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Question 2021Question →

A client returns to the medical-surgical unit immediately after a percutaneous liver biopsy. To minimize the risk of bleeding from the puncture site, which of the following positions should the practical nurse place the client in?

Right side-lying position with a folded towel under the puncture site

Left side-lying position with the knees flexed

Supine position with the head of the bed elevated 45 degrees

Prone position with the arms resting comfortably at the sides

Show answer & explanation

Answer: Right side-lying position with a folded towel under the puncture site

Answer

Right side-lying position with a folded towel under the puncture site

Following a percutaneous liver biopsy, the standard of care is to place the client in a right side-lying position, often with a small pillow or folded towel directly under the puncture site. The liver is a highly vascular organ located on the right side of the body. This specific position strategically uses the client's own body weight to apply direct, continuous pressure to the biopsy site, significantly reducing the risk of postoperative hemorrhage.

Step-by-Step Solution

Identify the anatomical location of the liver and the primary complication associated with a liver biopsy.

The liver is a highly vascular organ located in the right upper quadrant of the abdomen, making hemorrhage the most significant post-procedure risk.

Understanding the anatomy and potential risks dictates the specific nursing interventions required immediately after the procedure.

Determine the optimal client position that minimizes the identified risk.

The client must be placed on their right side to create a tamponade effect.

Placing the client on their right side allows their own body weight to compress the liver against the abdominal wall and mattress, providing direct hemostasis.

Key Concept

Post-procedure positioning for hemostasis

Question 2022Question →

A practical nurse is reviewing the morning data for a client who has been receiving a continuous intravenous heparin infusion for the past four days to treat a deep vein thrombosis. Which finding represents the greatest physiological risk to the client and requires immediate escalation to the registered nurse?

A morning platelet count that has decreased from

210,000/\text{mm}^3

95,000/\text{mm}^3

An activated partial thromboplastin time (aPTT) of

68\text{ seconds}

The presence of multiple small ecchymoses around recent peripheral intravenous puncture sites.

A resting heart rate of

92\text{ beats/min}

with a blood pressure of

116/72\text{ mm Hg}

Show answer & explanation

Answer: A morning platelet count that has decreased from $210,000/\text{mm}^3$ to $95,000/\text{mm}^3$ .

Answer

The morning platelet count that has decreased from

210,000/\text{mm}^3

95,000/\text{mm}^3

The correct answer identifies the significant decrease in the platelet count. A drop in platelets by more than 50% or a decline below

150,000/\text{mm}^3

in a client receiving heparin is a primary indicator of heparin-induced thrombocytopenia (HIT). This paradoxical immune reaction causes widespread microthrombi and severe vascular complications. It requires immediate escalation to the registered nurse so the heparin infusion can be stopped promptly.

Step-by-Step Solution

Identify the primary pharmacological risks associated with continuous intravenous heparin therapy.

The major risks include systemic hemorrhage and a paradoxical immune response known as heparin-induced thrombocytopenia (HIT).

Understanding potential complications dictates which assessment data must be prioritized.

Evaluate the provided assessment and laboratory data against expected therapeutic ranges.

The aPTT of

68\text{ seconds}

is therapeutic. The vital signs are stable. Small ecchymoses are expected side effects. However, the platelet count has dropped by over 50%.

Differentiating between expected therapeutic effects and critical adverse reactions is required to identify the true risk.

Determine which finding necessitates immediate escalation to the registered nurse.

The severe drop in platelets indicates suspected HIT, meaning the heparin must be stopped immediately to prevent life-threatening thrombotic events.

Practical nurses must promptly recognize and report critical laboratory shifts that threaten client safety.

Key Concept

Recognition of Heparin-Induced Thrombocytopenia (HIT)

Estimated Time:1m 30s

Question 2023Question →

A practical nurse (PN) is assisting a facilitator during a community support group for bereaved families. A parent expresses concern about their 16-year-old child following the sudden death of the child's other parent eight months ago. The parent states, "My teenager seemed to have accepted the loss a few months ago, but lately, they are lashing out in anger and refusing to talk. Aren't they supposed to be past the anger stage by now?"

Which response by the PN is most appropriate?

People often cycle back and forth through different emotions of grief over time; it is rarely a straight line.

Since eight months have passed, your child should be firmly in the acceptance stage and moving forward.

It is best not to worry; most teenagers go through angry phases that have nothing to do with grieving.

You should sit down with your teenager tonight and insist they explain exactly why they are angry.

Show answer & explanation

Answer: People often cycle back and forth through different emotions of grief over time; it is rarely a straight line.

Answer

The most appropriate response is to explain that people often cycle back and forth through different emotions of grief over time, as it is rarely a straight line.

The correct response accurately reflects that grief is an individualized, dynamic process rather than a strict sequence of stages. It is normal for individuals, particularly adolescents, to revisit emotions such as anger long after a loss. This response provides necessary education while therapeutically supporting the parent.

Step-by-Step Solution

Analyze the parent's statement and underlying concern.

The parent incorrectly believes that the grief process is a linear timeline and expects their teenager to be permanently in the 'acceptance' stage after eight months.

Identifying the knowledge gap helps determine the most therapeutic and educational response.

Recall the characteristics of normal and complicated grief, particularly in adolescents.

Grief is a highly individualized, dynamic process. Individuals often revisit stages such as anger or denial, especially around milestones, holidays, or subsequent life changes.

