CSLB General Building (B) — All Questions
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The LPN/LVN is collecting data on a client with heart failure. Which finding should be reported to the RN promptly?
- a.Sudden weight gain of 3 pounds overnight✓
- b.Blood pressure of 122/78 mmHg
- c.Clear lung sounds bilaterally
- d.Heart rate of 76 beats per minute
A sudden weight gain suggests fluid retention and worsening heart failure and should be reported. Normal blood pressure, clear lungs, and a normal heart rate are reassuring. Daily weights are a key monitoring tool in heart failure.
A client with diabetes reports shakiness, sweating, and dizziness. The blood glucose is 55 mg/dL. What should the LPN/LVN do first?
- a.Administer the client's evening insulin dose
- b.Give 15 grams of a fast-acting carbohydrate✓
- c.Encourage the client to rest until symptoms pass
- d.Withhold all food and recheck in one hour
Symptoms and a glucose of 55 mg/dL indicate hypoglycemia, treated with 15 grams of fast-acting carbohydrate and rechecking in 15 minutes. Giving insulin would worsen hypoglycemia. Prompt treatment prevents progression to severe hypoglycemia.
The LPN/LVN is caring for a client after a total hip replacement. Which position should be maintained to prevent dislocation?
- a.Legs crossed at the ankles
- b.Hip flexed greater than 90 degrees
- c.Legs abducted with a wedge pillow between the knees✓
- d.Turning fully onto the operative side
Keeping the legs abducted with a wedge pillow prevents adduction and dislocation of the new hip. Crossing the legs, flexing the hip beyond 90 degrees, and lying on the operative side are contraindicated. Positioning protects the prosthesis.
A client with chronic obstructive pulmonary disease has an oxygen order. Which oxygen flow is generally most appropriate?
- a.10 L/min by simple mask
- b.15 L/min by nonrebreather
- c.8 L/min by nasal cannula
- d.2 L/min by nasal cannula✓
Clients with COPD typically receive low-flow oxygen, such as 2 L/min, to maintain adequate oxygenation without suppressing respiratory drive. High flow rates may be used only in emergencies with close monitoring. Titrating to target saturation is important.
The LPN/LVN is monitoring a client receiving a blood transfusion. Which finding suggests a transfusion reaction and requires stopping the infusion?
- a.Fever, chills, and flank pain shortly after the start✓
- b.Blood pressure of 120/70 mmHg
- c.Temperature unchanged from baseline
- d.Report of feeling comfortable
Fever, chills, and flank pain suggest a hemolytic transfusion reaction; the transfusion must be stopped and the RN notified immediately. Stable vital signs and comfort are reassuring. Early recognition prevents serious harm.
A client is admitted with dehydration. Which finding supports this diagnosis?
- a.Bounding pulses and edema
- b.Dry mucous membranes and poor skin turgor✓
- c.Crackles in the lungs
- d.Distended neck veins
Dry mucous membranes and poor skin turgor are classic signs of fluid volume deficit. Bounding pulses, edema, crackles, and distended neck veins indicate fluid overload. Assessing hydration status guides fluid therapy.
The LPN/LVN is caring for a client with a nasogastric tube for decompression. Which finding requires prompt attention?
- a.The tube is connected to low suction
- b.Small amount of greenish drainage
- c.The client reports nausea and the tube has stopped draining✓
- d.The client's mouth is moist
If drainage stops and the client is nauseated, the tube may be clogged or malpositioned and requires prompt evaluation. Green drainage and connection to suction are expected. Maintaining patency relieves gastric distention.
A client with a new colostomy has a stoma that is dark purple. What does this finding indicate?
- a.Normal healthy stoma
- b.Expected postoperative bruising
- c.Adequate blood supply
- d.Possible impaired circulation that must be reported✓
A healthy stoma is pink or red and moist; a dark purple or black stoma suggests compromised blood supply and must be reported immediately. Impaired circulation can lead to necrosis. Prompt reporting allows early intervention.
