NCLEX-PN Nursing — All Questions

The LPN/LVN is collecting data on a client with heart failure. Which finding should be reported to the RN promptly?

• a.Clear lung sounds bilaterally
• b.Sudden weight gain of 3 pounds overnight✓
• c.Heart rate of 76 beats per minute
• d.Blood pressure of 122/78 mmHg

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.Encourage the client to rest until symptoms pass
• b.Withhold all food and recheck in one hour
• c.Give 15 grams of a fast-acting carbohydrate✓
• d.Administer the client's evening insulin dose

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 abducted with a wedge pillow between the knees✓
• b.Turned fully onto the operative side to relieve pressure
• c.Legs crossed at the ankles with the knees held together
• d.Hip flexed greater than 90 degrees while sitting upright

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.15 L/min by nonrebreather
• b.10 L/min by simple mask
• 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.Temperature unchanged from the pretransfusion baseline value
• b.Report of feeling comfortable and warm under the blankets
• c.Blood pressure of 120/70 mmHg, unchanged from baseline
• d.Fever, chills, and flank pain shortly after the start✓

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.Crackles heard throughout both lung fields
• b.Bounding pulses and pitting edema of the ankles
• c.Dry mucous membranes and poor skin turgor✓
• d.Distended neck veins while sitting upright

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 client reports nausea and the tube has stopped draining✓
• b.A small amount of greenish drainage in the suction canister
• c.The client's mouth and lips are moist following routine oral care
• d.The tube is connected to low intermittent suction as ordered

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.Expected bruising from surgery that will fade on its own
• b.Possible impaired circulation that must be reported✓
• c.A sign of an unusually rich blood supply to the stoma
• d.The normal color of a healthy, well-healed stoma

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.The cast feels dry and firm to the touch several hours later
• c.Pink, warm toes with brisk capillary refill below the cast edge
• d.Mild itching of the skin beneath the upper edge of the cast

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.Limit fluid intake to reduce the amount of secretions in the lungs
• b.Keep the client on strict bed rest until the incision is fully healed
• c.Withhold pain medication so the client stays alert enough to breathe
• d.Encourage use of an incentive spirometer and coughing and deep breathing✓

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.Fatigue, cold intolerance, and constipation✓
• b.Weight loss, heat intolerance, and difficulty sleeping
• c.Restlessness, fine hand tremors, and anxiety
• d.Tachycardia, diarrhea, and warm moist skin

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.Deep tissue injury
• b.Stage 3 pressure injury✓
• c.Stage 2 pressure injury
• d.Stage 1 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.Give the medication with a large glass of water despite the NPO order
• b.Double the next dose after the procedure to make up for the missed one
• c.Automatically hold all of the client's medications because the order is NPO
• d.Clarify with the RN or provider whether the medication should still be given✓

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.Prone position with the abdomen down
• b.Flat supine position with one pillow
• c.Semi-Fowler's or Fowler's position✓
• d.Trendelenburg, head-down 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.Clamp the catheter for two hours
• b.Increase the client's activity level
• c.Report the decreased output to the RN✓
• d.Document as a normal finding

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.Offer thin liquids through a straw so meals can be finished quickly
• b.Encourage rapid eating so meals are finished before fatigue sets in
• c.Position the client upright and provide thickened liquids as ordered✓
• d.Have the client lie flat during meals to relax the throat muscles

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.Document and reassess at the end of the shift
• d.Apply a warm compress and continue the infusion

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.Withhold oxygen until the provider rounds later in the day
• b.Offer a cold beverage and recheck the reading in an hour
• c.Apply oxygen as ordered and reposition to high Fowler's✓
• d.Encourage the client to lie flat to rest the breathing muscles

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 on the first day
• b.Small amount of drainage on the neck dressing
• c.Hoarse voice for a few hours after surgery
• d.Tingling around the mouth and muscle twitching✓

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.Urinary retention from bed rest
• b.Constipation from immobility
• c.Fat or pulmonary embolism✓
• d.Mild situational anxiety

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.Increase caffeine and fatty foods
• c.Eat large meals late in the evening
• d.Lie flat immediately after meals

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.Prone position
• b.Flat at 0 degrees
• c.At least 30 degrees✓
• d.No more than 10 degrees

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.Painless bright red rectal bleeding noted with stools
• b.Left upper quadrant burning an hour after meals
• c.Pain that is fully relieved by eating a meal
• d.Right lower quadrant pain with rebound tenderness✓

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 to raise the hemoglobin faster
• b.Ambulate the client rapidly and without assistance to build stamina
• c.Assist with slow position changes and monitor for dizziness✓
• d.Restrict all fluids so that the blood becomes more concentrated

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.Strip the tubing vigorously and continuously until the bubbling stops
• b.Check the tubing and connections for an air leak and notify the RN✓
• c.Raise the drainage system above the level of the client's chest
• d.Clamp the chest tube for the rest of the shift and recheck later

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.Urinary tract infection✓
• b.Obstructing kidney stone
• c.Acute gallbladder disease
• d.Early acute appendicitis

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.Avoid blood pressure measurement and venipuncture on the affected arm✓
• b.Draw blood samples from the affected arm to spare the other side
• c.Keep the affected arm dependent below heart level so that fluid drains
• d.Take blood pressure readings on the affected arm at every check

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.Trim calluses at home with a razor blade after bathing
• b.Soak the feet in hot water every day to soften them
• c.Inspect the feet daily and wear well-fitting shoes✓
• d.Walk barefoot at home so the ulcer stays uncovered

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.Left-sided weakness with no change in speech
• b.Right-sided weakness and difficulty with speech✓
• c.Inability to hear in both ears with normal strength
• d.Complete loss of vision in both eyes with no weakness

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.Fresh vegetables and grilled chicken✓
• b.Processed lunch meat sandwiches
• c.Canned soup and cured ham
• d.Salted nuts and pickles

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.Reposition the client at least every 2 hours✓
• b.Massage reddened bony prominences vigorously
• c.Use a doughnut-shaped cushion under the sacrum
• d.Keep the head of the bed elevated to 90 degrees continuously

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.Position the client flat on the back to relax the abdomen
• b.Maintain NPO status to rest the pancreas as ordered✓
• c.Encourage a high-fat diet to keep up calorie intake
• d.Provide frequent large meals throughout the day

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.

An immobile client is at risk for pressure injury. Which action does the nurse take?

