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Question 2041Question →

An assigned client with generalized weakness needs to be transferred from the bed to a bedside wheelchair. Arrange the following nursing actions in the correct sequence from first to last.

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Answer

The correct sequence for a bed-to-wheelchair transfer is: position and lock the wheelchair, assist the client to sit on the edge of the bed, apply the transfer belt, and finally pivot the client into the wheelchair.
When transferring a client from a bed to a wheelchair, the nurse must first prioritize environmental safety by placing the wheelchair in the proper position and locking the brakes. Second, the nurse assists the client to sit on the edge of the bed to allow their blood pressure to adjust, reducing the risk of dizziness or fainting. Third, while the client is safely seated, a transfer belt is applied around the waist to provide a secure grip. Finally, the nurse assists the client to stand, bear weight, and pivot safely into the wheelchair.

Step-by-Step Solution

1
Position the wheelchair and lock the brakes.
The wheelchair is secured and ready to receive the client safely.
Preparing the environment prevents the wheelchair from rolling backward during the transfer, averting potential falls.
2
Assist the client to a sitting position on the edge of the bed.
The client is seated with their legs dangling over the side of the mattress.
This allows the client to adjust to an upright position and minimizes the risk of orthostatic hypotension.
3
Apply the transfer belt securely.
The nurse has a safe, designated way to grip and support the client's weight.
A transfer belt protects both the client and the nurse from injury during the weight-bearing and pivot phases.
4
Pivot the client into the wheelchair.
The client is successfully seated in the wheelchair.
This action completes the mobility transfer using safe body mechanics and proper support.

Key Concept

Safe client mobility transfers and prioritization of safety measures.
Question 2042Question →

A practical nurse (PN) is reviewing clinical data for a 74-year-old client who is 12 hours post-operative following an open bowel resection with colostomy placement. The client is receiving continuous intravenous (IV) fluids and pain management via patient-controlled analgesia (PCA). Which of the following findings indicate a high risk for a developing complication and require immediate escalation to the registered nurse (RN)? Select all that apply.

Select all that apply

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Answer: The client's heart rate has increased from a preoperative baseline of 78 beats/min to 116 beats/min, with a current blood pressure of 104/68 mm Hg.; The client exhibits new-onset restlessness, repeatedly pulling at the bedsheets and asking to get out of bed.; The client's most recent laboratory results show a hemoglobin level of 9.4 g/dL (94 g/L), down from a preoperative level of 13.8 g/dL (138 g/L).

Answer

The findings requiring immediate escalation are the increasing heart rate with borderline blood pressure, the new-onset restlessness, and the significant drop in hemoglobin.
The correct selections all point to a developing postoperative hemorrhage and subsequent hypovolemic shock. A dropping hemoglobin level confirms blood loss, while the compensatory tachycardia and new-onset restlessness (indicating cerebral hypoxia) are classic early signs of shock that demand immediate RN and provider intervention.

Step-by-Step Solution

1
Analyze the client's postoperative timeframe and surgical risk factors.
The client is 12 hours post-abdominal surgery, placing them at high risk for hemorrhage, hypovolemic shock, and respiratory complications.
Identifying the highest risk timeframes directs the focus of the clinical assessment.
2
Evaluate the vital signs, laboratory data, and neurological status for signs of hypoperfusion.
The client demonstrates tachycardia, a significant hemoglobin drop, and new-onset restlessness.
These combined findings are classic indicators of active internal bleeding and early compensatory shock.
3
Differentiate critical complications from expected postoperative findings.
Incisional pain, a beefy red stoma, and a urine output of 35 mL/hr are expected or adequate findings that do not require emergency escalation.
Safe prioritization requires recognizing what constitutes an immediate threat to life versus routine postoperative recovery.

Key Concept

Early recognition of hypovolemic shock and internal hemorrhage requires synthesizing subtle vital sign changes, neurological alterations, and critical laboratory trends.
Question 2043Question →

A practical nurse is planning care for a newly admitted client who is a devout member of the Church of Jesus Christ of Latter-day Saints. Which of the following nursing actions are appropriate to support the client's spiritual and cultural needs? Select all that apply.

Select all that apply

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Answer: Ensure that coffee and black tea are omitted from the client's meal tray.; Seek the client's permission before removing their sacred undergarments for a physical examination.; Provide a private space when church elders arrive to administer a blessing of the sick.

