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Question 1 of 5.

The nurse cares for a confused client who continues to pull at the intravenous (IV) catheter on the left forearm despite frequent instructions not to do so. What is the nurse's next action?

A. Apply a gauze wrap and elastic stockinette around the IV site

B. Apply a mitt on the right hand

C. Apply a soft wrist restraint on the right wrist

D. Apply an arm board to the left arm

Explanation: An arm board on the left arm stabilizes the IV site, reducing pulling without restraining the client, aligning with least-restrictive interventions. Mitts or restraints on the right side do not protect the left-sided IV.

Question 2 of 5.

The LPN is caring for all of the following women on the postpartum unit. Which situation requires further attention?

A. A woman who gave birth four hours ago has red vaginal drainage on her perineal pad.

B. The nurse palpates the uterine fundus 3 cm above the umbilicus in a woman who gave birth 12 hours ago.

C. A woman who had a 20-hour labor and gave birth 8 hours ago asks the nurse not to bring her baby in for breastfeeding during the night.

D. A woman who gave birth yesterday is sweating profusely and producing large amounts of urine.

Explanation: A fundus 3 cm above the umbilicus 12 hours postpartum suggests uterine atony or retained clots, requiring further assessment to prevent hemorrhage. Other findings are normal or less urgent.

Question 3 of 5.

An adult asks the nurse what could be causing him to have a black tongue and black stools. The following items are in the client's history. Which is most likely to be causing his symptoms?

A. He is taking bismuth subsalicylate (Pepto-Bismol) for loose stools.

B. He has been eating a lot of beets and broccoli recently.

C. He has been taking iron tablets for anemia.

D. He eats a lot of red meat.

Explanation: Bismuth subsalicylate commonly causes black tongue and stools, a harmless side effect, unlike the other options.

Question 4 of 5.

The nurse is caring for a woman admitted with heart failure. The client has an IV running at 125 mL/hr. The client calls the nurse stating she is having difficulty breathing. The nurse observes that she is short of breath and in distress. What should the nurse do initially?

A. Slow the IV and raise the head of the bed

B. Call the physician

C. Take the client's blood pressure

D. Notify the charge nurse

Explanation: Raising the head of the bed improves breathing, and slowing the IV prevents fluid overload exacerbation in heart failure, addressing immediate distress.

Question 5 of 5.

An adult is being discharged on a low-sodium, low-fat diet. Which menu, if selected by the client, indicates an understanding of the diet?

A. Hamburger with fries, apple pie, milkshake

B. Tossed salad with vinaigrette dressing, baked skinny chicken, applesauce

C. Steak, corn on the cob, fruit salad

D. Fried shrimp, coleslaw, strawberry shortcake

Explanation: Tossed salad, baked skinless chicken, and applesauce are low in sodium and fat, aligning with the prescribed diet.

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