NCLEX-PN

E.​ Use alternative voiding methods

Correct Response: A, C, E Explanation : LPNs are responsible for assessing and managing alterations in elimination, providing skin care for incontinent clients, and evaluating restoration/maintenance of elimination. Performing blood transfusions and administering anesthesia are generally beyond the scope of practice for LPNs. (See Urinary and Bladder Elimination ) 7.​ As the nurse in an ambulatory care area, you see a new client enter with a cane that appears too short for the client. What should you do? A.​ Place the client in a wheelchair to protect their safety in the clinic

B.​ Remove the cane from the client to protect their safety C.​ Teach the client about the proper length of a cane D.​ Have the client use a wheelchair rather than a cane Correct Response: C

Explanation: The proper length of the cane should be the length that only permits the client’s elbow to be slightly flexed. Some canes, like a wooden cane, are not adjustable to the client’s height, and others can be adjusted to meet the height needs of the client. You would not place the client in a wheelchair or ask the client to use a wheelchair, and you would also not take the cane, which is their personal property, away from them. You would use this observation as a learning need assessment, and, as such, you should teach the client about the proper length of a cane and help them adjust the height of the cane if the client’s cane is a height-adjustable one. (See Assessing the client's Use of Assistive Devices ) 8.​ Which of the following impacts the client’s preferences in terms of hygiene routines and

practices? A.​ Culture B.​ Locus of control C.​ Bodily surface area D.​ Diaphoresis

Correct Response: A Explanation: There are a wide variety of different factors that influence and impact our clients’ hygiene habits and routines. For example, cultural practices and beliefs, ethical factors, religious practices and beliefs, and the client’s level of growth and development Although the locus of control, bodily surface area, and diaphoresis, in addition to other factors such as economic constraints, the client’s level of energy, the client’s level of cognition, and environmental factors can impact on hygiene, these are not factors that impact the client’s hygiene and hygiene practices; they do not typically impact the lifelong development of hygiene and hygiene practices. (See Assessing Clients' Personal Hygiene Habits and Routines )

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