The LPN/LVN is caring for a client with a cast on the right lower leg. Which finding indicates possible compartment syndrome?
- a.Severe pain unrelieved by medication and numbness of the toes✓
- b.Mild itching under the cast
- c.Pink, warm toes with brisk capillary refill
- d.The cast feels dry and firm
Unrelieved severe pain and numbness are warning signs of compartment syndrome, a limb-threatening emergency. Pink, warm toes with brisk capillary refill are normal findings. Neurovascular changes must be reported immediately.
A client is 1 day postoperative after abdominal surgery. Which intervention best prevents postoperative pneumonia?
- a.Keep the client on strict bed rest
- b.Encourage use of an incentive spirometer and coughing and deep breathing✓
- c.Withhold pain medication so the client stays alert
- d.Limit fluid intake to reduce secretions
Incentive spirometry with coughing and deep breathing expands the lungs and clears secretions, preventing atelectasis and pneumonia. Immobility and unrelieved pain reduce lung expansion. Adequate hydration keeps secretions thin.
The LPN/LVN collects data on a client with hypothyroidism. Which finding is consistent with this condition?
- a.Weight loss and heat intolerance
- b.Tachycardia and diarrhea
- c.Fatigue, cold intolerance, and constipation✓
- d.Restlessness and tremors
Hypothyroidism slows metabolism, causing fatigue, cold intolerance, and constipation. Weight loss, heat intolerance, tachycardia, and tremors indicate hyperthyroidism. Recognizing the pattern guides monitoring.
A client with a pressure injury has a wound with visible subcutaneous fat but no muscle or bone. How is this best described?
- a.Stage 1 pressure injury
- b.Deep tissue injury
- c.Stage 2 pressure injury
- d.Stage 3 pressure injury✓
A stage 3 pressure injury involves full-thickness skin loss with visible subcutaneous fat but no exposed muscle or bone. Stage 1 has intact skin, and stage 2 involves partial-thickness loss. Accurate staging guides treatment.
The LPN/LVN is caring for a client with a seizure history who is NPO for a procedure. Which action is most appropriate regarding antiseizure medication?
- a.Clarify with the RN or provider whether the medication should still be given✓
- b.Automatically hold all medications because the client is NPO
- c.Give the medication with a large glass of water
- d.Double the next dose to make up for the missed one
Antiseizure medications are often continued even when a client is NPO, so the nurse should clarify orders rather than automatically holding them. Withholding may precipitate seizures. Doubling doses is unsafe.
A client with cirrhosis has ascites. Which position best promotes comfort and breathing?
- a.Flat supine position
- b.Semi-Fowler's or Fowler's position✓
- c.Trendelenburg position
- d.Prone position
Elevating the head of the bed to a semi-Fowler's or Fowler's position eases breathing by reducing pressure of ascitic fluid on the diaphragm. Flat, head-down, and prone positions increase respiratory effort. Positioning improves ventilation.
The LPN/LVN reviews intake and output for a client with an indwelling catheter. Urine output has been less than 30 mL/hour for several hours. What should the nurse do?
- a.Document as a normal finding
- b.Increase the client's activity level
- c.Report the decreased output to the RN✓
- d.Clamp the catheter for two hours
Urine output persistently below 30 mL/hour may indicate impaired kidney perfusion or obstruction and should be reported. It is not a normal finding to document without action. Timely reporting supports early intervention.
A client recovering from a stroke has difficulty swallowing. Which intervention best reduces the risk of aspiration during meals?
- a.Have the client lie flat while eating
- b.Offer thin liquids through a straw quickly
- c.Encourage rapid eating to finish meals
- d.Position the client upright and provide thickened liquids as ordered✓
Sitting upright and using thickened liquids as ordered reduces aspiration risk in clients with dysphagia. Lying flat, thin liquids, and rapid eating increase risk. Safe swallowing precautions protect the airway.