Answer

The correct actions are omitting coffee and black tea from the meal tray, seeking permission before removing sacred undergarments, and providing privacy for a blessing of the sick.
Members of the Church of Jesus Christ of Latter-day Saints observe the Word of Wisdom, which prohibits coffee and black tea. Devout members often wear sacred temple garments that should be treated with deep respect and removed only when medically necessary, ideally with the client's permission. Additionally, receiving a priesthood blessing from church elders is a core spiritual practice during illness, requiring the nurse to facilitate privacy and respect.

Step-by-Step Solution

1
Identify the client's specific religious affiliation and associated practices.
The client is a member of the Church of Jesus Christ of Latter-day Saints. Key practices include the Word of Wisdom (no coffee or black tea), wearing temple garments, and receiving priesthood blessings.
Accurate identification of spiritual needs prevents the application of incorrect cultural stereotypes.
2
Evaluate each nursing intervention against the client's religious practices and the practical nurse scope of practice.
Omitting coffee and tea, respecting sacred garments, and allowing priesthood blessings align directly with the client's faith and the nurse's role.
Culturally competent care requires accommodating specific religious practices when they do not interfere with medical safety.
3
Identify and exclude interventions that represent nursing errors or fall outside the PN scope of practice.
Providing false reassurance, ordering a kosher diet (which is for Judaism), and explaining surgical risks (which is the provider's role) must be excluded.
Safe and effective care requires therapeutic communication, accurate dietary accommodations, and strict adherence to legal scope of practice.

Key Concept

Culturally competent care and spiritual support for Latter-day Saint clients within the practical nursing scope of practice.
Question 2044Question →

A practical nurse (PN) is assigned to care for a 48-hour-old neonate born at 38 weeks gestation who has been prescribed conventional overhead phototherapy for hyperbilirubinemia. Arrange the following actions in the correct sequence to safely initiate this therapy.

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Answer

The correct sequence is: verify the prescription and reinforce education, undress the neonate to a diaper, apply opaque eye shields, turn on the phototherapy lights, and finally document the initiation and monitoring schedule.
The correct sequence logically flows from pre-procedure safety checks, to physical preparation of the body, to targeted safety application (eye shields), to equipment activation, and concludes with post-procedure documentation. Applying eye shields before undressing the baby could result in the shields becoming displaced while removing clothing, so the infant must be undressed first.

Step-by-Step Solution

1
Verify the provider's prescription and reinforce education with the parents about the procedure.
Ensures the correct client receives the correct treatment and parents understand the intervention.
Safe practice standards require verification and informed care before any physical intervention begins.
2
Remove the neonate's clothing and blankets, leaving only a standard diaper in place.
Exposes maximum skin surface area.
Bilirubin breakdown requires therapeutic ultraviolet light exposure directly to the skin. Undressing the infant first prevents the risk of dislodging eye shields later.
3
Secure properly sized opaque eye shields over the neonate's gently closed eyes.
Protects the delicate retina from the phototherapy light.
High-intensity phototherapy lights can cause irreversible retinal damage; protection must be secured immediately prior to activation.
4
Turn on the overhead phototherapy unit positioned at the manufacturer-recommended distance.
Initiates the prescribed therapy.
The neonate is now completely exposed and safely protected, allowing therapy to begin without hazard.
5
Document the initiation time and establish a schedule for monitoring axillary temperature.
Creates a legal health record and ensures proper follow-up care.
Continuous monitoring for complications like hyperthermia, hypothermia, and dehydration is an essential nursing responsibility during phototherapy.

Key Concept

Phototherapy Initiation and Neonatal Safety
Question 2045Question →

A client is resting in bed 6 hours after an open cholecystectomy. While measuring vital signs, the practical nurse notes a heart rate of 118 beats per minute and a blood pressure of 88/52 mm Hg. The client's peripheral pulses are weak. What is the most appropriate next action for the nurse?

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Answer: Escalate these clinical findings to the registered nurse or healthcare provider immediately.

Answer

Escalate these clinical findings to the registered nurse or healthcare provider immediately.
Tachycardia, hypotension, and weak pulses in a postoperative client are critical indicators of hypovolemic shock or internal bleeding. The most appropriate action for the practical nurse is to immediately escalate these findings to the registered nurse or healthcare provider so emergency interventions can be initiated to restore circulatory volume.