• a.Vigorously massage any reddened areas
• b.Reposition the client at least every 2 hours✓
• c.Keep the head of the bed elevated at all times
• d.Limit repositioning to reduce the client's discomfort

Reposition an immobile client at least every 2 hours to relieve pressure. Vigorous massage of reddened skin worsens tissue injury, constant head-of-bed elevation increases sacral shear, and limiting repositioning raises pressure-injury risk.

A client's urine output has been 25 mL/hr for three hours. The nurse should:

• a.Report the finding as it may indicate poor perfusion✓
• b.Clamp the catheter for one hour and reassess
• c.Document it as an expected postoperative finding
• d.Encourage the client to drink more water and continue monitoring

Urine output persistently below 30 mL/hr may indicate poor perfusion or obstruction and should be reported. Simply encouraging fluids or charting the output as expected delays care, and clamping the catheter is unsafe.

A conscious client with diabetes is diaphoretic and confused; a fingerstick reads 54 mg/dL. The nurse should:

• a.Give 15 g of fast-acting carbohydrate, wait 15 minutes, and recheck✓
• b.Withhold all food and fluids until the provider can be notified
• c.Administer the next scheduled dose of insulin as ordered
• d.Notify the provider, then wait for orders before giving anything by mouth

For symptomatic hypoglycemia in a conscious client, apply the 15-15 rule: 15 g of fast-acting carbohydrate, wait 15 minutes, recheck. Insulin would drive the glucose lower still; waiting for orders or withholding food delays needed treatment.

Fifteen minutes into a blood transfusion, a client develops chills, fever, and low-back pain. The nurse's first action is to:

• a.Stop the transfusion and keep the line open with normal saline✓
• b.Give an antipyretic and continue the transfusion at the prescribed rate
• c.Slow the infusion rate and continue the transfusion as ordered
• d.Increase the rate so the unit finishes before symptoms worsen

Signs of an acute transfusion reaction require you to stop the transfusion immediately and keep the line open with normal saline, then notify the RN. Slowing the rate, medicating and continuing, or speeding up all keep incompatible blood flowing.

A client with dysphagia is eating lunch. Which action prevents aspiration?

• a.Have the client lie flat so the muscles of the throat can relax
• b.Position the client upright and provide thickened liquids as ordered✓
• c.Offer plenty of thin liquids to help wash the food down quickly
• d.Encourage large bites so the client can finish the meal while it is hot

For dysphagia, position the client upright and provide thickened liquids as ordered to prevent aspiration. Thin liquids, lying flat, and large hurried bites all increase aspiration risk.

A client is receiving a tube feeding. To reduce aspiration risk, the nurse keeps the head of the bed at least:

• a.Flat (0 degrees)
• b.90 degrees at all times, even during sleep
• c.About 10 degrees
• d.30 degrees✓

Keep the head of the bed at least 30 degrees during and after tube feeding to reduce aspiration. Flat or barely raised positions increase the risk, and a rigid 90 degrees at all times is neither required nor practical for sleep.

A client 6 hours after a total hip replacement needs positioning. The nurse should:

• a.Elevate both knees sharply on pillows
• b.Turn the client fully onto the operative side
• c.Keep the legs abducted with a pillow between them✓
• d.Cross the client's legs at the ankles for comfort

After a total hip replacement, keep the legs abducted with a pillow between them to prevent dislocation. Crossing the legs, turning onto the operative side, and sharp flexion all risk dislocation.

A client with COPD is short of breath. Which oxygen approach is appropriate?

• a.High-flow oxygen at 10 L/min by simple face mask
• b.Low-flow oxygen, for example 2 L/min, targeting about 88–92%✓
• c.A nonrebreather mask at 15 L/min for routine use
• d.No supplemental oxygen, to preserve the client's hypoxic respiratory drive

In COPD, use low-flow oxygen (for example 2 L/min) targeting about 88–92%. High-flow delivery can blunt the hypoxic respiratory drive, and withholding oxygen from a hypoxic client is unsafe. *(Confirm the target with provider orders.)*

After a thyroidectomy, a client reports tingling around the mouth and muscle twitching. The nurse recognizes this as a sign of:

• a.Hyperkalemia
• b.Normal anesthesia after-effects
• c.Expected postoperative numbness that needs no action
• d.Hypocalcemia that should be reported promptly✓

Perioral tingling and muscle twitching after thyroidectomy indicate hypocalcemia (parathyroid involvement) and should be reported promptly. These findings are not benign postoperative numbness or anesthesia after-effects, and the electrolyte involved is calcium, not potassium.

Which finding in a client with heart failure should the nurse report promptly?

• a.A single episode of mild fatigue after the afternoon walk
• b.A weight gain of 3 pounds since yesterday with new crackles✓
• c.A blood pressure of 118/72 mmHg on the morning check
• d.Clear breath sounds and no edema on the evening data collection

A 3-pound weight gain with new crackles signals fluid overload in heart failure and must be reported promptly. Mild fatigue, a normal blood pressure, and clear lungs without edema are not urgent.

A client recovering from surgery is at risk for atelectasis and pneumonia. Which intervention does the nurse reinforce?

• a.Shallow breathing to protect the incision
• b.Withholding fluids to reduce secretions
• c.Strict bed rest with minimal movement
• d.Incentive spirometry, coughing, and deep breathing✓

Incentive spirometry, coughing, and deep breathing (with early ambulation) prevent atelectasis and pneumonia. Strict bed rest, withheld fluids, and shallow breathing increase the risk.

A client with a chest tube has continuous bubbling in the water-seal chamber. The nurse recognizes this as:

• a.Expected and requiring no action
• b.A reason to clamp the tube immediately
• c.A possible air leak that should be reported✓
• d.An indication to disconnect and flush the tubing

Continuous bubbling in the water-seal chamber suggests an air leak and should be reported. It is not an expected finding, and clamping or disconnecting the tube can cause a tension pneumothorax.

An LPN/VN is preparing to give a bolus feeding through a nasogastric tube. How should the client be positioned?

• a.With the head of the bed raised 30 to 45 degrees✓
• b.Flat on the back with the head turned to one side
• c.Sitting upright with the neck flexed toward the chest
• d.On the left side with the head of the bed lowered

Elevating the head of the bed 30 to 45 degrees during and after a feeding reduces reflux and aspiration. Supine positioning and Trendelenburg increase reflux, and neck flexion narrows the airway.

A client with a newly inserted nasogastric tube is about to receive the first feeding. What confirms correct tube placement?