Accurate clinical knowledge is required to provide correct reinforcement of teaching to the family.

Evaluate the response options against principles of therapeutic communication.

The correct response addresses the misconception about linear grief stages without being dismissive, giving unwanted advice, or providing false reassurance.

The PN must use communication techniques that encourage coping and provide accurate psychosocial education.

Key Concept

Non-linear progression of the grieving process

Question 2024Question →

A practical nurse (PN) responds to a call light and finds an older adult client with age-related presbycusis and diminished visual acuity attempting to climb over the bed rails. The client, who is currently hospitalized for pneumonia, appears restless and states they need to go look for their spouse. Arrange the following practical nursing actions in the priority order they should be implemented. (Place the highest priority action first.)

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct priority order is to first secure physical safety, then accommodate sensory changes, collect physiological data, provide cognitive reorientation, and finally report the findings.

In an older adult client exhibiting sudden confusion and unsafe behavior, the first priority according to the nursing process and Maslow's Hierarchy of Needs is immediate physical safety (preventing a fall). Next, the nurse must accommodate age-related sensory deficits (presbycusis and vision changes) by improving lighting and communicating clearly, which helps de-escalate the situation. Once the client is safe and calm, the nurse collects physiological data (vital signs and oxygen saturation) to rule out physical causes of delirium, such as hypoxia from pneumonia. After data collection, therapeutic cognitive reorientation can be attempted. Finally, the nurse reports the acute changes and assessment data to the supervising RN for further evaluation and intervention.

Step-by-Step Solution

Secure the client's physical safety.

The client is guided back to a safe position in bed.

Preventing immediate injury or falls is always the first priority when a client is engaged in an unsafe behavior like climbing over bed rails.

Accommodate age-related sensory changes.

Room lights are turned on and the PN speaks directly to the client's face.

Presbycusis and decreased visual acuity exacerbate confusion; maximizing sensory input helps de-escalate the situation and calms the older adult.

Perform focused data collection.

Vital signs and oxygen saturation are obtained.

Acute confusion (delirium) in older adults is frequently a symptom of an underlying physical issue like hypoxia from pneumonia.

Implement cognitive reorientation.

The client is reminded of their location and situation.

Verbal reorientation is therapeutic but requires the client to be physically safe and sensually engaged first to be effective.

Communicate with the healthcare team.

The supervising RN is notified of the acute changes.

The PN must report the findings to ensure the medical plan of care is updated, which is done after the client is safe and initial data is gathered.

Key Concept

Prioritization of safety, sensory accommodation, and physiological assessment during acute delirium in older adults.

Question 2025Question →

A practical nurse is caring for a client in a rehabilitation facility who is 48 hours postoperative following a right below-the-knee amputation. To prevent flexion contractures, which of the following positioning strategies should the nurse implement?

Place the client in a prone position for 20 to 30 minutes several times a day.

Elevate the residual limb continuously on two pillows while the client is resting in bed.

Encourage the client to sit upright in a bedside chair for the majority of the day.

Maintain the client in a supine position with the knee of the residual limb resting in a flexed state.

Show answer & explanation

Answer: Place the client in a prone position for 20 to 30 minutes several times a day.

Answer

Place the client in a prone position for 20 to 30 minutes several times a day.

Following a lower extremity amputation, placing the client in a prone position for 20 to 30 minutes several times a day is the correct standard of basic care. This specific position extends and stretches the flexor muscles of the hip and knee, preventing the development of flexion contractures. Preventing these contractures is essential because they are a major complication that can permanently inhibit the proper fitting and use of a prosthetic device.

Step-by-Step Solution

Identify the time elapsed since the surgery (48 hours) and the specific complication to prevent (flexion contractures).

After the first 24 postoperative hours, the primary clinical focus shifts from edema prevention to contracture prevention.

Understanding the timeline is critical because basic care and positioning rules for amputations change significantly after the first 24 hours.

Evaluate the anatomical impact of each positioning strategy on the client's hip and knee joints.

Prone positioning physically stretches the hip flexor muscles, preventing them from tightening and shortening.

Flexion contractures can severely impair the client's future ability to be fitted for and successfully use a prosthetic limb.

Key Concept

Postoperative Positioning and Contracture Prevention for Amputations

Question 2026Question →

A practical nurse is collecting data from a 4-year-old child and their caregiver at an outpatient pediatric clinic. The caregiver expresses frustration, stating, "My child insists their stuffed dog is scared of the dark and constantly blames the toy when milk gets spilled." Which of the following statements by the nurse is the most appropriate response?

This is a common developmental stage where children believe inanimate objects have lifelike feelings and qualities.

I will report this to the provider, as children typically outgrow these imaginary beliefs by three years of age.

Why do you think your child is feeling anxious enough to project their own fears onto the stuffed dog?

You should consistently correct this behavior so your child learns to differentiate fantasy from reality.

Show answer & explanation

Answer: This is a common developmental stage where children believe inanimate objects have lifelike feelings and qualities.

Answer

The correct response is to reassure the caregiver that this is a common developmental stage where children believe inanimate objects have lifelike feelings and qualities.

For a 4-year-old preschooler, animism (attributing lifelike qualities to inanimate objects) and magical thinking are expected, normal developmental behaviors. The most appropriate action for the practical nurse is to reassure and educate the caregiver that this is a typical phase, rather than a behavioral problem.