Step-by-Step Solution

1
Analyze the client's postoperative vital signs.
The client has tachycardia (118 beats/min), hypotension (88/52 mm Hg), and weak peripheral pulses.
Identifying abnormal clinical data is the first step in risk reduction.
2
Correlate the findings with potential postoperative complications.
These findings are classic indicators of hypovolemia or internal hemorrhage.
Post-surgical clients are at high risk for fluid volume deficit and bleeding.
3
Determine the safest and most appropriate nursing action within the practical nurse's scope of practice.
The nurse must immediately inform the RN or provider.
Acute shock requires rapid advanced interventions, such as intravenous fluid resuscitation or blood transfusions, which must be initiated by the provider or RN.

Key Concept

Early Recognition and Escalation of Hypovolemic Shock
Question 2046Question →

A client who takes warfarin for atrial fibrillation is scheduled to receive their daily dose. The practical nurse reviews the client's morning laboratory report and notes an International Normalized Ratio (INR) of 5.8. Which action should the nurse take?

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Answer: Withhold the scheduled dose and immediately report the laboratory findings to the registered nurse.

Answer

The practical nurse should withhold the scheduled dose of warfarin and immediately report the critically high INR finding to the registered nurse.
For a client taking warfarin for atrial fibrillation, the standard therapeutic International Normalized Ratio (INR) is between 2.0 and 3.0. An INR of 5.8 is critically high and indicates excessive anticoagulation. The practical nurse must prioritize client safety by withholding the medication to prevent hemorrhage and immediately reporting the finding to the registered nurse or healthcare provider.

Step-by-Step Solution

1
Evaluate the client's morning laboratory results prior to medication administration.
The client has an INR of 5.8.
Warfarin dosage is directly guided by the INR level, which must be checked to ensure administration is safe.
2
Compare the client's INR to the expected therapeutic range.
The result of 5.8 is critically high, as the standard therapeutic range is typically 2.0 to 3.0 for a client with atrial fibrillation.
Recognizing critical lab values is essential to prevent severe medication toxicity.
3
Determine the appropriate nursing intervention based on the practical nurse scope of practice.
The medication must be withheld and the registered nurse or provider must be notified.
Administering the medication would cause harm, and abnormal findings must be escalated to the supervising nurse.

Key Concept

Recognizing critical laboratory values and withholding medication to prevent client harm.
Question 2047Question →

A practical nurse is collecting vital signs for a client who is 44 hours post-operative following an open cholecystectomy. The client's current vital signs are a blood pressure of 92/5892/58 mm Hg, a heart rate of 114114 beats/minute, and respirations of 2020 breaths/minute. The client states, "I feel a little dizzy and weak." Which action should the practical nurse take first?

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Answer: Notify the registered nurse immediately about the client's vital signs and symptoms.

Answer

Notify the registered nurse immediately about the client's vital signs and symptoms.
The correct action is to immediately notify the registered nurse. The client's tachycardia, hypotension, and dizziness 44 hours after major abdominal surgery are early signs of hypovolemic shock or internal bleeding. Prompt escalation is necessary to initiate life-saving interventions such as fluid resuscitation or returning to the operating room.

Step-by-Step Solution

1
Analyze the client's vital signs and reported symptoms.
Tachycardia, hypotension, and dizziness are identified.
These are early clinical indicators of hypovolemia or hemorrhage following major abdominal surgery.
2
Prioritize the nursing response based on the LPN scope of practice.
The practical nurse determines that immediate escalation is required.
Suspected shock is a life-threatening complication that requires RN assessment and provider intervention.

Key Concept

Early Recognition and Escalation of Hypovolemic Shock
Question 2048Question →

An older adult client is 48 hours postoperative following a right below-the-knee amputation. The client requests assistance with morning hygiene and reports a dull, aching sensation in the missing lower right leg. Which basic care and comfort measures should the practical nurse implement? Select all that apply.

Select all that apply

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Answer: Assist the client into a prone position for 20 to 30 minutes multiple times a day.; Wash the intact skin around the residual limb gently with mild soap and warm water.; Guide the client through active range-of-motion exercises for the unaffected extremities.

Answer

The correct interventions are assisting the client into a prone position periodically, washing the intact skin of the residual limb with mild soap, and guiding the client through active range-of-motion exercises for the unaffected extremities.
The correct basic care measures focus on preventing complications and promoting comfort. Assisting the client into a prone position several times a day prevents hip flexion contractures, which are a major risk following an amputation. Gentle hygiene of the intact skin around the residual limb maintains skin integrity and promotes comfort. Additionally, guiding the client through active range-of-motion exercises for unaffected extremities preserves the mobility and strength required for future rehabilitation.