• a.A radiograph read after the tube was inserted✓
• b.Air injected while listening over the epigastrium
• c.Aspirate with a pH of 5.5 from the tube
• d.Absence of coughing when the client swallows water

Radiographic confirmation is the standard before the first use of a blindly inserted feeding tube. A pH of 5.5 is not clearly gastric, the auscultatory air method is unreliable, and absence of coughing does not exclude a tube in the airway.

An LPN/VN is repositioning a client who is on bed rest. How should the client be turned to reduce pressure on the trochanter?

• a.To a 90-degree side-lying position on the hip
• b.To a 30-degree side-lying position✓
• c.To a prone position with the arms above the head
• d.To a fully supine position with the knees flexed

A 30-degree lateral tilt keeps weight off the greater trochanter. Lying directly on the hip concentrates pressure there, supine loading shifts pressure to the sacrum and heels, and prone positioning is not tolerated by most clients.

An LPN/VN observes a reddened area over a client's sacrum that does not turn white when pressed. How should this be described?

• a.Intact skin with nonblanchable redness of the area✓
• b.Partial-thickness skin loss with a shallow open base
• c.Skin loss covered by adherent yellow slough tissue
• d.Full-thickness skin loss with visible subcutaneous fat

Nonblanchable erythema over intact skin is the earliest recognizable pressure injury. Partial-thickness loss, visible fat, and slough-covered loss all describe deeper or obscured injuries.

An LPN/VN is providing care for a client with a stage 2 pressure injury on the heel. Which action is appropriate?

• a.Position the client on that heel for short periods
• b.Massage the reddened skin around the injury
• c.Apply a heat lamp to the area twice each day
• d.Keep the heel elevated off the surface of the bed✓

Offloading the heel removes the pressure that caused the injury. Massage over a compromised area causes further tissue damage, heat lamps dry and burn fragile skin, and any weight bearing continues the injury.

A client who had a stroke has difficulty swallowing. What should the LPN/VN do during meals?

• a.Place food on the weaker side of the client's mouth
• b.Offer thin liquids through a straw between the bites
• c.Seat the client upright and have the chin tucked down✓
• d.Seat the client upright and have the chin lifted up

An upright position with a chin tuck narrows the airway entrance and directs food toward the esophagus. Chin lift opens the airway to food, thin liquids through a straw move fastest and are hardest to control, and the weaker side pockets food.

An LPN/VN is helping a client ambulate with a cane after a right hip replacement. How should the cane be used?

• a.Held in the left hand and moved with the right leg✓
• b.Held in the left hand and moved with the left leg
• c.Held in the right hand and moved before both legs
• d.Held in the right hand and moved with the right leg

The cane is held on the stronger side and advanced together with the weaker leg so the two share the load. Holding it on the affected side, pairing it with the strong leg, or advancing it alone all fail to unload the operative hip.

An LPN/VN is teaching a client with an ostomy about emptying the pouch. When should the pouch be emptied?

• a.When it is completely full at the end of the day
• b.Only when the seal begins to leak
• c.Every four hours whether or not there is output
• d.When it is about one-third to one-half full✓

Emptying at one-third to one-half full keeps the weight from breaking the seal. Waiting until full or until leakage begins guarantees seal failure, and a fixed schedule ignores actual output.

An LPN/VN is caring for a client with an indwelling urinary catheter. Which action prevents infection?

• a.Empty the drainage bag once each work shift
• b.Coil the extra tubing loosely on the bed surface
• c.Disconnect the tubing to obtain a urine specimen
• d.Keep the drainage bag below the bladder✓

Keeping the bag below the bladder prevents backflow of contaminated urine. A fixed emptying schedule may allow overfilling, breaking the closed system introduces organisms, and tubing on the bed can allow dependent loops and reflux.

A client reports constipation and is on a bowel management protocol. Which nonpharmacological measure should the LPN/VN reinforce first?

• a.Increase fluid intake and daily walking as tolerated✓
• b.Increase dietary fiber without changing fluid intake
• c.Restrict food intake until the bowel pattern returns
• d.Use a bedpan rather than walking to the bathroom

Fluid and activity together restore normal transit. Fiber without fluid worsens constipation, bedpan use makes evacuation harder, and restricting food removes the bulk the colon needs.

An LPN/VN is providing morning care for a client with diabetes. Which foot care action is correct?

• a.Dry carefully between the toes after washing✓
• b.Soak the feet in warm water for twenty minutes
• c.Apply lotion generously between the toes
• d.Trim the toenails in a curve at the corners

Moisture between the toes promotes fungal infection and skin breakdown, so the area is dried thoroughly. Soaking macerates skin, curved nail trimming causes ingrown nails, and lotion between the toes traps moisture.

An LPN/VN is caring for a client who is receiving continuous enteral feeding. Which finding suggests intolerance?

• a.Two soft formed stools during the day shift
• b.Abdominal distention with new nausea✓
• c.A residual volume of 60 mL after four hours
• d.Bowel sounds present in all four quadrants

Distention with nausea suggests delayed gastric emptying and possible aspiration risk. A modest residual, normal stools, and present bowel sounds are all expected during tolerated feeding.

An LPN/VN is planning nonpharmacological pain relief for a client with chronic low back pain. Which measure is appropriate?

• a.Ice applied continuously for two hours at a time
• b.Vigorous deep massage directly over the spine
• c.Repositioning with pillow support and slow massage✓
• d.Complete bed rest until the pain fully resolves

Repositioning with support and gentle massage relieve muscle tension without harm. Prolonged bed rest worsens back pain, deep pressure over the spine can injure, and unbroken two-hour ice application damages tissue.

An LPN/VN is measuring intake and output for a client. Which item counts as intake?

• a.The applesauce the client ate at breakfast
• b.The gelatin dessert the client ate at lunch✓
• c.The mashed potatoes served with the dinner
• d.The oatmeal the client finished this morning

Gelatin is liquid at body temperature and is counted as fluid intake. Applesauce, mashed potatoes, and oatmeal are semisolid foods and are not recorded as fluid.

An LPN/VN is performing range-of-motion exercises for an immobilized client. Which action is correct?

• a.Move each joint to the point of resistance only✓
• b.Complete the movements as quickly as tolerated
• c.Perform the exercises only on the unaffected side
• d.Move each joint slightly beyond the point of pain

Movement stops at resistance to protect the joint. Pushing past pain injures tissue, exercising only one side allows contractures on the other, and rapid movement increases spasticity and injury risk.

A client with a hearing aid is admitted to a long-term care unit. How should the LPN/VN store the device overnight?