Step-by-Step Solution

Analyze the client's developmental stage.

The child is 4 years old, which places them in the preschool developmental stage.

Different age groups have distinct, expected cognitive and psychosocial milestones.

Evaluate the described behavior.

Believing toys have feelings and blaming them for accidents is recognized as animism and magical thinking.

This confirms whether the behavior is a normal finding or a potential developmental delay.

Determine the appropriate nursing intervention.

The nurse should reinforce teaching with the caregiver that this behavior is expected and normal for a 4-year-old.

Reassuring the caregiver aligns with the practical nurse's role in health promotion and education.

Key Concept

Preschooler Developmental Milestones (Animism and Magical Thinking)

Question 2027Question →

A practical nurse (PN) is assisting with the admission of a client to an inpatient mental health unit. The client is acutely intoxicated with methamphetamine and experiencing paranoid delusions. The client is diaphoretic, pacing rapidly around the dayroom, and stating, "They followed me here, I know they are waiting right outside the window." Which of the following actions should the PN include in the client's immediate care? Select all that apply.

Select all that apply

Monitor the client's vital signs frequently for severe hypertension and tachycardia.

Decrease environmental stimuli by maintaining low unit lighting and minimizing noise.

Stand close to the client to establish trust while explaining that the facility windows are secure.

Request a prescription for mechanical restraints to prevent the pacing client from exhausting themselves.

Provide reassurance by telling the client, "Everything is fine, and no one is going to hurt you here."

Maintain a safe physical distance and ensure a clear exit path during all interactions.

Show answer & explanation

Answer: Monitor the client's vital signs frequently for severe hypertension and tachycardia.; Decrease environmental stimuli by maintaining low unit lighting and minimizing noise.; Maintain a safe physical distance and ensure a clear exit path during all interactions.

Answer

The correct actions include monitoring vital signs frequently for hypertension and tachycardia, decreasing environmental stimuli, and maintaining a safe physical distance with a clear exit path.

Clients experiencing acute methamphetamine intoxication and active paranoia require interventions that prioritize physical safety, physiologic stability, and de-escalation. Frequent vital sign monitoring is critical due to the risk of sympathetic nervous system overstimulation, which can cause hypertensive crisis, severe tachycardia, and hyperthermia. Decreasing environmental stimuli (dimming lights, reducing noise) helps lower sensory overload that feeds paranoid delusions. Furthermore, maintaining a safe physical distance and a clear exit path protects the nurse while preventing the client from feeling trapped, which could otherwise trigger an aggressive 'fight or flight' response.

Step-by-Step Solution

Analyze the client's presentation and substance involved.

The client is intoxicated with methamphetamine (a powerful central nervous system stimulant) and is exhibiting paranoia, agitation (pacing), and sympathetic overactivation (diaphoresis).

Identifying the physiological and psychological effects of the specific substance guides immediate safety and medical priorities.

Determine physiological safety priorities.

Stimulant toxicity carries a high risk of cardiovascular collapse, hypertensive crisis, and hyperthermia, requiring frequent vital sign monitoring.

Airway, breathing, and circulation (including blood pressure and heart rate) remain the highest priority in acute toxicity.

Determine psychological and environmental safety priorities.

The nurse must reduce stimuli to avoid worsening the paranoia, maintain a safe distance so the client does not feel cornered, and avoid arguing with the delusions or offering false reassurance.

Proper de-escalation techniques and environmental management prevent the escalation of agitation into physical violence.

Key Concept

Nursing Management of Acute Stimulant Intoxication and Paranoia

Question 2028Question →

A practical nurse is reviewing the clinical status of a mother-baby dyad on the maternity unit. The client experienced an uncomplicated vaginal delivery at 40 weeks gestation, and the neonate is currently 18 hours old. Which of the following documented findings represents an expected physiological adaptation that the nurse should document without initiating an immediate clinical escalation?

The client experiences episodes of heavy diaphoresis during sleep, with dark red lochia and small, dime-sized clots on the perineal pad.

The neonate displays a sustained resting respiratory rate of 70 breaths per minute accompanied by mild intercostal retractions.

The neonate fails to symmetrically abduct and extend their arms when a loud, unexpected noise occurs in the room.

The client presents with a soft, boggy uterine fundus and reports saturating a thick perineal pad in 40 minutes.

Show answer & explanation

Answer: The client experiences episodes of heavy diaphoresis during sleep, with dark red lochia and small, dime-sized clots on the perineal pad.

Answer

The client experiencing heavy diaphoresis during sleep, with dark red lochia and small, dime-sized clots.

Postpartum diaphoresis is an expected physiological mechanism that allows the body to excrete excess fluid volume accumulated during pregnancy. Additionally, dark red lochia rubra with small (dime-sized) clots is a completely normal finding within the first few days following delivery.

Step-by-Step Solution

Analyze the maternal diaphoresis and lochia characteristics.

Heavy diaphoresis and dark red lochia with dime-sized clots are identified as normal.

Diaphoresis eliminates excess pregnancy fluid, and lochia rubra with very small clots is an expected finding 18 hours postpartum.

Analyze the neonate's respiratory data.

A respiratory rate of 70 breaths per minute with retractions indicates respiratory distress.

Normal neonatal respiratory rate is 30 to 60 breaths per minute; tachypnea and retractions indicate compromised airway/breathing (ABC priority).