Step-by-Step Solution

1
Analyze the client's postoperative timeframe (48 hours) and surgical procedure (below-the-knee amputation) to determine safe positioning and mobility requirements.
After 24 hours, interventions must strictly avoid promoting hip or knee flexion to prevent permanent contractures.
Contractures can severely delay or prevent the successful fitting and use of a prosthetic limb.
2
Identify non-pharmacological comfort measures and basic hygiene routines appropriate for the healing residual limb.
Gentle washing of intact skin and acknowledging phantom limb pain are prioritized.
Maintaining cleanliness prevents skin breakdown, while validating the client's pain experience supports both physiological comfort and psychosocial integrity.
3
Select all options that align with safe positioning, mobility maintenance, and therapeutic communication within the practical nurse's scope of basic care.
Prone positioning, gentle hygiene, and active range-of-motion for unaffected limbs are selected as correct.
These actions directly fulfill the learning objective of providing basic care and comfort while preventing common postoperative complications.

Key Concept

Postoperative Basic Care and Comfort for Amputation
Question 2049Question →

A practical nurse is providing care for a client who is 11 day post-operative following an open abdominal surgery. Which of the following actions by the practical nurse demonstrate appropriate risk reduction and safe clinical practice? Select all that apply.

Select all that apply

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Answer: Verifying two distinct client identifiers by checking the identification band prior to administering a prescribed oral analgesic.; Notifying the registered nurse (RN) immediately regarding a morning serum potassium result of 2.8 mEq/L2.8\text{ mEq/L} (2.8 mmol/L2.8\text{ mmol/L}).; Escalating care to the RN when the client's resting heart rate increases to 118 beats/min118\text{ beats/min} with a blood pressure of 92/56 mm Hg92/56\text{ mm Hg}.

Answer

The correct actions include verifying two client identifiers before medication administration, immediately notifying the RN of a critical potassium level, and escalating care for borderline vital signs indicating potential shock.
Safe practical nursing care requires strict adherence to risk reduction principles. This includes mandatory safety checks like verifying two distinct client identifiers. Furthermore, the practical nurse plays a critical role in early complication detection by identifying and immediately escalating critical laboratory values (such as a severely low potassium level of 2.8 mEq/L2.8\text{ mEq/L}, which risks cardiac dysrhythmias) and subtle signs of impending complications (such as unexpected tachycardia and hypotension, which are early indicators of hypovolemic shock or hemorrhage).

Step-by-Step Solution

1
Analyze the client's post-operative status and identify the practical nurse's scope of practice.
The client is at risk for post-operative complications, requiring vigilant monitoring and interventions within the PN scope.
Reduces risk potential by recognizing boundaries and critical physiological changes.
2
Evaluate each potential action for safety, physiological rationale, and appropriate delegation.
Identifying patients correctly, reporting critical labs (hypokalemia), and recognizing early shock signs are safe, necessary actions.
These actions directly reduce the risk of adverse outcomes and fall within the PN scope of practice.
3
Identify and exclude contraindicated actions.
IV push medications are out of scope, knee pillows risk DVT, and ignoring hypoxia violates ABC prioritization.
These actions increase risk potential and represent unsafe clinical practice.

Key Concept

Reduction of Risk Potential: Recognizing Complications and Scope of Practice
Question 2050Question →

An interdisciplinary care team has established a treatment plan for a client admitted with acute decompensated heart failure and atrial fibrillation. The pharmacological prescriptions include a continuous intravenous heparin infusion, intravenous push furosemide, oral spironolactone, and topical nitroglycerin ointment. Which medication administration action should the practical nurse identify as being within their scope of practice?

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Answer: Apply the topical nitroglycerin ointment to a hairless area of the chest using a dose-measuring applicator while wearing clean gloves.

Answer

The practical nurse should safely apply the topical nitroglycerin ointment to the client using a dose-measuring applicator while wearing clean gloves.
Applying topical medications, such as nitroglycerin ointment, is a foundational skill within the practical nurse scope of practice. Using a dose-measuring applicator ensures correct dosing, and wearing clean gloves is a critical safety measure to prevent the nurse from absorbing the medication and experiencing adverse effects like hypotension and a severe headache.