• a.Turned on and left in the client's bedside drawer
• b.Turned off and sealed in an airtight plastic bag
• c.Turned off with the battery compartment open✓
• d.Turned on and placed in a cup of clean water

Turning the aid off and opening the battery door conserves the battery and lets moisture escape. Water destroys the device, an airtight bag traps moisture, and leaving it on drains the battery.

An LPN/VN is providing postmortem care. Which action should be completed first?

• a.Confirm that the death has been pronounced✓
• b.Wash the body and apply a clean gown
• c.Remove all tubes and lines from the body
• d.Place the body in a supine position with a pillow

Care begins only after the death has been formally pronounced, and in some cases lines must remain in place for the medical examiner. Removing lines, positioning, and bathing all come after that confirmation.

An LPN/VN is preparing a client for sleep. Which measure promotes rest?

• a.Offer a caffeinated beverage in the early evening
• b.Encourage a two-hour nap in the late afternoon
• c.Cluster care so the client has uninterrupted time✓
• d.Keep the overhead lights on for safety checks

Grouping care allows longer uninterrupted sleep cycles. Evening caffeine, bright overhead light, and long late naps all interfere with sleep onset and continuity.

An LPN/VN is assisting a client with a bed bath. Which action is correct?

• a.Wash from the inner to the outer corner of the eye✓
• b.Wash from the outer to the inner corner of the eye
• c.Use soap on the eyelids to remove dried drainage
• d.Use the same section of cloth for both of the eyes

Cleansing from inner to outer canthus moves debris away from the lacrimal duct. Reversing the direction pushes debris into the duct, soap irritates the eye, and reusing the cloth transfers organisms between eyes.

A client with an ileostomy asks about the expected output. What should the LPN/VN reinforce?

• a.The output becomes formed within a few weeks
• b.The output should be measured only once each day
• c.The output requires irrigation each morning
• d.The output stays loose and is emptied often✓

An ileostomy drains loose stool continuously because the colon is no longer absorbing water, so the pouch is emptied frequently and the output never becomes formed. Formed stool, once-daily measurement, and irrigation apply to a descending or sigmoid colostomy, not an ileostomy.

An LPN/VN is caring for a client who uses a walker. Which observation indicates safe use?

• a.The client steps forward before moving the walker
• b.The client's elbows are slightly bent on the grips✓
• c.The client's arms are fully straight when gripping it
• d.The client lifts the walker with each single step

About 15 to 30 degrees of elbow flexion means the walker height is correct. Fully straight arms mean it is too tall, stepping before advancing it removes the support, and lifting it with every step is unstable for a client who needs one.

An LPN/VN is caring for a client on a bladder management protocol after catheter removal. Which finding should be reported?

• a.Voiding 250 mL four hours after the catheter removal
• b.No voiding eight hours after the catheter was removed✓
• c.Mild burning during the first voiding after removal
• d.A sensation of urgency with the first two voidings

No urine output eight hours after removal suggests retention and requires a bladder scan and further action. An adequate first void, transient urgency, and brief burning are all common after catheter removal.

An LPN/VN is irrigating a client's ear as ordered. Which action is correct?

• a.Direct the solution toward the wall of the ear canal✓
• b.Direct the solution straight at the tympanic membrane
• c.Occlude the canal with the syringe tip during flow
• d.Use a solution taken directly from the refrigerator

Aiming at the canal wall lets solution flow around and out, carrying debris with it. Direct pressure on the eardrum can rupture it, cold solution causes vertigo, and occluding the canal traps pressure inside.

An LPN/VN is assisting an immobilized client to prevent complications. Which measure prevents venous stasis?

• a.Keep the legs crossed at the ankles while in bed
• b.Place a pillow under the knees to support the legs
• c.Massage the calf muscles firmly twice each day
• d.Perform hourly ankle pumping while awake✓

Active ankle movement uses the calf muscle pump to move venous blood. A pillow under the knees and crossed ankles both compress popliteal vessels, and calf massage can dislodge an existing clot.

An LPN/VN is evaluating pain in a client with advanced dementia who cannot report it. Which tool is appropriate?

• a.A numeric rating scale explained slowly to the client
• b.A visual analog line the client marks with a pen
• c.The family member's estimate of the client's pain
• d.A behavioral observation scale validated for dementia✓

A validated behavioral scale scores observed indicators such as breathing, vocalization, and body language. Numeric and visual analog scales require abstraction the client cannot do, and a family estimate is not a validated measure.

An LPN/VN is providing site care for a client's gastrostomy tube. Which finding should be reported?

• a.A small amount of clear drainage at the site
• b.Slight rotation of the external bumper on the tube
• c.Green drainage with redness at the site✓
• d.A healed track with intact skin around the tube

Purulent drainage with erythema suggests infection at the exit site. Scant clear drainage, minor bumper rotation, and intact healed skin are all expected findings.

A client on a mechanical soft diet is served a meal tray. Which item should the LPN/VN remove?

• a.The scrambled eggs served with the meal
• b.The raw carrot and celery sticks✓
• c.The ground meat with gravy on the plate
• d.The canned peaches in the small dish

Raw crisp vegetables require chewing that a mechanical soft diet is designed to avoid. Ground meat, scrambled eggs, and canned fruit all meet the texture requirement.

An LPN/VN uses music therapy with a client who has chronic pain. Which action is appropriate?

• a.Play the unit's usual relaxation recording for all
• b.Use the music instead of the ordered analgesic dose
• c.Play the music at a volume that masks unit noise
• d.Let the client select the music that will be played✓

Client-selected music is what makes the intervention effective. A standard recording ignores preference, substituting music for an ordered analgesic withholds treatment, and loud volume adds a stressor.

An LPN/VN finds a client's intravenous site cool, pale, and swollen with no blood return. What should the LPN/VN do first?

• a.Slow the infusion rate and recheck in an hour
• b.Stop the infusion and remove the catheter✓
• c.Reposition the arm and restart the infusion
• d.Apply a warm compress and continue the infusion

Infiltration is managed by stopping the infusion and removing the catheter, which the 2026 PN test plan lists as an LPN/VN activity. Repositioning and restarting, slowing the rate, and applying heat while the infusion continues all allow more fluid into the tissue.

An LPN/VN is monitoring a client receiving a unit of packed red blood cells. Which finding requires the transfusion to be stopped?