Analyze the neonate's neurological data.

The failure to symmetrically extend arms to a loud noise indicates an absent Moro reflex.

An intact, symmetrical Moro (startle) reflex is an expected developmental milestone in a healthy term neonate.

Analyze the maternal fundal and lochia volume data.

A boggy fundus and pad saturation in 40 minutes indicates postpartum hemorrhage.

Normal lochia should not saturate a pad in under an hour, and the fundus must remain firm to prevent excessive bleeding.

Key Concept

Differentiation between normal maternal-newborn physiological adaptations and clinical danger signs

Question 2029Question →

Following a subtotal thyroidectomy, a client is admitted to the medical-surgical floor for postoperative recovery. The practical nurse is implementing non-pharmacological interventions for this client. Which specific actions should be included? Select all that apply.

Select all that apply

Support the client's head and neck with a pillow when assisting with position changes

Keep the client in a flat, supine position while resting to maintain cervical alignment

Apply a prescribed ice collar to the anterior neck area

Instruct the client to perform active neck extension exercises hourly to reduce muscle spasms

Offer small sips of cool water and gentle oral hygiene once the gag reflex is confirmed

Assign the unlicensed assistive personnel (UAP) to perform the initial evaluation of the client's swallowing ability

Show answer & explanation

Answer: Support the client's head and neck with a pillow when assisting with position changes; Apply a prescribed ice collar to the anterior neck area; Offer small sips of cool water and gentle oral hygiene once the gag reflex is confirmed

Answer

The correct interventions are supporting the head and neck during movement, applying an ice collar, and providing cool fluids with oral hygiene after verifying the gag reflex.

Following a thyroidectomy, basic care focuses on minimizing tension on the surgical incision and reducing swelling. Supporting the head and neck prevents strain on the sutures during movement. Applying an ice collar provides localized analgesia and decreases edema that could otherwise threaten the airway. Providing oral care and cool liquids promotes mucosal hydration and comfort without causing the thermal vasodilation that warm liquids might provoke.

Step-by-Step Solution

Analyze the specific physiological risks associated with a thyroidectomy.

The primary concerns are airway compromise from edema and tension on the cervical suture line.

Understanding surgical risks dictates the necessary comfort and safety measures.

Evaluate positioning and mobility interventions against these risks.

The head and neck must be supported during repositioning to prevent strain. A flat position or neck extension is contraindicated.

Proper alignment without tension prevents dehiscence and promotes venous drainage.

Select appropriate localized comfort measures.

An ice collar is indicated to reduce swelling and provide pain relief.

Cold therapy is standard basic care for localized postoperative inflammation.

Determine safe nutritional and hygiene practices.

Providing oral care and cool liquids is safe only after the nurse confirms an intact gag reflex.

Basic care must prioritize aspiration prevention while ensuring hydration.

Key Concept

Postoperative Basic Care and Comfort

Question 2030Question →

A licensed practical nurse (LPN) in a pediatric clinic is reinforcing teaching with the parents of an 8-year-old child whose sibling recently died. Which of the following behaviors or statements by the child should the LPN explain are expected developmental responses to grief for this age group? Select all that apply.

Select all that apply

Asking specific questions about what happens to a person's physical body after they die

Believing that a recent argument magically caused the sibling to die

Displaying sudden aggressive behaviors and experiencing a drop in academic performance

Stating that the sibling is just sleeping and will come back home next week

Expressing intense anxiety and fear that their parents might also become sick and die

Moving rapidly and permanently through the stages of grief without any regression

Show answer & explanation

Answer: Asking specific questions about what happens to a person's physical body after they die; Displaying sudden aggressive behaviors and experiencing a drop in academic performance; Expressing intense anxiety and fear that their parents might also become sick and die

Answer

The expected developmental responses for an 8-year-old include asking specific questions about physical body changes, displaying aggressive behaviors with a drop in academic performance, and expressing fear that their parents might also die.

School-age children (ages 6 to 12) have developed the cognitive ability to understand that death is permanent, irreversible, and universal. Because they recognize the finality of death, they often fear that other loved ones, such as their parents, might also become sick and die. Their growing logical thought process leads to a factual curiosity about the biological and physical aspects of what happens to the body after death. Additionally, children in this age group may have difficulty verbalizing their complex emotions, often expressing their grief through behavioral changes, such as aggression, acting out, or experiencing a sudden decline in academic performance.

Step-by-Step Solution

Identify the developmental stage of the client's child.

The child is 8 years old, which falls into the school-age developmental stage.

Understanding of death evolves with cognitive development, making chronological age a critical factor in assessing normal grief responses.

Recall the characteristics of a school-age child's understanding of death.

School-age children understand that death is permanent, universal, and irreversible. They often display curiosity about the physical aspects of death and may act out their grief behaviorally rather than verbally.

This knowledge allows the nurse to differentiate normal developmental grief from regressive behaviors or prolonged complications.

Evaluate each option against school-age developmental milestones.

Interest in the physical body, fear of others dying, and behavioral changes are expected at this age. Magical thinking and believing death is temporary are preschool concepts.

Selecting the expected behaviors ensures the LPN reinforces accurate, developmentally appropriate information to the grieving parents.