Step-by-Step Solution

1
Evaluate the order for the continuous intravenous heparin infusion.
Determine that titrating this infusion is outside the practical nurse scope.
Titrating high-alert continuous infusions based on laboratory results requires the advanced clinical judgment of a registered nurse.
2
Evaluate the order for intravenous push furosemide.
Determine that administering intravenous push medications is not permitted for the practical nurse.
Intravenous push medications carry high risks, act rapidly, and require immediate registered nurse assessment.
3
Evaluate the medication verification scenario regarding the oral spironolactone.
Determine that bypassing barcode scanning violates safe medication administration principles.
Two client identifiers must be verified before every single medication administration to prevent errors.
4
Evaluate the order for the topical nitroglycerin ointment.
Determine that applying topical medications is a safe, standard procedure for the practical nurse.
Wearing gloves is a critical safety step to prevent unintended self-administration and systemic vasodilation in the nurse.

Key Concept

Practical Nurse Scope of Practice in Pharmacological Therapies
Question 2051Question →

During rounds on the behavioral health unit, a client recovering from amphetamine toxicity suddenly backs into the corner of the dayroom. The client is heavily diaphoretic, glaring at the ceiling, and shouting, "The drones are dropping poison on me!" Which action is the priority for the nurse to implement?

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Answer: Assume a non-threatening posture at a safe distance while ensuring the exit path remains clear.

Answer

Assume a non-threatening posture at a safe distance while ensuring the exit path remains clear.
The priority when managing a client experiencing stimulant-induced psychosis and paranoia is establishing physical safety. By maintaining a safe distance and ensuring an unobstructed exit, the nurse protects themselves and prevents the client from feeling trapped, which reduces the immediate risk of violence.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client is exhibiting symptoms of severe stimulant-induced psychosis, including paranoia, visual hallucinations, and backing into a corner.
Recognizing the signs of a psychotic break allows the nurse to anticipate unpredictable or defensive behavior.
2
Evaluate the priority of care based on the scenario.
Immediate physical safety for both the client and the nursing staff is the absolute highest priority.
A cornered, terrified client experiencing hallucinations may resort to violence in an attempt to protect themselves from perceived threats.
3
Select the safest initial nursing intervention.
The nurse must secure the environment by keeping a safe physical distance and ensuring an unblocked escape route.
This strategy de-escalates the immediate environmental tension and provides the nurse with a safe way out if the client becomes physically aggressive.

Key Concept

Crisis Intervention and Safety in Substance-Induced Psychosis
Question 2052Question →

A client is making a lifestyle modification to eliminate high-sugar beverages from their diet. Arrange the client's statements in chronological order, representing their progression through the sequential stages of behavioral change (from the earliest stage to the final stage).

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Answer

The correct chronological sequence aligns with the Transtheoretical Model of Change: Precontemplation (denial), Contemplation (ambivalence), Preparation (small steps), Action (active change for less than six months), and Maintenance (sustained change for over six months).
The Transtheoretical Model of Change dictates that individuals modifying a lifestyle choice progress through five distinct stages. They begin with denial or unawareness (precontemplation), move to acknowledging the issue while remaining hesitant (contemplation), take small preliminary steps to get ready (preparation), execute the behavioral change (action), and finally sustain the change long-term to prevent relapse (maintenance).

Step-by-Step Solution

1
Identify the statement reflecting the earliest phase of change, known as the Precontemplation stage.
The client denying any link between sodas and weight gain is placed first.
In the earliest stage, individuals do not intend to take action and often remain unaware that their behavior is problematic.
2
Identify the statement reflecting the Contemplation stage.
The client acknowledging the health effects but remaining ambivalent is placed second.
During this phase, individuals recognize their lifestyle choice may be problematic but are not yet fully committed to making a change.
3
Identify the statement reflecting the Preparation stage.
The client buying a water bottle and stopping soda purchases is placed third.
The individual is ready to take action soon and takes small preliminary steps toward the behavior change.
4
Identify the statement reflecting the Action stage.
The client successfully replacing sodas with water for three weeks is placed fourth.
The individual has actively changed their behavior and intends to keep moving forward, though it has been less than six months since the change began.
5
Identify the statement reflecting the final phase, known as the Maintenance stage.
The client avoiding sugary beverages for over eight months is placed last.
The individual has sustained their behavior change for more than six months and has successfully integrated the new habit into their lifestyle.

Key Concept

Transtheoretical Model of Behavioral Change
Question 2053Question →

A client is transferred to the clinical unit after undergoing a lumbar puncture. Which resting position should the practical nurse encourage the client to maintain to minimize the risk of a spinal headache?