• a.Chills and low back pain fifteen minutes into the unit✓
• b.A brief feeling of coolness from the refrigerated blood
• c.Anxiety about receiving blood from an unknown donor
• d.A temperature rise from 36.8 to 37.0 degrees Celsius

Chills with flank or low back pain early in a transfusion suggests an acute hemolytic reaction, and the transfusion is stopped immediately with the line kept open by normal saline. A 0.2-degree rise, the sensation of cool blood, and anxiety are not transfusion reactions.

An LPN/VN is preparing to collect a clean-catch midstream urine specimen. Which instruction is correct?

• a.Begin voiding, then collect the middle portion✓
• b.Collect the entire voiding in the sterile cup
• c.Collect a specimen from the toilet water bowl
• d.Collect the first portion of the urine stream

The midstream portion is collected after the initial stream has flushed the urethra. The first portion carries periurethral organisms, a whole voiding overflows the cup, and toilet water is contaminated.

An LPN/VN performs a blood glucose check and the result is 48 mg/dL in an alert client. What should the LPN/VN do first?

• a.Recheck the glucose on a second meter
• b.Notify the nursing supervisor of the glucose value
• c.Give the client a peanut butter and cheese snack
• d.Give 15 grams of a fast-acting carbohydrate✓

An alert, hypoglycemic client is treated at once with 15 grams of rapidly absorbed carbohydrate and rechecked in 15 minutes. Reporting first, repeating the test, and offering a protein and fat snack all delay the sugar the client needs now.

An LPN/VN is applying sequential compression devices to a postoperative client. Which action is correct?

• a.Apply the sleeves over the client's knee-high socks
• b.Confirm that two fingers fit under the applied sleeve✓
• c.Apply the sleeves to a leg with a newly reddened calf
• d.Remove the sleeves only during the night sleep hours

A two-finger fit means the sleeve is snug without constricting. Applying over bunched socks creates pressure points, removing them at night defeats their purpose during the least mobile hours, and applying them to a leg with suspected thrombosis can dislodge a clot.

An LPN/VN is performing a venipuncture. How long may the tourniquet remain in place?

• a.Until the site has been cleaned and has dried
• b.Until every tube in the order has been filled
• c.No longer than five minutes
• d.No longer than one minute before the draw✓

A tourniquet left longer than about one minute causes hemoconcentration and alters results. Five minutes, the length of the whole draw, and the cleaning interval all exceed that limit.

An LPN/VN is caring for a client who returned from a cardiac catheterization through the right femoral artery. Which finding requires immediate reporting?

• a.A heart rate of 68 with the client lying flat
• b.A cool right foot with a weak pedal pulse✓
• c.A report of mild aching in the right groin area
• d.A small bruise at the insertion site of the catheter

Coolness with a diminished distal pulse suggests arterial occlusion in the catheterized limb. Bruising, mild groin aching, and a normal heart rate on bed rest are expected after the procedure.

An LPN/VN is monitoring a client after a thyroidectomy. Which finding should be reported immediately?

• a.A small amount of drainage on the dressing
• b.A sore throat when the client swallows fluids
• c.Tingling around the mouth and in the fingers✓
• d.Hoarseness of the voice on the first day

Perioral and fingertip tingling suggests hypocalcemia from parathyroid injury and can progress to tetany and laryngospasm. Sore throat, temporary hoarseness, and scant drainage are expected after this surgery.

An LPN/VN is caring for a client with a new plaster cast on the right forearm. Which finding requires immediate reporting?

• a.An itching sensation under the cast
• b.Slight swelling of the fingers on elevation
• c.Pain that increases despite analgesia✓
• d.Warmth of the cast during the drying period

Escalating pain unrelieved by analgesia is the earliest sign of compartment syndrome. Itching, warmth from the curing plaster, and mild swelling that responds to elevation are all expected.

An LPN/VN is preparing a client for surgery in the morning. Which action reduces postoperative pulmonary complications?

• a.Teach the incentive spirometer before surgery✓
• b.Plan to keep the client on bed rest for two days
• c.Teach the client to breathe rapidly and shallowly
• d.Teach the client to avoid coughing after surgery

Learning the spirometer before surgery, when the client is comfortable and alert, makes postoperative use effective. Avoiding cough, prolonged bed rest, and shallow breathing all promote atelectasis.

An LPN/VN checks a client for urinary retention. Which method gives the most reliable measurement?

• a.The client's report of a full or empty bladder
• b.Palpation of the lower abdomen above the pubis
• c.A bladder scan done after the client voids✓
• d.A record of the volume of the client's last void

A postvoid bladder scan measures residual volume directly and noninvasively. Palpation is imprecise, a voided volume says nothing about what remains, and a client's sensation is unreliable in retention.

An LPN/VN is monitoring nasogastric suction for a client after abdominal surgery. Which finding should be reported?

• a.Green drainage collecting slowly in the canister
• b.Complaints of dryness of the mouth and lips
• c.Bright red blood filling the collection canister✓
• d.Intermittent bubbling in the suction control chamber

Bright red blood in gastric drainage suggests active bleeding and must be reported. Green gastric drainage, expected suction function, and oral dryness are all typical during nasogastric suction.

An LPN/VN is performing neurological checks on a client after a head injury. Which change should be reported immediately?

• a.A blood pressure that has risen by 4 millimeters
• b.A pulse that has changed from 74 to 80 per minute
• c.A report of a mild headache relieved by rest
• d.A pupil that is now larger and reacts sluggishly✓

A newly dilated, sluggish pupil suggests rising intracranial pressure with cranial nerve compression. Small blood pressure and pulse changes and a relieved headache are not signs of deterioration.

An LPN/VN is assisting with a lumbar puncture. How should the client be positioned?

• a.Prone with a pillow placed under the abdomen
• b.Sitting upright with the neck extended backward
• c.Side-lying with the knees drawn up to the chest✓
• d.Supine with the head of the bed fully flat

A side-lying curled position separates the vertebral spaces so the needle can pass. Prone positioning blocks access, supine positioning gives no separation, and neck extension does not affect the lumbar spine.

An LPN/VN is caring for a client with a central venous catheter and notices the cap is off and the line is open to air. What should the LPN/VN do first?

• a.Place a new sterile cap on the open catheter hub
• b.Lower the head of the bed and observe the client
• c.Clamp the catheter close to the insertion site✓
• d.Notify the nursing supervisor about the open line

Clamping stops air entry immediately, which is the danger in an open central line. Reporting, capping before clamping, and repositioning all leave the line open while they are done.

An LPN/VN is collecting a sputum specimen for culture. When should the specimen be collected?

