mild butterfly rash on my face.”
What is
C. “I’ve noticed blood in my urine today.”
Rationale: Hematuria may indicate lupus nephritis, a serious complication involving kidney damage. This requires prompt provider notification and intervention.
What is an appropriate outcome statement for a patient with a nursing diagnosis of ineffective airway clearance related to thick secretions?
a. The patient will increase intake to 1000 mL daily to liquefy secretions.
b. The patient will cough more frequently within 3 days.
c. The patient will breathe better within 3 days.
d. The patient will perform deep-breathing exercises four times daily.
What is
a. The patient will increase intake to 1000 mL daily to liquefy secretions.
A client receiving immunosuppressive therapy after organ transplantation asks why they must avoid crowds and wear a mask. What is the best response by the LVN?
A. “You may feel weak and need protection from heat exhaustion.”
B. “Your medication makes you more likely to develop allergies.”
C. “You are more likely to reject your organ if exposed to others.”
D. “Your immune system is weakened, increasing your risk for infection.”
What is
“Your immune system is weakened, increasing your risk for infection.”
Rationale:
Immunosuppressants reduce the body’s ability to fight infections. Precautions like mask-wearing and avoiding crowds reduce the client’s exposure to pathogens.
A nurse is caring for a client who is postoperative and has an NG tube that has drained 2,500 mL in the past 6 hr. The nurse should monitor the client for which of the following electrolyte imbalances?
What is Decreased potassium level
Rationale: Loss of gastric fluid is a common cause of potassium depletion
Which of the following actions demonstrates proper sterile technique during a dressing change?
A. Holding sterile gauze with gloved hands and touching the bedside table
B. Pouring saline onto gauze while holding the bottle 6 inches above the field
C. Opening sterile supplies with the field wet from saline
D. Cleaning the wound from the outer edges toward the center
What is B. Pouring saline onto gauze while holding the bottle 6 inches above the field
Rationale: This technique keeps the sterile field intact by avoiding contamination through contact or splash.
A client undergoing chemotherapy tells the LVN they are feeling very tired and "just a little feverish." Which response by the LVN is most appropriate?
A. “It’s common to feel that way after chemo—just rest and drink fluids.”
B. “Let me take your temperature and check with the RN right away.”
C. “Try to walk around to boost your energy and prevent blood clots.”
D. “You can take some acetaminophen and see if it helps.”
What is B. “Let me take your temperature and check with the RN right away.”
Rationale: Chemotherapy suppresses the immune system, and even a low-grade fever may signal life-threatening neutropenic infection. Prompt assessment and provider notification are critical.
A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the charge nurse include? SATA
A. Writing a prescription for morphine sulfate as needed for pain
B. Inserting a nasogastric (NG) tube to relieve gastric distention
C. Showing a client how to use progressive muscle relaxation
D. Performing a daily bath after the evening meal
E. Repositioning a client every 2 hr to reduce pressure injury risk
What is
C. Showing a client how to use progressive muscle relaxation
D. Performing a daily bath after the evening meal
E. Repositioning a client every 2 hr to reduce pressure injury risk
Four clients arrive at the outpatient clinic. Which client should the LVN assess first, based on risk of a serious immune complication?
A. A client with seasonal allergies and watery eyes
B. A client with a low-grade fever after receiving a flu shot
C. A client on chemotherapy with a temperature of 101.2°F (38.4°C)
D. A client reporting fatigue after a mild cold
What is C. A client on chemotherapy with a temperature of 101.2°F (38.4°C)
Rationale:
Clients receiving chemotherapy are immunocompromised. A fever may indicate a serious infection such as sepsis and requires immediate assessment.
A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of 7/min. The arterial blood gas (ABG) values include: pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Oxygen saturation 80% Bicarbonate 28 mEq/L
Which of the following interpretations of the ABG values should the nurse make?
What is Respiratory acidosis
Rationale: The nurse should identify the client who has respiratory problems such as obstruction or depression of the respiratory system as at risk for the development of respiratory acidosis. The expected pH range is 7.35 to 7.45. The pH of 7.22 indicates that this client is acidotic. The pH is decreased while the PaCO2 is elevated. Therefore, the correct interpretation of the results is that the client is in respiratory acidosis.
The LVN is assigned to care for four clients with wounds. Which client should the LVN assess first?