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Answer: Supine with the bed completely flat

Answer

Supine with the bed completely flat
Following a lumbar puncture, the primary goal of positioning is to prevent a spinal headache, which occurs due to the leakage of cerebrospinal fluid from the puncture site. Keeping the client in a flat, supine position minimizes pressure and gravity at the site, reducing this leakage.

Step-by-Step Solution

1
Identify the procedure the client underwent.
The client had a lumbar puncture.
Different procedures require specific post-operative positioning to prevent complications and ensure comfort.
2
Determine the primary post-procedure complication associated with a lumbar puncture.
Spinal headache caused by the leakage of cerebrospinal fluid (CSF).
Understanding the risk guides the appropriate nursing intervention for comfort and safety.
3
Select the position that minimizes this complication.
The supine (flat) position.
Lying flat reduces pressure on the dural puncture site, decreasing the likelihood of CSF leakage.

Key Concept

Post-procedure Positioning
Question 2054Question →

A practical nurse (PN) is reinforcing discharge instructions for a client who had a permanent pacemaker implanted the previous day. The client laughs and states, 'I do not need to check my pulse or go to those follow-up appointments. This little machine is a magic fix, and my heart is completely bulletproof now.' Which therapeutic response should the PN provide?

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Answer: I understand you are feeling relieved, but checking your pulse daily is still a necessary part of your care.

Answer

The response stating that the nurse understands the client is feeling relieved, but checking the pulse daily is still a necessary part of care.
The correct response is therapeutic because it validates the client's positive feelings ('I understand you are feeling relieved') while gently but firmly presenting reality ('checking your pulse daily is still a necessary part of your care'). This technique addresses the client's denial without being confrontational and ensures that critical safety information is reinforced.

Step-by-Step Solution

1
Identify the client's behavior and underlying coping mechanism.
The client is demonstrating denial by ignoring the reality of needing ongoing cardiac monitoring and follow-up care.
Recognizing the defense mechanism is essential to formulating a therapeutic response.
2
Determine the appropriate practical nurse (PN) intervention.
The PN must use therapeutic communication to acknowledge the client's emotional state while gently orienting them to reality and reinforcing the established teaching plan.
Validating feelings builds trust, while presenting reality ensures client safety and compliance with the medical regimen.
3
Evaluate the options against communication principles and the PN scope of practice.
Eliminate options that use non-therapeutic blocks (like 'why' questions or false reassurance) and options that require RN-level assessment or care plan modification.
This leaves only the therapeutic response that safely reinforces adaptive coping and required health maintenance.

Key Concept

Therapeutic Communication and Adaptive Coping
Question 2055Question →

A practical nurse is preparing to administer a scheduled dose of gabapentin 300 mg300\text{ mg} PO to a client with neuropathic pain. The medication is supplied as an oral solution with a concentration of 250 mg/5 mL250\text{ mg}/5\text{ mL}. How many milliliters should the nurse administer? (Record answer as a whole number. Do not include units in answer.)

Show answer & explanation

Answer: 6

Answer

6
To determine the correct volume to administer, the nurse uses the formula: (Desired / Have) \times Quantity. The desired dose is 300 mg300\text{ mg}, the available dose (Have) is 250 mg250\text{ mg}, and the Quantity is 5 mL5\text{ mL}. Therefore, (300 mg/250 mg)×5 mL=1.2×5 mL=6 mL(300\text{ mg} / 250\text{ mg}) \times 5\text{ mL} = 1.2 \times 5\text{ mL} = 6\text{ mL}. The practical nurse should administer 6 mL6\text{ mL} of the gabapentin oral solution.

Step-by-Step Solution

1
Identify the prescribed dose and the available concentration.
Prescribed dose = 300 mg300\text{ mg}; Available concentration = 250 mg250\text{ mg} in 5 mL5\text{ mL}.
These values are required to set up the dosage calculation formula accurately.
2
Apply the basic dosage calculation formula: (Desired / Have) \times Quantity.
(300 mg250 mg)×5 mL\left( \frac{300\text{ mg}}{250\text{ mg}} \right) \times 5\text{ mL}
This formula determines the correct volume of medication to administer to achieve the prescribed dose.
3
Perform the calculation.
1.2×5 mL=6 mL1.2 \times 5\text{ mL} = 6\text{ mL}.
Mathematical computation provides the final volume in milliliters to administer.