• a.At bedtime after the evening oral care
• b.Immediately after the client finishes breakfast
• c.Early in the morning before the client eats✓
• d.During the afternoon when secretions loosen

An early morning specimen contains overnight secretions and the highest organism yield. Post-meal collection risks emesis and contamination, and afternoon and bedtime specimens are more dilute.

An LPN/VN is applying elastic compression stockings. When should they be applied?

• a.In the evening before the client goes to sleep
• b.After the client has been sitting up for an hour
• c.In the morning before the client gets out of bed✓
• d.After the client has walked in the hallway once

Applying them before the legs become dependent prevents venous pooling. Any application after the client has been upright traps the pooled blood the stockings are meant to prevent.

An LPN/VN is monitoring a client on a continuous cardiac monitor and the tracing shows a flat line. What should the LPN/VN do first?

• a.Check the client for a pulse and responsiveness✓
• b.Notify the nursing supervisor about the tracing
• c.Print the strip and place it in the client's record
• d.Replace the electrodes and reposition the leads

A monitor finding is confirmed at the bedside before anything else, because the client is either in asystole or the leads are loose. Reporting, changing electrodes, and printing all delay identifying an arrest.

An LPN/VN is caring for a client scheduled for a colonoscopy. Which finding indicates the preparation was effective?

• a.The client drank half of the prescribed solution
• b.The client reports feeling hungry now
• c.The client passed three formed stools overnight
• d.The last stool passed was clear yellow liquid✓

Clear liquid effluent shows the bowel is adequately cleansed. Formed stool, partial preparation intake, and hunger do not demonstrate cleansing.

An LPN/VN is performing a circulatory check on a client's leg after a vascular procedure. Which technique is correct?

• a.Assess only the leg that had the procedure done
• b.Compare pulses, color, and warmth to the other leg✓
• c.Ask the client whether the leg feels the same as before
• d.Use a blood pressure cuff to check the leg pulses

Side-to-side comparison identifies changes that a single-limb check misses. Checking only the treated leg, using a cuff instead of palpating pulses, and relying on the client's sensation all miss early arterial compromise.

An LPN/VN is preparing to perform a 12-lead electrocardiogram. Where is lead V1 placed?

• a.At the fourth intercostal space to the left of the sternum
• b.At the fifth intercostal space in the anterior axillary line
• c.At the fifth intercostal space in the midclavicular line
• d.At the fourth intercostal space to the right of the sternum✓

V1 sits at the fourth intercostal space at the right sternal border. The left fourth space is V2, the left fifth midclavicular is V4, and the left fifth anterior axillary is V5.

An LPN/VN reviews a client's laboratory results and finds a potassium level of 2.8 mEq/L. Which finding is consistent with this result?

• a.Increased deep tendon reflexes with cramping
• b.Muscle weakness with a soft, distended abdomen✓
• c.Muscle spasm with a positive Chvostek sign
• d.Numbness of the lips with muscle twitching

Hypokalemia produces skeletal muscle weakness and decreased gastrointestinal motility. Chvostek sign, perioral numbness with twitching, and hyperreflexia all reflect hypocalcemia rather than low potassium.

An LPN/VN is monitoring a client with a peripheral intravenous catheter and finds the vein red, warm, and firm along its course. What should the LPN/VN do?

• a.Flush the catheter with saline to test the patency
• b.Apply a cold pack and leave the catheter in place
• c.Discontinue the infusion and remove the catheter✓
• d.Reduce the infusion rate and continue the therapy

A red, warm, cordlike vein is phlebitis, and the catheter is removed. Slowing the rate, cooling the site, and flushing all continue to expose the inflamed vein.

An LPN/VN is preparing to insert an indwelling urinary catheter in a female client. Which action maintains sterile technique?

• a.Hold the labia apart until the catheter is inserted✓
• b.Release the labia to reach for the lubricated catheter
• c.Use the dominant hand to hold the labia apart
• d.Reposition the client after the field has been opened

The hand separating the labia becomes contaminated and must not move until the catheter is in place. Releasing the labia recontaminates the meatus, holding with the dominant hand contaminates the insertion hand, and repositioning disturbs the field.

An LPN/VN measures a client's orthostatic vital signs. Which result indicates orthostatic hypotension?

• a.A pulse increase of 8 beats per minute on standing
• b.A diastolic drop of 6 millimeters of mercury on standing
• c.A systolic drop of 8 millimeters of mercury on standing
• d.A systolic drop of 24 millimeters of mercury on standing✓

Orthostatic hypotension is a fall of at least 20 mmHg systolic or 10 mmHg diastolic within three minutes of standing. Drops of 8 and 6 mmHg and a rise of 8 beats per minute are all within normal variation.

An LPN/VN is reinforcing education before a client's magnetic resonance imaging study. Which client statement requires follow-up?

• a.I still have my pacemaker from last year✓
• b.I can ask for earplugs during the loud scan
• c.I will need to lie still for the whole study
• d.I removed my watch and my wedding ring

An implanted pacemaker may be a contraindication and must be reported before the study. Lying still, noise protection, and removing metal objects are all correct understandings.

An LPN/VN is monitoring a client after a paracentesis. Which finding should be reported immediately?

• a.A weight that is 3 kilograms lower than before
• b.A report of relief from the abdominal pressure
• c.A small amount of fluid at the site
• d.A pulse of 124 with a falling blood pressure✓

Tachycardia with hypotension after fluid removal suggests hypovolemia or bleeding. Minor site leakage, symptom relief, and weight loss matching the volume removed are all expected.

An LPN/VN is caring for a client whose only working glucometer on the unit has failed its quality control check. What should the LPN/VN do?

• a.Borrow a client's personal meter from the bedside
• b.Delay the glucose checks until the next work shift
• c.Use the failed meter and note the result
• d.Ask the nursing supervisor for a working meter✓

A device that fails quality control is removed from use and replacement equipment is arranged through the chain of command. Using it anyway, borrowing an uncalibrated personal device, and skipping ordered checks all produce unsafe glucose management.

An LPN/VN finds an unresponsive adult client with no normal breathing and no pulse. At what rate should chest compressions be delivered?

• a.80 to 100 compressions each minute
• b.100 to 120 compressions each minute✓
• c.130 to 150 compressions each minute
• d.60 to 80 compressions each minute

Current resuscitation guidelines specify a compression rate of 100 to 120 per minute for adults. Slower rates deliver inadequate perfusion, and rates above 120 shorten filling time between compressions.

An LPN/VN is performing chest compressions on an adult during a cardiac arrest. How deep should each compression be?