Key Concept

Developmental understanding of grief in school-age children

Estimated Time:1m 30s

Question 2031Question →

An older adult client is admitted to the medical-surgical unit with a severe infection. During the night, the client develops acute confusion and repeatedly attempts to climb out of bed unassisted. The healthcare provider prescribes a vest restraint. Which of the following nursing actions should the practical nurse (PN) implement? (Select all that apply.)

Select all that apply

Secure the restraint straps to the movable portion of the bed frame using a quick-release tie.

Release the restraint at least every 2 hours to provide skin care, toileting, and range-of-motion exercises.

Implement the prescribed restraint immediately before attempting less restrictive safety measures.

Assign the unlicensed assistive personnel (UAP) to independently evaluate the client's respiratory status and skin integrity.

Reassure the client's family that the sudden onset of confusion is a normal part of the aging process that necessitates physical restraint.

Show answer & explanation

Answer: Secure the restraint straps to the movable portion of the bed frame using a quick-release tie.; Release the restraint at least every 2 hours to provide skin care, toileting, and range-of-motion exercises.

Answer

The correct actions are to secure the restraint to the movable portion of the bed frame with a quick-release tie and to release the restraint every 2 hours for care and assessment.

The correct actions involve prioritizing client safety through proper restraint application and routine monitoring. Securing the straps to the movable portion of the bed frame ensures the restraint does not tighten if the head or foot of the bed is adjusted, while a quick-release tie allows for rapid emergency access. Releasing the restraint at least every 2 hours is a mandatory standard of practice to assess skin integrity, perform range-of-motion exercises, and meet basic physiological needs.

Step-by-Step Solution

Analyze the prescribed intervention (vest restraint) and identify safe application techniques.

Recognize that restraints must be tied to the movable bed frame with a quick-release knot.

This prevents patient injury during bed adjustments and allows rapid removal in emergencies.

Determine the required ongoing care and monitoring for a restrained client.

Identify the need to release restraints every 2 hours for skin care, toileting, and range-of-motion.

Regular release prevents complications such as skin breakdown, contractures, and poor circulation.

Evaluate the remaining options against legal and scope-of-practice standards.

Eliminate options that bypass less restrictive alternatives, delegate nursing assessments to UAPs, or mischaracterize acute confusion.

These actions violate the principles of least restrictive care, safe delegation, and accurate clinical knowledge.

Key Concept

Safe application and monitoring of physical restraints, including the mandatory use of least restrictive alternatives and appropriate delegation.

Question 2032Question →

A practical nurse is caring for an Orthodox Jewish client who is observing the Sabbath (Shabbat) and requires assistance with activities of daily living. Knowing that the client's religious practices prohibit the use of electrical devices during this time, which action should the nurse take?

Perform frequent, scheduled rounding to anticipate the client's needs without requiring the use of the electronic call light.

Unwrap and transfer the client's sealed kosher meals onto standard hospital dishware to improve presentation.

Tell the client, 'I understand it is your Sabbath, but why can't you just press the button if you need to use the restroom?'

Explain the clinical risks of refusing the call bell and independently obtain the client's signature on a waiver of liability form.

Show answer & explanation

Answer: Perform frequent, scheduled rounding to anticipate the client's needs without requiring the use of the electronic call light.

Answer

The nurse should perform frequent, scheduled rounding to anticipate the client's needs without requiring the use of the electronic call light.

During the Sabbath (Shabbat), which lasts from sunset on Friday to sunset on Saturday, Orthodox Jewish clients strictly refrain from activities considered 'work', which includes operating electrical devices like televisions, motorized beds, and electronic call lights. Because the client cannot summon help using the standard call bell system for routine needs, the most appropriate and culturally competent nursing action is to perform frequent, scheduled rounding. This proactive approach ensures the client's safety, hygiene, and comfort needs are met without forcing them to compromise their spiritual beliefs.

Step-by-Step Solution

Identify the cultural and religious restrictions of the client during the Sabbath (Shabbat).

The nurse recognizes that Orthodox Jewish clients abstain from using electrical devices, including call lights, from sunset Friday to sunset Saturday.

Understanding specific religious prohibitions is necessary to plan culturally competent care.

Determine how the restriction impacts the client's safety and ability to communicate needs.

The client cannot use the standard electronic call bell to request help for activities of daily living.

Safety is a primary nursing priority, and alternative communication or monitoring methods must be established.

Implement an appropriate nursing intervention that accommodates the belief while maintaining safety.

The nurse initiates frequent, proactive rounding to check on the client.

Frequent rounding ensures the client's needs are met promptly without forcing them to violate their religious principles by operating a device.

Key Concept

Culturally Competent Care: Sabbath Observance

Question 2033Question →

A practical nurse is caring for a pediatric client who weighs $60\text{ lb } 8\text{ oz}$ . The health care provider originally prescribed valproic acid $18\text{ mg/kg/day}$ PO divided into equal doses administered every 8 hours. Due to a recent subtherapeutic serum trough level, the provider wrote a new prescription to increase the client's total daily dose by $25\%$ . The pharmacy dispenses valproic acid oral syrup at a concentration of $250\text{ mg}/5\text{ mL}$ .

How many mL should the practical nurse administer for ONE dose? (Record answer to the nearest tenth. Do not include units in answer.)

Show answer & explanation

Answer: 4.1

Answer

4.1

The correct calculation requires converting the client's weight from pounds and ounces to kilograms, determining the base daily dose, applying a 25% increase, dividing that amount by 3 to account for the every 8-hour schedule, and finally using the pharmacy's supplied concentration to find the liquid volume per dose.