Key Concept

Oral Dosage Calculation
Question 2056Question →

A practical nurse is collecting data during a routine wellness visit for a 5-month-old infant. The parents ask about the physical skills their baby should be developing at this time. Which finding should the nurse identify as an expected developmental milestone for this infant?

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Answer: Rolling over from the abdomen to the back

Answer

The expected developmental milestone for a 5-month-old is rolling over from the abdomen to the back.
At 5 months of age, an infant is typically expected to have mastered rolling from their abdomen (prone) to their back (supine). This normal gross motor milestone generally develops between 4 and 5 months of age as the infant gains sufficient head control and core strength.

Step-by-Step Solution

1
Identify the client's age and the specific domain of development being assessed.
The client is a 5-month-old infant, and the question asks for an expected physical developmental milestone.
Developmental milestones are age-specific, making the infant's exact chronological age the critical factor in selecting the correct answer.
2
Recall the standard gross and fine motor milestones for a 5-month-old infant.
By 4 to 5 months, an infant typically gains the core strength to roll from their abdomen to their back.
Recalling normal physiological development is necessary to differentiate expected findings from those that occur later in infancy.
3
Evaluate the distractors against the 5-month timeline.
Sitting unsupported (8 months), using a pincer grasp (9-10 months), and pulling to a stand (9 months) are all milestones that occur in the second half of the infant's first year.
Ruling out milestones that are too advanced confirms the correct choice.

Key Concept

Infant gross motor developmental milestones (4 to 6 months)
Question 2057Question →

A practical nurse (PN) in a long-term care facility is talking with an older adult client whose spouse died three months ago. The client tearfully states, "Sometimes I still hear his footsteps in the hallway and think he is coming into the room. I feel like I am going crazy." Which of the following is the most therapeutic response by the PN?

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Answer: It is very common for people to experience the sensation of hearing or seeing their loved one while grieving.

Answer

The most therapeutic response is to validate that experiencing the sensation of hearing or seeing a deceased loved one is a common and normal part of the grieving process.
The correct answer utilizes the therapeutic technique of providing information and validation. By reassuring the client that sensory experiences of the deceased are a common, normal aspect of the grieving process, the nurse alleviates the client's fear of losing their mind and encourages further expression of feelings.

Step-by-Step Solution

1
Analyze the client's statement and current emotional state.
The client is experiencing brief sensory illusions related to their deceased spouse and feels distressed, fearing they are 'going crazy.'
Understanding the client's experience is necessary to formulate a therapeutic and supportive response.
2
Evaluate the clinical significance of the client's experience.
Brief auditory or visual sensations of a recently deceased loved one are a normal manifestation of acute grief, not a sign of psychosis.
Differentiating normal grief manifestations from pathological conditions guides the nurse's intervention.
3
Select the response that utilizes therapeutic communication techniques.
The response that normalizes the experience provides empathy and validation, avoiding non-therapeutic blocks like advice-giving, false reassurance, or rigid expectations.
Therapeutic communication fosters trust and helps the client process their grief.

Key Concept

Therapeutic Communication in Normal Grief
Question 2058Question →

A practical nurse (PN) is caring for a client who is a devout Roman Catholic. It is a Friday during the season of Lent, and the PN is delivering the client's lunch tray, which contains a pork chop, mashed potatoes, and green beans. The client looks at the tray and appears distressed. Which action is the most appropriate for the PN to take?

Show answer & explanation

Answer: Ask the client if they prefer a meatless meal and contact dietary services to request a replacement tray.

Answer

Ask the client if they prefer a meatless meal and contact dietary services to request a replacement tray.
Many Roman Catholics abstain from eating meat on Fridays during the season of Lent. By acknowledging the client's distress, clarifying their preference, and proactively contacting dietary services for a meatless alternative, the practical nurse demonstrates cultural competence and supports the client's psychosocial and spiritual well-being.

Step-by-Step Solution

1
Analyze the client's reaction and the cultural context of the situation.
The client is distressed by the presence of meat on a Friday during Lent, a time when many Roman Catholics observe abstinence from meat.
Recognizing spiritual and religious influences is essential for providing culturally competent and holistic care.
2
Determine the appropriate, therapeutic nursing intervention.
The PN validates the client's concern, verifies their dietary preference, and coordinates with dietary services for a proper replacement meal.
This action supports the client's psychosocial integrity, ensures nutritional needs are safely met without cross-contamination, and demonstrates respect for their spiritual practices.

