Final Exam- LVN Term 1 UNITEK COLLEGE

Subjective data

What the patient told you.

Objective data

What the nurse can measure

Which of the following are nursing interventions for wound irrigation?

Keep syringe 1 inch above the wound. Clean from least contaminated to most contaminated site. Clean area around the skin with antiseptic swabs first.

Which brain controls the basic vital functions?

Medulla Oblongata in the brainstem

Which hormone acts on kidneys to regulate sodium and potassium levels?

Aldosterone

I stimulate the maturation of lymphocytes into T cells and coordinates immune defenses. What gland am I?

Thymus gland

What does epinephrine and norepinephrine do?

Raise heart rate, vasoconstriction, release glucose reserves, produce adrenal glands, neurotransmitters

Blood is returned to which part of the heart?

Right atrium/superiorvenacava

Oxygenated blood exits through which part of the heart?

Aorta in the left ventricle

Range of motion (ROM)

Move joints smoothly and gently, repeat based on orders, perform to the point of resistance, stop if patient is in pain

What is the BEST method to maintain privacy for a patient when doing a bed bath?

Close the curtains

What enzymes are produced by the pancreas and what are their functions?

amylase ( digest sugars- carbohydrates), trypsin (digest proteins), lipase (digest fat)

What is normal blood pressure?

120/80

What is considered hypotension?

84/58

What is considered prehypertension?

126/78

What is considered stage 1 HTN?

132/80

What is considered stage 2 HTN?

140/98

What is considered HTN crisis?

184/122

A patient weighs 357 lbs, convert to kg (round to the nearest tenth)

162.3 kg (divide by 2.2)

You work as a home health nurse and see a client being abused. You should:

Follow your agency's protocol

The best method to stop the spread of germs is:

hand hygiene

The role of the LVN includes:

The LVN is supervised by an RN or MD, develop the roles of future LVNs, continued education.

A patient with Alzheimer's disease care would include:

providing predictable routines

Delirium includes:

behavior change, new environment can trigger it, it is reversible.

Which of the following statements is false about an aging patient?

Lower blood pressure

Aging patients include symptoms such as:

poor visual acuity, high blood pressure, poor cough reflex, dehydration of intervertebral disc.

Before starting a feeding in the NG tube, what should the LVN do?

Test pH of gastric contents (pH must be 4 or less)

Which foods are appropriate for mechanical soft diet?

Banana, yogurt, milk, eggnog, ice cream, cheese

Hypoxemia is:

low level of oxygen in the blood

Hypoxia is:

deprived of oxygen in the body

Which of the following is appropriate for trach care?

Always secure new ties before removing the old ties

When collecting a urine specimen with a straight catheter, what is appropriate?

Use a sterile specimen container

When collecting a urine specimen with a Foley catheter, what is appropriate?

Collect specimen from catheter port

What organ is pear-shaped and is located under the liver?

Cholecyst (Gallbladder)

What is stored in the gallbladder before it releases into the small intestine?

Bile

The reabsorption of water and solutes during urine formation is called:

Proximal convoluted tubule (PCT)

Major regulator of respiratory activity is the:

PCo2 (partial pressure of carbon dioxide)

What happens to an increase in thoracic volume?

Air moves in and through the respiratory passageways

Decrease in lung volume is due to:

recoil

Hamstring muscles include:

biceps femoris, semitendinosus, semimembranosus

What stimulates bone growth in adults?

Weight bearing exercises

How did Florence Nightingale improve standards for the soldiers from the Crimean War?

Nutritional improvement, improved hygiene, use of new medical equipment, organized record keeping

What is the bottom of Maslow's hierarchy? What does it include?

Physiological needs- human survival, air, water, food, shelter, clothing, warmth, sleep

What are the key points in an enema procedure?

warm water/solution, left Sim's position, insert 4 inches into rectum, lubricate 3-4 inches, have patient hold solution as long as possible or at least 5 minutes

What are the key points in an indwelling catheter?

Time/date of procedure, size of French, response from patient, amount of mL solution of balloon inflated, patient teaching, procedure completed.

When a nurse educator is promoting a "safe hospital environment", what are they preventing?

an injury

What is the correct way of taking a blood pressure?

at heart level, do not cross legs, cuff snug, 2 fingers fit underneath, brachial artery

A patient who has a hx of HTN has recently developed paralysis on one side of the face. What would be the B in SBAR?

Hypertension

The patient mentions that she is nervous. The nurse states "you seem worried about the procedure, what are your concerns?".

This clarification from the patient.

What can help with wound healing?

Vitamin C, Zinc and protein, Vitamin A

What can help with improving nutritional intake for the patient?

Small, frequent meals with snacks

A new admission comes to the facility and is concerned about falling during the night. What should the LVN do?

use a night light

A patient states that, "Am I going to die". You should say:

What makes you feel that way?

What affects older clients and sleep?

Chronic pain and sickness can disturb sleep patterns

You have a patient from a foreign country, what is appropriate?

Address the patient by the name the patient prefers

In the nursing process, the nurse establishes interventions of the care of the patient. Which part is this from?

Planning (ADPIE)

What does ADPIE stand for in the nursing process?

Assessment

Diagnosis

Planning

Implementation

Evaluation

What does SBAR stand for?

Situation

Background

Assessment

Recommendation

Maslow's Hierarchy of Needs Theory

Physiological

Safety

Love/Belonging

Esteem

Self-actualization