The LPN/LVN is caring for a client with a peripheral IV. The site is red, warm, and tender. What is the priority action?
- a.Stop the infusion and remove the IV catheter✓
- b.Increase the infusion rate to flush the vein
- c.Apply a warm compress and continue the infusion
- d.Document and reassess at the end of the shift
Redness, warmth, and tenderness indicate phlebitis; the infusion should be stopped and the catheter removed to prevent complications. Increasing the rate or continuing infusion worsens the problem. The site is then restarted elsewhere as needed.
A client with pneumonia has an oxygen saturation of 88% on room air. Which action should the LPN/LVN take first?
- a.Encourage the client to lie flat
- b.Apply oxygen as ordered and reposition to high Fowler's✓
- c.Withhold oxygen until the provider rounds
- d.Offer a cold beverage
An oxygen saturation of 88% indicates hypoxemia; applying oxygen as ordered and positioning upright improves oxygenation. Lying flat and withholding oxygen worsen the problem. Prompt oxygenation is the priority.
The LPN/LVN is monitoring a client after a thyroidectomy. Which finding requires immediate attention?
- a.Sore throat when swallowing
- b.Hoarse voice for a few hours
- c.Tingling around the mouth and muscle twitching✓
- d.Small amount of drainage on the dressing
Tingling around the mouth and muscle twitching suggest hypocalcemia from inadvertent parathyroid injury, a serious complication after thyroidectomy. A sore throat, temporary hoarseness, and minimal drainage are expected. Calcium changes require prompt reporting.
A client with a fractured femur suddenly develops shortness of breath, chest pain, and confusion. What complication should the nurse suspect?
- a.Constipation
- b.Mild anxiety
- c.Urinary retention
- d.Fat or pulmonary embolism✓
Sudden dyspnea, chest pain, and confusion after a long-bone fracture may indicate a fat or pulmonary embolism, a medical emergency. These symptoms are not explained by constipation or urinary retention. Rapid recognition and response are critical.
The LPN/LVN is reinforcing teaching to a client with a new diagnosis of gastroesophageal reflux disease. Which instruction is appropriate?
- a.Avoid lying down for 2 to 3 hours after eating✓
- b.Eat large meals late in the evening
- c.Lie flat immediately after meals
- d.Increase caffeine and fatty foods
Remaining upright for several hours after meals reduces reflux. Large late meals, lying flat after eating, and caffeine and fatty foods worsen symptoms. Lifestyle changes are first-line management.
A client is receiving continuous enteral tube feeding. To reduce the risk of aspiration, the head of the bed should be maintained at what minimum elevation?
- a.Flat at 0 degrees
- b.At least 30 degrees✓
- c.No more than 10 degrees
- d.Prone position
Keeping the head of the bed elevated at least 30 degrees during enteral feeding reduces the risk of aspiration. A flat position increases reflux and aspiration risk. Elevation is a key safety measure.
The LPN/LVN collects data on a client with appendicitis. Which finding is most consistent with this condition?
- a.Pain relieved by eating
- b.Left upper quadrant burning
- c.Right lower quadrant pain with rebound tenderness✓
- d.Painless bright red rectal bleeding
Appendicitis classically causes right lower quadrant pain with rebound tenderness. Pain relieved by eating and left upper quadrant burning suggest other conditions. Recognizing the pattern supports timely care.
A client with anemia has a hemoglobin of 7 g/dL and reports fatigue and dizziness on standing. Which intervention is a priority?
- a.Encourage vigorous exercise
- b.Restrict all fluids
- c.Ambulate the client rapidly and independently
- d.Assist with slow position changes and monitor for dizziness✓
Low hemoglobin reduces oxygen delivery, causing fatigue and orthostatic symptoms; assisting with slow position changes prevents falls. Vigorous exercise and rapid independent ambulation are unsafe. Safety and energy conservation are priorities.
