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Question 1 of 5

A very tall, heavy-set man is admitted. The nurse is taking vital signs. Which statement is correct concerning taking the blood pressure?

Correct Answer: C

Rationale: An extra-large cuff ensures accurate blood pressure measurement in large individuals; a standard cuff falsely elevates readings. Adjusting readings or lying down is unnecessary.

Question 2 of 5

A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse?

Correct Answer: A

Rationale: In asthma, the airways are narrowed, creating difficulty getting air in. A wheezing sound results.

Question 3 of 5

The nurse administers subcutaneous insulin lispro at 0730 to a client as prescribed and the client consumes breakfast 30 minutes later. At what time is the client at highest risk for experiencing insulin-related hypoglycemia?

Correct Answer: B

Rationale: Insulin lispro peaks 1-2 hours after administration, so 1100 (
B), about 3.5 hours post-injection, is the highest risk time for hypoglycemia.

Question 4 of 5

All of the following clients assigned to LPN/LVN ring their call bells. Which client needs the most immediate attention?

Correct Answer: C

Rationale: Chest pain during a blood transfusion suggests a possible transfusion reaction, a life-threatening emergency requiring immediate intervention. Bathroom needs, arthritis pain, or postoperative pain are less urgent.

Question 5 of 5

The clinic nurse evaluates a client who was prescribed lithium therapy a month ago for bipolar disorder. Which client statement would cause the most concern?

Correct Answer: C

Rationale: Stomach flu (
C) can cause dehydration, increasing lithium toxicity risk, requiring immediate concern. Naps (
A), weight gain (
B), and dry mouth (
D) are less urgent side effects.

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A client is being discharged after having a coronary artery bypass grafting x5. The client asks questions about the care of chest and leg incisions. Which instructions should the nurse reinforce? Select all that apply.
The nurse is caring for a client who had a chest tube inserted and attached to portable water seal drainage two days ago. There is no bubbling in the water seal chamber. What should the nurse assess initially?
The nurse is caring for a client who has bacterial meningitis. Which of the following actions should the nurse take? Select all that apply.
A client diagnosed with cirrhosis is experiencing pruritus. Which strategies are appropriate for the nurse to teach the client to promote comfort and skin integrity? Select all that apply.

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