• a.At least 2 inches, about 5 centimeters✓
• b.At least half the depth of the chest wall
• c.At least 1 inch, about 2.5 centimeters
• d.At least 3 inches, about 7.5 centimeters

Adult compressions are at least 2 inches deep and not more than about 2.4 inches. One inch is too shallow to generate flow, 3 inches exceeds the safe range, and half the chest depth is the pediatric guideline of about one third.

An LPN/VN is giving CPR alone to an adult before a defibrillator arrives. What compression to ventilation ratio should be used?

• a.10 compressions to 2 breaths
• b.15 compressions to 2 breaths
• c.5 compressions to 1 breath
• d.30 compressions to 2 breaths✓

A single rescuer without an advanced airway uses 30 compressions to 2 breaths in an adult. Fifteen to two is the two-rescuer pediatric ratio, and the other ratios are not used in current practice.

An LPN/VN is suctioning a client's tracheostomy. How long should each suction pass last?

• a.No longer than 40 to 45 seconds
• b.Until the secretions have all cleared
• c.No longer than 25 to 30 seconds
• d.No longer than 10 to 15 seconds✓

Each pass is limited to 10 to 15 seconds because suction removes oxygen along with secretions. Longer passes and suctioning until clear both cause hypoxemia and can trigger bradycardia.

An LPN/VN is suctioning a client's tracheostomy. When should suction be applied?

• a.Continuously from insertion until removal
• b.While advancing the catheter into the airway
• c.Only after the catheter reaches the carina
• d.While withdrawing and rotating the catheter✓

Suction is applied on withdrawal to limit hypoxemia and mucosal injury. Applying it on insertion or continuously damages tissue, and advancing to the carina causes trauma and bradycardia.

An LPN/VN finds a client's chest tube disconnected from the drainage system. What should the LPN/VN do first?

• a.Notify the nursing supervisor that the tube came apart
• b.Tape the two ends together and check for bubbling
• c.Clamp the chest tube close to the chest wall
• d.Place the open end in sterile water at the bedside✓

Submerging the end creates a temporary water seal that stops air from entering the pleural space. Reporting, clamping, and reconnecting a contaminated end all risk a tension pneumothorax or infection.

An LPN/VN is caring for a client with a chest tube and observes continuous bubbling in the water seal chamber. What does this indicate?

• a.Obstruction of the tubing by a clot or debris
• b.An air leak in the system or the client✓
• c.Full reexpansion of the client's collapsed lung
• d.Normal function of the chest drainage system

Continuous bubbling in the water seal chamber signals an air leak that must be located. Intermittent bubbling with exhalation is normal, reexpansion produces no bubbling and no tidaling, and obstruction stops both bubbling and tidaling.

An LPN/VN is caring for a client receiving peritoneal dialysis and notes that the drained effluent is cloudy. What should the LPN/VN do?

• a.Record the finding and complete the next exchange
• b.Increase the dwell time for the next exchange
• c.Warm the next dialysate bag before instilling it
• d.Report the cloudy effluent to the registered nurse✓

Cloudy effluent is the classic early sign of peritonitis and must be reported so a specimen can be obtained and treatment started. Changing the dwell, warming the solution, and simply documenting all allow an infection to progress.

An LPN/VN is caring for a client with an arteriovenous fistula in the left arm. Which action is correct?

• a.Draw the morning blood work from the fistula
• b.Start an intravenous line in the left forearm
• c.Take blood pressures in the client's left arm
• d.Take blood pressures in the client's right arm✓

The fistula arm is protected from compression and punctures so the access stays patent. Cuff pressure, an intravenous start, and a venipuncture in that arm can all thrombose the access.

An LPN/VN checks a client's arteriovenous fistula and finds no thrill on palpation. What should the LPN/VN do?

• a.Document the finding and check again before dialysis
• b.Report the absent thrill to the nurse at once✓
• c.Apply a warm compress and recheck in one hour
• d.Elevate the arm on a pillow and observe the site

A missing thrill suggests the access has clotted, which is a time-sensitive problem. Warm compresses, elevation, and delayed rechecks all consume the time in which the access might be salvaged.

An LPN/VN is caring for a client with a Jackson-Pratt drain. How is suction maintained?

• a.Clamp the drain tubing between the emptying times
• b.Compress the bulb before recapping it each time✓
• c.Attach the bulb to low continuous wall suction
• d.Leave the bulb expanded so drainage flows freely

Squeezing the bulb before recapping creates the negative pressure that pulls drainage. Wall suction is not used, an expanded bulb exerts no suction, and clamping stops drainage altogether.

An LPN/VN is caring for a client whose surgical wound edges have separated with a loop of bowel visible. What should the LPN/VN do first?

• a.Apply a dry pressure dressing over the open area
• b.Cover the area with sterile saline-moistened gauze✓
• c.Notify the nursing supervisor about the open wound
• d.Push the exposed tissue gently back into the wound

Evisceration is covered with sterile moist gauze to keep the tissue viable while help is summoned and the client is kept still. Reporting first, replacing the tissue, and drying the exposed bowel all cause harm.

An LPN/VN is caring for a client with a tracheostomy who suddenly becomes restless with noisy breathing. What should the LPN/VN do first?

• a.Suction the tracheostomy to clear the airway✓
• b.Notify the registered nurse about the restlessness
• c.Raise the head of the bed and observe the client
• d.Increase the oxygen flow rate through the collar

Noisy breathing with restlessness in a client with a tracheostomy usually means secretions are obstructing the airway, and suctioning is within LPN/VN scope. Reporting, adding oxygen past an obstruction, and repositioning all leave the airway blocked.

An LPN/VN is caring for a client whose temperature is 35.1 degrees Celsius after surgery. Which measure should the LPN/VN use?

• a.Apply warmed blankets and cover the client's head✓
• b.Rub the client's arms and legs briskly with a towel
• c.Give a hot beverage while the client is still drowsy
• d.Place a heating pad on high under the client

Passive external warming with warmed blankets and head covering restores temperature safely. Vigorous rubbing can trigger arrhythmias, a heating pad under a client causes burns, and oral fluids are unsafe in a drowsy client.

An LPN/VN is performing a dressing change on a wound ordered to be packed. Which action is correct?

• a.Place a single large piece across the wound top
• b.Fill the cavity level with the surrounding skin
• c.Pack the gauze tightly into the cavity
• d.Pack the gauze loosely into the wound cavity✓

Loose packing keeps the cavity open for drainage without pressure on the wound bed. Tight packing impairs perfusion, filling level with the skin macerates the edges, and a cover piece does not pack the cavity.

