LPN - Certified Practical Nurse Reduction of Risk Potential Questions and Answers 1 — Questions and Answers
Question 1: An LPN is assisting with the care of a client who is immobile after a stroke. To reduce the risk of deep vein thrombosis (DVT), which of the following interventions is most appropriate for the LPN to implement?
- Massaging the client's lower legs firmly twice a day.
- Encouraging the client to perform active range-of-motion exercises with the unaffected limbs.
- Applying anti-embolism stockings and encouraging ankle pump exercises. (Correct answer)
- Keeping the client's knees in a flexed position with a pillow for comfort.
Correct answer: Applying anti-embolism stockings and encouraging ankle pump exercises.
Applying anti-embolism stockings helps promote venous return, and ankle pump exercises activate the calf muscles, which helps prevent venous stasis, a primary risk factor for DVT. Massaging the legs is contraindicated as it could dislodge a pre-existing clot. While active range-of-motion for unaffected limbs is good, it does not directly address DVT risk in the affected, immobile limbs as effectively. Keeping the knees flexed can impede venous return from the lower legs, increasing the risk.
Question 2: An LPN is caring for a client who is scheduled for a colonoscopy. The client's preparation includes a polyethylene glycol solution. The LPN should monitor the client for which potential complication related to this bowel prep?
- Hypertension and fluid overload.
- Electrolyte imbalances and dehydration. (Correct answer)
- Hyperglycemia and increased urine output.
- Constipation and abdominal cramping.
Correct answer: Electrolyte imbalances and dehydration.
Polyethylene glycol solutions are osmotic laxatives that cause a large volume of liquid stool to clean the colon. This can lead to significant fluid and electrolyte losses, putting the client at risk for dehydration, hyponatremia, and hypokalemia. The LPN's role includes monitoring for signs of these imbalances, such as weakness, confusion, or cardiac dysrhythmias.
Question 3: A newly admitted client has a history of generalized tonic-clonic seizures. Which of the following items is essential for the LPN to ensure is at the client's bedside to reduce the risk of injury?
- A padded tongue blade.
- An oral airway.
- Suction equipment and an oxygen source. (Correct answer)
- Four-point leather restraints.
Correct answer: Suction equipment and an oxygen source.
During and after a seizure, a client is at risk for aspirating secretions and may become hypoxic. Having suction available to clear the airway and oxygen for administration are critical safety measures. Padded tongue blades and oral airways should not be inserted into the mouth of a seizing client as this can cause dental and soft tissue trauma. Restraints should not be used as they can cause injury while the client is convulsing.
Question 4: An LPN is assisting in the transfer of a client with right-sided weakness from the bed to a wheelchair. Which action demonstrates the use of safe patient handling principles?
- Placing the wheelchair on the client's weak (right) side.
- Having the client put their arms around the nurse's neck for support.
- Positioning the wheelchair at a 45-degree angle to the bed on the client's strong (left) side. (Correct answer)
- Keeping the bed at the highest position during the transfer.
Correct answer: Positioning the wheelchair at a 45-degree angle to the bed on the client's strong (left) side.
Positioning the wheelchair on the client's stronger side allows them to use their functional strength to pivot and support their weight during the transfer. Angling the chair at 45 degrees minimizes the distance the client has to move. The client should not put their arms around the nurse's neck, as this can cause injury to the nurse. The bed should be in a low position to reduce the risk of injury from a fall.
Question 5: The LPN is reviewing laboratory results for a client receiving warfarin therapy. The client's International Normalized Ratio (INR) is 4.5. What is the LPN's priority action?
- Administer the daily dose of warfarin as ordered.
- Notify the registered nurse (RN) or healthcare provider of the result. (Correct answer)
- Encourage the client to increase intake of leafy green vegetables.
- Document the result as within the normal therapeutic range.
Correct answer: Notify the registered nurse (RN) or healthcare provider of the result.
A therapeutic INR for a client on warfarin is typically between 2.0 and 3.0. An INR of 4.5 is critically high and indicates an excessive anticoagulant effect, placing the client at high risk for bleeding. The LPN's priority is to report this critical value immediately to the RN or provider for further orders, which may include holding the dose of warfarin or administering an antidote. Administering the warfarin would be unsafe. Leafy greens (high in Vitamin K) would counteract warfarin, but dietary changes are not the immediate priority. The result is well outside the therapeutic range.
Question 6: An LPN is caring for an older adult client who is identified as a high risk for falls. Which of the following interventions should the LPN implement to reduce this risk?
- Keep all four side rails raised on the bed at all times.
- Ensure the client wears smooth-soled slippers when ambulating.
- Place the bedside table and personal items within the client's reach. (Correct answer)
- Administer a sedative at bedtime to ensure the client stays in bed.
Correct answer: Place the bedside table and personal items within the client's reach.
Keeping essential items like the call light, water, and glasses on the bedside table and within easy reach prevents the client from trying to get out of bed unassisted, which is a common cause of falls. Raising all four side rails is considered a restraint and can increase the risk of injury if the client tries to climb over them. Clients should wear non-slip footwear. Sedatives can increase confusion and unsteadiness, thereby increasing fall risk.
LPN - Certified Practical Nurse Reduction of Risk Potential Questions and Answers 1
An LPN is assisting with the care of a client who is immobile after a stroke.
To reduce the risk of deep vein thrombosis (DVT), which of the following interventions is most appropriate for the LPN to implement?