A. A client with a stage II pressure injury reporting mild discomfort
B. A diabetic client with a foot ulcer and foul-smelling drainage
C. A postoperative client with a clean, dry abdominal dressing
D. A client with a healing surgical incision and moderate serosanguinous drainage
What is
B. A diabetic client with a foot ulcer and foul-smelling drainage
Rationale: Diabetics are at high risk for wound infections and poor healing. Foul-smelling drainage suggests possible infection or necrosis, which requires prompt attention.
While caring for a client with a chest tube, the LVN notes continuous bubbling in the water-seal chamber. What is the first action the LVN should take?
A. Clamp the chest tube to stop the bubbling
B. Reinforce the dressing and notify the RN
C. Check the tubing and connections for air leaks
D. Lower the drainage system to the floor
What is C. Check the tubing and connections for air leaks
Rationale: Continuous bubbling may indicate an air leak. The LVN should assess the system for disconnections or cracks before escalating. Never clamp the tube unless specifically ordered.
The LVN is caring for four clients on a medical-surgical unit. Which client should the LVN assess first, based on the risk of transmitting an infectious disease to others?
A. A client with a productive cough and night sweats awaiting tuberculosis testing
B. A client with a urinary tract infection on antibiotics reporting burning with urination
C. A postoperative client with a low-grade fever on day one after abdominal surgery
D. A client with cellulitis of the lower leg receiving IV antibiotics
What is A client with a productive cough and night sweats awaiting tuberculosis testing
Rationale:
This client shows classic signs of active tuberculosis (TB), a highly contagious airborne disease. The LVN must assess and isolate this client promptly to reduce the risk of transmission to others. This situation requires immediate attention and appropriate infection control measures such as placing the client in airborne precautions.
A client with systemic lupus erythematosus (SLE) reports new joint pain, a red rash on the face, and fatigue. Which action should the LVN take first?
A. Reassure the client this is normal with lupus
B. Document the symptoms in the chart
C. Notify the RN or provider of a potential flare-up
D. Administer acetaminophen as ordered
What is
C. Notify the RN or provider of a potential flare-up
Rationale:
These are classic signs of an acute lupus flare, which can lead to serious systemic complications if untreated. While documentation and comfort measures are important, reporting for further evaluation is the priority action.
A 76-year-old client is brought to the emergency department with confusion, muscle weakness, and abdominal cramping. The nurse notes dry mucous membranes, hypotension, and an irregular pulse. The client’s current medications include furosemide and digoxin. Based on the assessment findings, which electrolyte imbalance does the nurse suspect?
What is Hypokalemia
rationale:
Hypernatremia typically presents with restlessness, irritability, and signs of dehydration but not an irregular pulse.
Hypercalcemia often causes constipation, lethargy, and bone pain.
Hyponatremia may also cause confusion, but the presence of an irregular pulse and use of furosemide points more strongly to hypokalemia.
A client with a large abdominal wound has a new negative pressure wound therapy (NPWT) dressing applied. Which observation by the LVN requires immediate intervention?
A. The dressing has some condensation inside
B. The suction machine is set to continuous
C. The dressing has collapsed and is firm to the touch
D. The sponge in the wound appears dry and the suction is silent
What is D. The sponge in the wound appears dry and the suction is silent
Rationale: A dry sponge and silent suction indicate the NPWT system is not functioning properly, putting the client at risk for impaired healing or infection. This needs to be corrected immediately.
A client recovering from abdominal surgery reports pain rated 8 out of 10, but is refusing opioid medication, stating, “I don’t want to get addicted.” The client appears tense and is guarding the surgical site. Which action by the LVN is most appropriate?
A. Explain that addiction is rare when opioids are used for post-op pain
B. Encourage the client to accept the opioid to prevent complications
C. Document the refusal and reassess pain in one hour
D. Collaborate with the RN to implement non-pharmacologic pain relief methods
What is D. Collaborate with the RN to implement non-pharmacologic pain relief methods
Rationale
Rationale:
This question requires understanding client advocacy, education, and multidisciplinary collaboration. While education (Option A) is helpful, it doesn’t directly address the client’s refusal. Forcing or insisting on opioids (Option B) doesn’t respect autonomy. Waiting to reassess without offering an alternative (Option C) risks unmanaged pain. Collaborating with the RN to explore alternatives like repositioning, guided imagery, or cold therapy both respects the client's wishes and promotes comfort, making D the most appropriate.