NCLEX-PN

Explanation: The correct answer is (C). Numbness and tingling in a limb raise concerns about compromised circulation or nerve function, potentially indicating compartment syndrome related to the cast or surgery. This situation demands urgent attention and reporting to the primary healthcare provider (PHCP). (A) is not correct as addressing discomfort and obstruction related to an NG tube, while important, does not take precedence over the symptoms described in (C). (B) is also incorrect, as bladder spasms and blood in the foley bag are common postoperative occurrences after a prostatectomy and are expected in the early postoperative period. (D) is not correct since symptoms related to hepatitis A, such as stomach pain and itchy skin, are important but do not necessitate the same immediate attention as the potential neurological concerns and post-operative complications described in the other options. (See Prioritization ) 7. A client receiving a blood transfusion experiences a hemolytic reaction. Which finding will the LPN expect when assessing this client?

A.​ Hypotension, backache, low back pain, fever. B.​ Wet breath sounds, severe shortness of breath. C.​ Chills and fever occurred about an hour after the infusion started. D.​ Urticaria, itching, respiratory distress. Correct Response: A

Explanation: The correct answer is (A) as it accurately identifies the signs and symptoms of a hemolytic reaction, including chills, headache, backache, and dyspnea. In contrast, (B) incorrectly associates wet breath sounds and severe shortness of breath with circulatory overload. (C) is also incorrect because chills and fever about 1 hour after the infusion indicate a febrile or pyrogenic reaction. Similarly, (D) is inaccurate as it suggests that urticaria, itching, and respiratory distress indicate an allergic reaction. (See Addressing Blood Transfusion Complications ) 8. The LPN is assisting a physician at the client's bedside with inserting a chest tube. What is the most important intervention by the LPN? A.​ Keep a sterile field B.​ Make sure the client is comfortable C.​ Make sure the client is still D.​ Have all supplies ready when the physician arrives. Correct Response: A Explanation: The correct answer is (A) , as the LPN's paramount intervention during the chest tube insertion is to maintain a sterile field. This is crucial because the central line, which is a type of IV, will be inserted with its tip resting in the client's heart. Therefore, it is imperative that the procedure is conducted in a sterile environment to prevent infections. While ensuring client comfort and stillness is important, especially in the context of a chest tube insertion, the priority in this situation is maintaining a sterile field to minimize the risk of infection. The LPN should collaborate with another team member, such as a second LPN, to address client comfort and stability while focusing on the sterile field during the procedure. (B) and (C) , which involve ensuring client comfort and stillness, are important aspects of client care but are secondary to the critical need for a sterile environment during the insertion of the

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