Key Concept

Accommodating religious and spiritual dietary practices in the healthcare setting
Estimated Time:1m 0s
Question 2059Question →

During afternoon rounds on a rehabilitation unit, a practical nurse observes a client who is 72 hours post-transfemoral amputation of the right leg. The client is resting with the head of the bed elevated to 90 degrees, and the right residual limb is supported on two stacked pillows. The client states, 'My right hip feels extremely tight and stiff.' Which action should the practical nurse implement?

Show answer & explanation

Answer: Remove the pillows from beneath the residual limb and assist the client into a prone position.

Answer

The practical nurse should remove the pillows from beneath the residual limb and assist the client into a prone position.
Following a transfemoral amputation, preventing a hip flexion contracture is a primary nursing priority. After the initial 24 to 48 hours, the residual limb should never be elevated on pillows, and sitting in high-Fowler's position should be minimized. Removing the pillows and assisting the client into a prone position actively stretches the shortened hip flexor muscles, preventing contracture formation and ensuring the client can eventually be fitted for a prosthesis.

Step-by-Step Solution

1
Evaluate the postoperative timeframe.
The client is 72 hours post-transfemoral (above-the-knee) amputation.
Post-amputation positioning guidelines change drastically after the first 24 to 48 hours.
2
Analyze the mechanical effects of the client's current position.
Sitting at 90 degrees with the limb on pillows forces the hip joint into extreme and prolonged flexion.
Prolonged hip flexion rapidly leads to debilitating flexion contractures, making future prosthetic fitting impossible.
3
Interpret the client's symptom of 'tight and stiff' hip.
The stiffness is a physiological warning sign that the hip flexor muscles are shortening due to the improper positioning.
Connecting patient symptoms to physical alignment allows the nurse to prioritize structural correction over secondary interventions.
4
Select the appropriate therapeutic positioning intervention.
Remove all elevation under the limb and place the client flat or prone.
The prone position (usually implemented for 20-30 minutes, 3 to 4 times daily) actively extends and stretches the hip flexor muscles, countering the risk of contracture.

Key Concept

Post-operative positioning to prevent hip flexion contractures following transfemoral amputation
Estimated Time:1m 30s
Question 2060Question →

An adult client is preparing for a scheduled colonoscopy at an outpatient endoscopy center. The gastroenterologist has completed the pre-procedure consultation, discussed the risks of bleeding and perforation, and returned to the procedure room. The registered nurse delegates the practical nurse to obtain the client's signature on the consent document. As the practical nurse hands the pen to the client, the client states, "I know the doctor explained everything, but I am suddenly terrified about the risk of my bowel tearing. Can you explain how often that actually happens?" Which action by the practical nurse is most appropriate?

Show answer & explanation

Answer: Withhold the consent document and immediately notify the registered nurse or gastroenterologist about the client's inquiry.

Answer

The most appropriate action is to withhold the consent document and immediately notify the registered nurse or gastroenterologist about the client's inquiry.
The role of the practical nurse during the informed consent process is strictly limited to advocating for the client, witnessing the signature, and verifying that the client is acting voluntarily. If a client expresses hesitation or asks specific questions about procedural risks just before signing, they have not achieved informed consent. The practical nurse must not answer these questions or explain the risks, as providing medical clarification on surgical complications is outside their scope of practice. Instead, the nurse must withhold the form and immediately notify the registered nurse or provider so the provider can return and address the client's concerns directly.

Step-by-Step Solution

1
Analyze the client's statement to determine their current level of understanding regarding the procedure.
The client is explicitly expressing fear and asking for specific statistical details about surgical risks, indicating they do not currently feel fully informed.
Informed consent is a legal process requiring the client to have a complete, clear understanding of risks and benefits before signing any documents.
2
Identify the practical nurse's legal scope of practice regarding informed consent.
The practical nurse is legally authorized only to witness the signature and verify that the client is signing voluntarily. Explaining risks or answering specific medical questions about complications is strictly the responsibility of the provider.
The healthcare provider performing the procedure is legally responsible for ensuring the client comprehends the risks.
3
Determine the priority nursing action based on the client's hesitation.
The practical nurse must halt the consent process and escalate the situation by notifying the registered nurse or the provider.
Advocating for the client means ensuring their questions are answered by the appropriate personnel (the provider) before any binding legal documents are signed.

Key Concept

Practical Nurse Role in Informed Consent
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