LVN Fundamentals 2 Exam Questions and Answers

LVN Fundamentals 2 Exam Questions and Answers A client admitted to the hospital with a diagnosis of malabsorption syndrome exhibits signs of tetany. The nurse concludes that the tetany was precipitated by the inadequate absorption of which electrolyte? 1. Sodium 2. Calcium 3. Potassium 4. Phosphorus - ANSWER Answer: 2. Calcium Reason: The muscle contraction-relaxation cycle requires an adequate serum calciumphosphorus ratio; the reduction of the ionized serum calcium level associated with malabsorption syndrome causes tetany (spastic muscle spasms). Sodium is the major extracellular cation. Sodium's major route of excretion is the kidneys, under the control of aldosterone. Although it plays a part in neuromuscular transmission, potassium is not related to the development of tetany. Potassium is the major intracellular cation. Potassium is part of the sodium-potassium pump and helps to balance the response of nerves to stimulation. Potassium is not related to the development of tetany. Although phosphorus is closely related to calcium because they exist in a specific ratio, phosphorus is not related to the development of tetany. A nurse discusses the philosophy of Alcoholics Anonymous (AA) with the client who has a history of alcoholism. What need must self-help groups such as AA meet to be successful? 1. Trust 2. Growth 3. Belonging 4. Independence - ANSWER Answer: 3. Belonging LVN Fundamentals 2 Exam Questions and Answers Reason: Self-help groups are successful because they support a basic human need for acceptance. A feeling of comfort and safety and a sense of belonging may be achieved in a nonjudgmental, supportive, sharing experience with others. AA meets dependency needs rather than focusing on independence, trust, and growth. A postoperative client says to the nurse, "My neighbor—I mean the person in the next room—sings all night and keeps me awake." The neighboring client has dementia and is awaiting transfer to a nursing home. How can the nurse best handle this situation? 1. Tell the neighboring client to stop singing. 2. Close the doors to both clients' rooms at night. 3. Give the complaining client the prescribed as needed sedative. 4. Move the neighboring client to a room at the end of the hall. - ANSWER Answer: 4. Move the neighboring client to a room at the end of the hall. Reason: Moving the client who is singing away from the other clients diminishes the disturbance. A client with dementia will not remember instructions. It is unsafe to close the doors of clients' rooms because they need to be monitored. The use of a sedative should not be the initial intervention. A nurse is caring for a client who has a Hemovac portable wound suction device after abdominal surgery. What is the reason why the nurse empties the device when it is half full? 1. Emptying the unit is safer when it is half full. 2. Accurate measurement of drainage is facilitated. 3. Negative pressure in the unit lessens as fluid accumulates, interfering with further drainage. 4. Fluid collecting in the unit exerts positive pressure, forcing drainage back up the tubing and into the wound. - ANSWER Answer: 3. Negative pressure in the unit lessens as fluid accumulates, interfering with further drainage Reason: LVN Fundamentals 2 Exam Questions and Answers As drainage collects and occupies space, the original level of negative pressure decreases; the less the negative pressure, the less effective the drainage. A portable wound suction device is easy and safe to empty regardless of the amount of drainage in the unit. Drainage can be measured accurately by the calibrations on the unit or in a calibrated container after emptying. A one-way valve between the tubing and the collection chamber prevents drainage from entering the tubing and causing trauma to the wound. A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcers? 1. Stage I 2. Stage II 3. Stage III 4. Stage IV - ANSWER Answer: 3. Stage III Reason: A pressure ulcer that is full thickness with necrosis and ulceration into the subcutaneous tissue and down to, but not through, the underlying fascia is characteristic of a stage III pressure ulcer. A stage I pressure ulcer is defined as an area of persistent redness with no break in skin integrity. A stage II pressure ulcer is a partial thickness wound with skin loss involving the epidermis, dermis, or both; the ulcer is superficial and may present as an abrasion, blister, or shallow crater. A stage IV pressure ulcer involves full thickness skin loss with extensive damage and tissue necrosis to muscles, support tissues, and bone; undermining and sinus tracts may also be present