An LPN/VN is caring for a client with a colostomy in the descending colon. Which stoma finding should be reported?

• a.A stoma that has become dusky purple in color✓
• b.A stoma that is pink and moist at the surface
• c.Slight swelling of the stoma in the first days
• d.A small amount of bleeding when it is cleaned

A dusky or purple stoma indicates impaired blood supply and possible necrosis. A pink moist stoma, minor bleeding from the vascular mucosa during cleaning, and early edema are all expected.

An LPN/VN is caring for a client on a ventilator and the high pressure alarm sounds. What is the most likely cause?

• a.An increase in the client's tidal volume
• b.Secretions obstructing the client's airway✓
• c.A leak around the endotracheal tube cuff
• d.A disconnection of the ventilator circuit

A high pressure alarm means resistance has increased, most often from secretions, biting, or a kink. A disconnection, a cuff leak, and a larger delivered volume all lower circuit pressure and trigger the low pressure alarm.

An LPN/VN is caring for a client with a permanent pacemaker. Which finding should be reported?

• a.A pulse of 48 with reports of light-headedness✓
• b.A pulse of 72 that is regular at rest
• c.A small bruise under the skin near the device
• d.Mild soreness at the insertion site on day one

A rate below the pacemaker's set rate with symptoms suggests the device is not capturing. A normal paced rate, early incisional soreness, and a small hematoma are expected findings.

An LPN/VN observes a client's cardiac monitor and sees a chaotic waveform with no identifiable complexes. The client is unresponsive. What should the LPN/VN do first?

• a.Obtain a full set of vital signs and a rhythm strip
• b.Check the electrodes and lead connections
• c.Start compressions and call for the defibrillator✓
• d.Notify the nursing supervisor about the rhythm change

An unresponsive client with a chaotic rhythm is in ventricular fibrillation and needs compressions and early defibrillation. Reporting, checking leads, and gathering vital signs all delay the only treatments that work.

An LPN/VN is reinforcing education for a client going home with a new tracheostomy. Which instruction should be included?

• a.Swim in a shallow pool with the neck kept above water
• b.Seal the stoma with an adhesive patch when outdoors
• c.Cover the stoma with a loose cloth when going outside✓
• d.Use a cotton ball taped over the stoma while sleeping

A loose breathable cover filters air without blocking it. Sealing the stoma obstructs breathing, swimming risks drowning through the stoma, and cotton fibers can be inhaled into the airway.

An LPN/VN is caring for a client with heart failure. Which finding suggests worsening fluid overload?

• a.A report of thirst after a salty evening meal
• b.A weight gain of 2 kilograms since yesterday✓
• c.Ankle swelling that resolves with overnight rest
• d.A weight gain of 2 kilograms over two months

Rapid weight gain of about 2 kilograms in a day reflects retained fluid, not tissue. Slow gain, dependent edema that clears overnight, and thirst after salt are not signs of decompensation.

An LPN/VN is caring for a client with chronic obstructive pulmonary disease who is receiving oxygen at 2 liters per minute by nasal cannula. The client reports increased breathlessness. What should the LPN/VN do first?

• a.Notify the nursing supervisor about the breathlessness
• b.Ask the client to breathe through the mouth
• c.Increase the oxygen flow rate to 6 liters per minute
• d.Raise the head of the bed and check the saturation✓

Positioning to ease the work of breathing and measuring the saturation are immediate LPN/VN actions that also produce the data any next step needs. Reporting first, raising the flow without an order, and rapid mouth breathing all fail the client.

An LPN/VN is removing skin staples from a healed surgical incision as ordered. Which finding should stop the procedure?

• a.A small amount of serous fluid appears at one end
• b.The incision line looks pink along its full length
• c.The wound edges separate as staples come out✓
• d.The client reports a pinching feeling with removal

Separation of the wound edges means the incision is not strong enough, and the remaining staples stay in place while the finding is reported. A pink line, a pinching sensation, and scant serous fluid are all expected.

An LPN/VN is caring for a client with a serum sodium of 122 mEq/L. Which finding should the LPN/VN expect?

• a.Extreme thirst with dry, sticky mucous membranes
• b.Increased urine output with a high specific gravity
• c.Flushed dry skin with a low-grade fever
• d.Confusion with muscle weakness and headache✓

Hyponatremia causes cerebral cell swelling, producing confusion, weakness, and headache. Intense thirst with dry membranes, flushed skin with fever, and concentrated high-volume urine all point toward hypernatremia or dehydration instead.

An LPN/VN is providing care for a client receiving hemodialysis three times weekly. Which food choice on the tray should be replaced?

• a.The baked potato served with the dinner✓
• b.The serving of applesauce with the meal
• c.The slice of white bread with the meal
• d.The white rice served with the dinner meal

Potatoes are high in potassium, which a dialysis client cannot excrete between treatments. White rice, white bread, and applesauce are all low in potassium.

An LPN/VN is caring for a client with a wound drainage device and the ordered dressing supplies are not stocked anywhere in the facility. What should the LPN/VN do?

• a.Delay the dressing change until the next work shift
• b.Reuse the outer layer of the current dressing again
• c.Ask the nursing supervisor to obtain the supplies✓
• d.Substitute the closest dressing available on the unit

When ordered supplies are unavailable facility-wide, the chain of command arranges procurement. Substituting a different product, postponing ordered care, and reusing a soiled dressing all change the treatment without authority.

An LPN/VN is caring for a client with a nasogastric tube who begins coughing and has a drop in oxygen saturation during a feeding. What should the LPN/VN do first?

• a.Stop the feeding and raise the head of the bed✓
• b.Notify the nursing supervisor about the coughing
• c.Slow the feeding rate and continue to observe
• d.Flush the tube with water to confirm patency

Stopping the infusion and elevating the head are the immediate actions that limit aspiration. Reporting, flushing, and slowing the rate all continue delivering formula into a possibly compromised airway.

An LPN/VN is reinforcing education with a client who has a new ileal conduit. Which statement indicates correct understanding?

• a.I will limit my fluids to reduce the output
• b.I will empty the pouch when it is one-third full✓
• c.I will change the pouch late in the evening
• d.I will expect the urine to be free of mucus

Emptying at one-third full protects the seal from the weight of urine. Pouch changes are easiest when output is lowest in the morning, fluids are encouraged to flush the conduit, and mucus in the urine is expected because bowel tissue produces it.