The LPN/LVN is caring for a client with a chest tube. The nurse notes continuous bubbling in the water-seal chamber. What is the appropriate action?
- a.Check the tubing and connections for an air leak and notify the RN✓
- b.Clamp the chest tube for the rest of the shift
- c.Strip the tubing vigorously and continuously
- d.Raise the drainage system above the chest
Continuous bubbling in the water-seal chamber may indicate an air leak in the system that should be investigated and reported. Clamping a chest tube can cause a tension pneumothorax. The system is kept below the chest.
A client reports burning on urination, urinary frequency, and lower abdominal discomfort. Which condition is most likely?
- a.Kidney stones only
- b.Urinary tract infection✓
- c.Appendicitis
- d.Gallbladder disease
Burning on urination, frequency, and suprapubic discomfort are classic signs of a urinary tract infection. These symptoms differ from appendicitis or gallbladder disease. Collecting a urine specimen supports diagnosis.
The LPN/LVN is caring for a client after a mastectomy. Which action helps prevent lymphedema in the affected arm?
- a.Take blood pressure on the affected arm
- b.Draw blood from the affected arm
- c.Avoid blood pressure measurement and venipuncture on the affected arm✓
- d.Keep the affected arm dependent below heart level
Avoiding blood pressure measurement and venipuncture on the affected arm helps prevent lymphedema after mastectomy. The arm is also elevated, not kept dependent, to promote lymph drainage. Protecting the arm reduces swelling and infection risk.
A client with diabetes has a foot ulcer. Which teaching point best supports healing and prevents further injury?
- a.Walk barefoot at home for comfort
- b.Soak the feet in hot water daily
- c.Trim calluses with a razor at home
- d.Inspect the feet daily and wear well-fitting shoes✓
Daily foot inspection and well-fitting footwear prevent unnoticed injury and support healing in clients with diabetes. Walking barefoot, hot soaks, and self-trimming calluses increase the risk of injury and infection. Foot care is essential in diabetes.
The LPN/LVN is collecting data on a client who had a stroke affecting the left side of the brain. Which deficit is most likely?
- a.Right-sided weakness and difficulty with speech✓
- b.Left-sided weakness only
- c.Complete loss of vision in both eyes
- d.Inability to hear in both ears
A stroke on the left side of the brain typically causes right-sided weakness and often affects speech because language centers are usually on the left. Left-sided weakness suggests a right-brain stroke. Recognizing deficits guides rehabilitation.
A client with heart failure is prescribed a low-sodium diet. Which food selection indicates understanding of the diet?
- a.Canned soup and cured ham
- b.Fresh vegetables and grilled chicken✓
- c.Salted nuts and pickles
- d.Processed lunch meat sandwiches
Fresh vegetables and unprocessed grilled chicken are low in sodium and appropriate for heart failure. Canned soup, cured meats, salted nuts, and processed meats are high in sodium. Limiting sodium helps control fluid retention.
The LPN/LVN is caring for an immobile client. Which intervention best prevents pressure injuries?
- a.Massage reddened bony prominences vigorously
- b.Keep the head of the bed elevated to 90 degrees continuously
- c.Reposition the client at least every 2 hours✓
- d.Use a doughnut-shaped cushion under the sacrum
Repositioning at least every 2 hours relieves pressure and prevents skin breakdown. Vigorous massage of reddened areas and doughnut cushions can worsen tissue damage. Frequent turning and skin care are key preventive measures.
The LPN/LVN is caring for a client with acute pancreatitis. Which measure is a priority in the acute phase?
- a.Encourage a high-fat diet
- b.Maintain NPO status to rest the pancreas as ordered✓
- c.Provide frequent large meals
- d.Position the client flat on the back
Keeping the client NPO reduces pancreatic stimulation and rests the inflamed organ during the acute phase. High-fat and large meals stimulate enzyme secretion and worsen pain. Pain control and monitoring are also priorities.