Step-by-Step Solution

Convert the client's weight from pounds and ounces to kilograms.

27.5\text{ kg}

Since 16 ounces equal 1 pound, 8 ounces is 0.5 pounds, making the total weight 60.5 pounds. Dividing by 2.2 lb/kg yields the weight in kilograms (

60.5 \div 2.2 = 27.5

Calculate the baseline total daily dose of valproic acid.

495\text{ mg/day}

Multiply the client's weight in kilograms by the prescribed base rate of

18\text{ mg/kg/day}

(

27.5 \times 18 = 495

Calculate the newly prescribed increased total daily dose.

618.75\text{ mg/day}

The provider increased the dose by

25\%

. Multiply the baseline daily dose by 1.25 (or add

25\%

of 495) to find the new required daily amount (

495 \times 1.25 = 618.75

Determine the amount of medication required for a single dose.

206.25\text{ mg/dose}

The medication is scheduled to be administered every 8 hours, which equals 3 doses per 24-hour period (

24 \div 8 = 3

). Divide the new total daily dose by 3 (

618.75 \div 3 = 206.25

Calculate the volume of oral syrup to administer for one dose.

4.125\text{ mL}

Use the desired over have formula: (Desired / Have) * Volume. The desired dose is

206.25\text{ mg}

, and the supplied concentration is

250\text{ mg}

per

5\text{ mL}

(

(206.25 \div 250) \times 5 = 4.125

Round the final volume to the nearest tenth as instructed.

4.1\text{ mL}

The hundredths place is 2 (which is less than 5), so the tenths place remains unchanged.

Key Concept

Complex pediatric weight-based dosage calculation including percentage adjustments and fractionated daily dosing.

Question 2034Question →

A practical nurse is assisting a client with a meal who is recovering from a recent cerebrovascular accident (CVA). The client has right-sided hemiplegia and has been diagnosed with oropharyngeal dysphagia. The dietary prescription is a pureed diet with honey-thick liquids. Which action should the practical nurse implement to ensure client safety and comfort during the feeding?

Instruct the client to flex the neck and tuck the chin downward toward the chest when swallowing.

Elevate the head of the client's bed to a semi-Fowler's position of 45 degrees before initiating the meal.

Place small spoonfuls of the pureed food directly into the right side of the client's mouth.

Provide a flexible drinking straw to help the client safely consume the honey-thick liquids.

Show answer & explanation

Answer: Instruct the client to flex the neck and tuck the chin downward toward the chest when swallowing.

Answer

The practical nurse should instruct the client to use a chin-tuck maneuver (flexing the neck downward) while swallowing to protect the airway and prevent aspiration.

The chin-tuck maneuver is an evidence-based compensatory strategy for clients with oropharyngeal dysphagia. Flexing the neck and tucking the chin downward before swallowing narrows the laryngeal opening, widens the vallecular space, and pushes the epiglottis backward to protect the airway, significantly reducing the risk of aspiration. This is a primary basic care and comfort priority for stroke recovery.

Step-by-Step Solution

Analyze the client's physiological deficits and risks based on the clinical presentation.

The client has right-sided paralysis and dysphagia, meaning they have impaired swallowing mechanics and a high risk of airway compromise (aspiration).

Identifying the specific impairments dictates which compensatory feeding strategies are required to maintain ABCs (Airway, Breathing, Circulation).

Select the appropriate evidence-based intervention for airway protection during oral intake.

The chin-tuck maneuver is identified as the safest technique, as it anatomically protects the trachea.

Flexing the neck widens the vallecular space and forces the epiglottis backward, mechanically blocking the airway during the swallow.

Key Concept

Dysphagia aspiration precautions and safe feeding techniques

Question 2035Question →

A practical nurse (PN) is planning care for an older adult client who is 4 hours postoperative following a percutaneous endoscopic gastrostomy (PEG) tube placement. The client has right-sided hemiplegia from a previous stroke, is receiving continuous enteral tube feedings, and is experiencing frequent episodes of liquid stool. Which of the following actions should the PN include in the client's plan of care? (Select all that apply.)

Select all that apply

Maintain the head of the bed elevated between 30 and 45 degrees while the enteral feeding is infusing.

Apply a prescribed moisture barrier cream to the perineal area after each episode of liquid stool.

Pause the continuous enteral feeding pump prior to lowering the head of the bed to turn and reposition the client.

Position the client completely flat in a supine position for extended periods to minimize physical tension on the new PEG tube insertion site.

Administer a prescribed PRN opioid analgesic for abdominal discomfort prior to assessing the client's respiratory rate and oxygen saturation.

Apply bilateral soft wrist restraints to protect the PEG tube if the client appears confused and attempts to touch the surgical dressing.

Show answer & explanation

Answer: Maintain the head of the bed elevated between 30 and 45 degrees while the enteral feeding is infusing.; Apply a prescribed moisture barrier cream to the perineal area after each episode of liquid stool.; Pause the continuous enteral feeding pump prior to lowering the head of the bed to turn and reposition the client.

Answer

The correct actions include maintaining the head of the bed elevated at 30 to 45 degrees during feeding, applying a moisture barrier cream after liquid stools, and pausing the feeding pump before lowering the head of the bed for repositioning.

