NCLEX LPN Physiological Adaptation 1 Exam Prep Questions And Answers
(202472025)
The LPN/LVN knows that which of the following laboratory findings reflects the signs and
symptoms of infection?
1. Serum creatinine level of 2.4 mg/dL.
2. AST (SGOT) 15 U/L.
3. White blood cell count of 16,000/mm3.
4. White blood cell count of 4,000/mm3. - ✔✔Strategy: Think about each answer.
(1)measures renal function; normal is 0.5 to 1.5 mg/dL; elevated in acute and chronic renal failure
(2)measures damage to liver and heart; normal is 10 to 40 U/L
(3)CORRECT—normal range is 4,500 to 11,000/mm3; elevation indicates infection
(4)indicates client becoming immunosuppressed
The nurse cares for a client diagnosed with spinal cord injury at the level of T1. The nurse notes
profuse sweating, and the client complains of a pounding headache and nasal stuffiness. Arrange
the following actions in the proper sequence from FIRST to LAST. All options must be used
immediately.
Instruct the client about how to prevent autonomic dysreflexia: instruct about signs/symptoms and
causes (full bladder, impaction, pressure on skin, cool draft)
Place the client in a sitting position: lowers blood pressure immediately
Check the Foley catheter tubing for kinks or obstruction: most common cause is distended bladder
or constipation
,Label the chart with a visible note about the risk for autonomic dysreflexia: ensures that staff is
aware of risk
Monitor the blood pressure every 10-15 minutes: if emptying the bladder or removing the fecal
mass does not decrease blood pressure, hydralazine hydrochloride (Apres - ✔✔Strategy:
Determine how best to decrease client's blood pressure.
(1) Place the client in a sitting position: lowers blood pressure immediately
(2) Check the Foley catheter tubing for kinks or obstruction: most common cause is distended
bladder or constipation
(3) Monitor the blood pressure every 10-15 minutes: if emptying the bladder or removing the fecal
mass does not decrease blood pressure, hydralazine hydrochloride (Apresoline) is administered IV
(4) Label the chart with a visible note about the risk for autonomic dysreflexia: ensures that staff
is aware of risk
(5) Instruct the client about how to prevent autonomic dysreflexia: instruct about signs/symptoms
and causes (full bladder, impaction, pressure on skin, cool draft)
To measure the pulse during adult cardiopulmonary resuscitation (CPR), the LPN/LVN should use
which of the following arteries?
1. The femoral artery.
2. The radial artery.
3. The carotid artery.
4. The brachial artery. - ✔✔Strategy: Think about the location of each artery.
(1) located below inguinal ligament, midway between symphysis pubis and anterior superior iliac
spine; assess status of circulation to leg
, (2) found on thumb side of forearm at wrist; used to assess peripheral pulse
(3) CORRECT—carotid artery is most accessible; if there is a weak pulse, it will most likely be
felt in the carotid artery
(4) found in groove between biceps and triceps muscles at antecubital fossa; used if performing
CPR on infant
The nurse enters the client's room during a blood transfusion. The LPN/LVN should attend to
which of the following sign/symptom FIRST?
1. Blood pressure 145/80 mm Hg.
2. The client complains of shortness of breath.
3. The client complains of pruritus.
4. Hemoglobinuria. - ✔✔Strategy: "FIRST" indicates priority.
(1) transfusion reactions usually cause hypotension; borderline systolic elevation is considered to
be related to psychological stress
(2) CORRECT—dyspnea may indicate an allergic reaction with a decrease in caliber of the
trachea, which signals an immediate life-threatening risk to the client's health; may also indicate
circulatory overload; place client in upright position, stop the transfusion, keep IV patent with very
slow infusion of IV normal saline
(3) indicates allergic reaction, but not immediately life-threatening
(4) hemoglobin is excreted in the urine and indicates hemolytic reaction caused by ABO
incompatibility; is extremely life-threatening but the dyspnea needs to be addressed FIRST
The LPN/LVN understands that psoriasis is which of the following?