Appropriate basic care for a client receiving continuous enteral nutrition includes keeping the head of the bed elevated between 30 and 45 degrees to prevent aspiration, and strictly pausing the feeding pump whenever the bed must be lowered to reposition the client. Additionally, applying a moisture barrier cream is a fundamental comfort and skin protection measure for clients experiencing frequent liquid stools.

Step-by-Step Solution

Analyze the client's airway and aspiration risks associated with continuous enteral feeding.

Identified that the client requires a 30 to 45-degree head of bed elevation, and that feedings must be paused whenever the bed is lowered.

Enteral formula can easily reflux into the airway if gravity is not utilized, causing aspiration pneumonia.

Evaluate the client's skin integrity risk due to frequent liquid stools.

Determined that perineal skin care with a moisture barrier cream is required.

Liquid stool is highly acidic and caustic to the skin, necessitating immediate and ongoing protective basic care.

Review the incorrect interventions for safety and scope of practice violations.

Eliminated options that violate ABC prioritization (giving opioids before respiratory assessment), bypass restraint alternatives, or position the client dangerously flat during feeding.

Nursing care must prioritize ABCs (Airway, Breathing, Circulation) and adhere strictly to least-restrictive restraint guidelines.

Key Concept

Basic Care and Comfort for Enteral Nutrition and Immobility

Question 2036Question →

A $44\text{-lb}$ pediatric client is receiving care for a respiratory tract infection. The client's pharmacological plan includes scheduled oral amoxicillin at $20\text{ mg/kg}$ per dose and an as-needed intravenous (IV) push antiemetic for nausea. The unit stocks the amoxicillin oral suspension in a concentration of $250\text{ mg}/5\text{ mL}$ . To maintain safety and adhere to the scope of practice, which action is correct for the practical nurse to perform?

Prepare

8\text{ mL}

of the oral amoxicillin suspension and verify two unique client identifiers prior to administration.

Prepare

17.6\text{ mL}

of the oral amoxicillin suspension by calculating the dose directly using the client's weight in pounds.

Administer the prepared oral amoxicillin after using the client's room number and parent's visual recognition as the primary identifiers.

Accept delegation from the registered nurse to administer the intravenous (IV) push antiemetic if the client develops acute nausea.

Show answer & explanation

Answer: Prepare $8\text{ mL}$ of the oral amoxicillin suspension and verify two unique client identifiers prior to administration.

Answer

The correct action is to accurately calculate the amoxicillin dose as 8 mL and ensure two unique client identifiers are verified before administering the medication.

This action demonstrates correct dosage calculation by first converting the client's weight to kilograms (

44 \div 2.2 = 20\text{ kg}

), finding the proper milligram dose (

20 \times 20 = 400\text{ mg}

), and accurately calculating the volume (

400 \div 250 \times 5 = 8\text{ mL}

). Furthermore, it adheres to essential medication safety protocols by appropriately requiring two unique client identifiers prior to oral administration.

Step-by-Step Solution

Convert the client's weight from pounds to kilograms.

44\text{ lb} \div 2.2 = 20\text{ kg}

Weight-based medication dosages must be calculated using kilograms to ensure therapeutic accuracy.

Calculate the required dose in milligrams.

20\text{ kg} \times 20\text{ mg/kg} = 400\text{ mg}

This determines the exact total milligram dose prescribed by the provider.

Calculate the required fluid volume using the supplied concentration.

(400\text{ mg} \div 250\text{ mg}) \times 5\text{ mL} = 8\text{ mL}

This converts the milligram requirement into the correct volume to draw up into the oral syringe.

Identify the correct scope of practice and safety protocols.

The nurse administers the oral medication after checking two identifiers and refuses the IV push delegation.

Practical nurses can safely administer oral medications with proper identification, but administering IV push medications is strictly outside their scope of practice.

Key Concept

Medication Safety, Weight-Based Dosage Calculation, and Practical Nurse Scope of Practice

Question 2037Question →

A practical nurse (PN) is preparing to collect a wound culture specimen from a client's stage 3 pressure injury. In what order should the PN perform the following actions to ensure an accurate specimen and reduce the risk of contamination? Arrange the actions in the correct sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence for obtaining a wound culture is to first remove the soiled dressing, then cleanse the wound with normal saline, next swab the viable tissue, followed by placing the swab in the culture tube, and finally labeling the specimen at the bedside.

Following the correct sequence ensures that the wound culture identifies the actual pathogen causing the infection rather than surface flora, and prevents cross-contamination or misidentification of the specimen.

Step-by-Step Solution

Remove the soiled wound dressing and dispose of it in the appropriate receptacle.

The wound bed is exposed for assessment and collection.

The old dressing contains surface bacteria and exudate that are not representative of the true infection and must be removed first.

Cleanse the wound bed with prescribed sterile normal saline to remove surface exudate.

Surface exudate and colonizing flora are washed away.

Culturing uncleaned exudate often yields colonizing bacteria rather than the pathogen responsible for the tissue infection, which can lead to inappropriate antibiotic therapy.

Rotate the sterile culture swab over an area of clean, viable granulation tissue.

The specimen is collected from actively infected, living tissue.

Pathogens grow best in viable tissue; swabbing slough or necrotic tissue may yield inaccurate diagnostic results.

Insert the swab into the sterile culture tube without touching the outside of the container.

The specimen is secured in the transport medium.