(202472025)
The LPN/LVN knows that which of the following laboratory findings reflects the signs and
symptoms of infection?
1. Serum creatinine level of 2.4 mg/dL.
2. AST (SGOT) 15 U/L.
3. White blood cell count of 16,000/mm3.
4. White blood cell count of 4,000/mm3. - ✔✔Strategy: Think about each answer.
(1)measures renal function; normal is 0.5 to 1.5 mg/dL; elevated in acute and chronic renal failure
(2)measures damage to liver and heart; normal is 10 to 40 U/L
(3)CORRECT—normal range is 4,500 to 11,000/mm3; elevation indicates infection
(4)indicates client becoming immunosuppressed
The nurse cares for a client diagnosed with spinal cord injury at the level of T1. The nurse notes
profuse sweating, and the client complains of a pounding headache and nasal stuffiness. Arrange
the following actions in the proper sequence from FIRST to LAST. All options must be used
immediately.
Instruct the client about how to prevent autonomic dysreflexia: instruct about signs/symptoms and
causes (full bladder, impaction, pressure on skin, cool draft)
Place the client in a sitting position: lowers blood pressure immediately
Check the Foley catheter tubing for kinks or obstruction: most common cause is distended bladder
or constipation
,Label the chart with a visible note about the risk for autonomic dysreflexia: ensures that staff is
aware of risk
Monitor the blood pressure every 10-15 minutes: if emptying the bladder or removing the fecal
mass does not decrease blood pressure, hydralazine hydrochloride (Apres - ✔✔Strategy:
Determine how best to decrease client's blood pressure.
(1) Place the client in a sitting position: lowers blood pressure immediately
(2) Check the Foley catheter tubing for kinks or obstruction: most common cause is distended
bladder or constipation
(3) Monitor the blood pressure every 10-15 minutes: if emptying the bladder or removing the fecal
mass does not decrease blood pressure, hydralazine hydrochloride (Apresoline) is administered IV
(4) Label the chart with a visible note about the risk for autonomic dysreflexia: ensures that staff
is aware of risk
(5) Instruct the client about how to prevent autonomic dysreflexia: instruct about signs/symptoms
and causes (full bladder, impaction, pressure on skin, cool draft)
To measure the pulse during adult cardiopulmonary resuscitation (CPR), the LPN/LVN should use
which of the following arteries?
1. The femoral artery.
2. The radial artery.
3. The carotid artery.
4. The brachial artery. - ✔✔Strategy: Think about the location of each artery.
(1) located below inguinal ligament, midway between symphysis pubis and anterior superior iliac
spine; assess status of circulation to leg
, (2) found on thumb side of forearm at wrist; used to assess peripheral pulse
(3) CORRECT—carotid artery is most accessible; if there is a weak pulse, it will most likely be
felt in the carotid artery
(4) found in groove between biceps and triceps muscles at antecubital fossa; used if performing
CPR on infant
The nurse enters the client's room during a blood transfusion. The LPN/LVN should attend to
which of the following sign/symptom FIRST?
1. Blood pressure 145/80 mm Hg.
2. The client complains of shortness of breath.
3. The client complains of pruritus.
4. Hemoglobinuria. - ✔✔Strategy: "FIRST" indicates priority.
(1) transfusion reactions usually cause hypotension; borderline systolic elevation is considered to
be related to psychological stress
(2) CORRECT—dyspnea may indicate an allergic reaction with a decrease in caliber of the
trachea, which signals an immediate life-threatening risk to the client's health; may also indicate
circulatory overload; place client in upright position, stop the transfusion, keep IV patent with very
slow infusion of IV normal saline
(3) indicates allergic reaction, but not immediately life-threatening
(4) hemoglobin is excreted in the urine and indicates hemolytic reaction caused by ABO
incompatibility; is extremely life-threatening but the dyspnea needs to be addressed FIRST
The LPN/LVN understands that psoriasis is which of the following?