This maintains the sterility of the container's exterior, protecting healthcare workers and laboratory personnel from exposure to the pathogen.

Label the specimen container in the presence of the client before sending it to the laboratory.

The specimen is accurately identified with the correct client information.

Labeling at the bedside immediately after collection eliminates the risk of mixing up specimens and ensures accurate diagnostic reporting.

Key Concept

Wound Culture Specimen Collection Principles

Question 2038Question →

While assisting in a pediatric clinic, a practical nurse observes a two-year-old client in the reception area. Which of the following observed behaviors indicate that the child is meeting expected developmental milestones? Select all that apply.

Select all that apply

Kicking a small ball forward without falling

Hopping on one foot across the room

Playing alongside another child without sharing toys

Drawing a recognizable stick figure of a person

Using two-word or three-word phrases to express needs

Show answer & explanation

Answer: Kicking a small ball forward without falling; Playing alongside another child without sharing toys; Using two-word or three-word phrases to express needs

Answer

The expected developmental behaviors for a two-year-old are kicking a ball forward, engaging in parallel play (playing alongside others without sharing), and using two-word to three-word phrases.

At two years of age (24 months), standard developmental milestones include specific gross motor skills like kicking a ball, language skills such as combining two to three words into short phrases, and psychosocial behaviors like parallel play, where the toddler plays adjacent to others without direct interaction or sharing.

Step-by-Step Solution

Identify the chronological age of the pediatric client.

The client is two years old (24 months).

Developmental milestones are heavily dependent on the specific age and stage of the child.

Evaluate the gross and fine motor skills presented in the options.

Kicking a ball is appropriate. Hopping on one foot and drawing stick figures represent older preschool milestones.

Differentiating between toddler and preschool motor abilities is required to identify normal development.

Assess the psychosocial and language behaviors presented.

Parallel play and short phrases (2-3 words) are expected for this age group.

Validates the normal progression of cognitive and social skills for a toddler.

Key Concept

Expected physical, cognitive, and psychosocial developmental milestones for a toddler.

Question 2039Question →

A practical nurse is reinforcing dietary lifestyle modifications for a client of Orthodox Jewish faith who has newly diagnosed hypertension. The client states, "I want to follow this new low-sodium diet, but it is very difficult to prepare acceptable meals during religious holidays." Which response by the nurse is the most appropriate?

Tell me more about the specific traditional foods you usually prepare during the holidays.

It would be best for you to completely avoid holiday meals until your blood pressure is under control.

You can use the standard hospital low-sodium menu as a guide for your holiday cooking.

I will formulate a comprehensive new care plan to accommodate your specific religious dietary needs.

Show answer & explanation

Answer: Tell me more about the specific traditional foods you usually prepare during the holidays.

Answer

The most appropriate response is to ask the client to tell more about the specific traditional foods they prepare.

The correct response uses a therapeutic communication technique (broad opening and exploring) to gather specific data about the client's cultural lifestyle practices. This allows the healthcare team to understand the client's specific barriers and subsequently reinforce dietary modifications that are both medically appropriate and culturally acceptable.

Step-by-Step Solution

Analyze the client's statement.

The client is expressing difficulty balancing a prescribed lifestyle modification (low-sodium diet) with important cultural and religious practices.

Identifying the core conflict helps determine the most therapeutic and culturally competent intervention.

Evaluate the options based on therapeutic communication principles.

Asking an open-ended question about the traditional foods encourages dialogue, while giving strict advice to avoid the meals is non-therapeutic and dismissive.

Therapeutic communication fosters trust and increases the likelihood of adherence to lifestyle changes.

Evaluate the options based on the practical nurse scope of practice.

The practical nurse can gather specific data about the client's dietary habits to reinforce teaching, but cannot independently formulate a new comprehensive care plan.

Ensuring actions remain within the legal scope of practice is essential for safe client care.

Key Concept

Culturally Competent Lifestyle Modifications

Question 2040Question →

A practical nurse (PN) is reviewing documentation for several clients in a community health setting. Match each client statement or behavior to the corresponding defense mechanism.

Click a left item, then click its matching right item

Show answer & explanation

Answer

The correct matches are: the parking excuse aligns with Rationalization, yelling at the aide aligns with Displacement, expressing extreme joy to mask resentment aligns with Reaction formation, and joining martial arts aligns with Sublimation.

Each scenario accurately illustrates a distinct defense mechanism: rationalization involves making excuses to protect self-esteem, displacement redirects strong emotions to a safer target, reaction formation expresses the exact opposite of true feelings to mask them, and sublimation channels unacceptable impulses into constructive, productive activities.

Step-by-Step Solution

Analyze the first scenario where the client makes excuses about the parking lot.

Matches with rationalization.

The client is using a socially acceptable reason to justify non-compliance with the treatment plan.

Evaluate the second scenario involving the client yelling at the dietary aide.

Matches with displacement.

The client transfers anger from a significant stressor onto a safer, secondary target.

Assess the third scenario where the caregiver expresses extreme joy despite known resentment.

Matches with reaction formation.

The caregiver is displaying outward emotions that directly contradict their true, unacceptable internal feelings.

Examine the fourth scenario regarding the client joining a martial arts program.

Matches with sublimation.

The client is channeling negative energy into a positive, socially acceptable outlet.

Key Concept

Ego Defense Mechanisms

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