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Question 2081Question →

A client on an oncology unit has just been informed by the provider that their cancer is no longer responding to treatment. The client's partner begins pacing the public hallway, breathing rapidly, and loudly stating, "This cannot be happening!" In which order should the licensed practical nurse (LPN) prioritize the following actions? (Arrange the actions from first to last.)

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Answer

The correct sequence is to first secure privacy (escort to a private area), second establish therapeutic presence (sit silently), third provide verbal validation (acknowledge the news is overwhelming), fourth mobilize resources (inquire about a support person), and finally perform administrative duties (document).
In psychosocial crises, the nursing process dictates prioritizing immediate safety and milieu management first (privacy), followed by nonverbal therapeutic techniques (presence), then verbal therapeutic techniques (validation), followed by mobilizing coping resources (support persons), and ending with administrative requirements (documentation).

Step-by-Step Solution

1
Ensure privacy and dignity by moving the partner out of the hallway.
The partner is in a safe, controlled environment away from other clients.
Milieu management and client/family dignity are foundational first steps during an acute emotional crisis.
2
Provide a silent, calming presence.
The partner has time and space to process the initial shock without pressure to communicate.
Offering self is a primary therapeutic communication technique that establishes trust when an individual is too overwhelmed for conversation.
3
Use verbal therapeutic communication to acknowledge the distress.
The partner's feelings of grief and disbelief are validated.
Stating that the news is overwhelming acknowledges the reality of the loss and opens the door for further expression of feelings.
4
Offer to contact external support systems.
The partner is connected with family, friends, or spiritual care.
The nurse assists with coping by integrating the family's preferred support network once the immediate panic has subsided.
5
Document the event in the medical record.
The health care team has an accurate record of the psychosocial event.
Documentation must always follow the completion of direct, immediate client or family care.

Key Concept

Nursing Management of Acute Grief and Loss
Question 2082Question →

An adult client is resting in bed after undergoing a right modified radical mastectomy with axillary lymph node dissection. How should the nurse position the client's right arm to promote optimal comfort and reduce swelling?

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Answer: Elevated on a pillow

Answer

Elevated on a pillow
Following a mastectomy with lymph node removal, the lymphatic drainage pathways in the affected arm are significantly compromised. Elevating the arm on a pillow uses gravity to promote lymphatic and venous return. This essential basic care measure prevents lymphedema (tissue swelling), decreases tension on the surgical site, and maximizes client comfort.

Step-by-Step Solution

1
Identify the surgical procedure and its associated risks.
The client had a right mastectomy with axillary lymph node dissection, which disrupts the normal lymphatic pathways and creates a high risk for fluid accumulation (lymphedema) in the right arm.
Understanding the physiological impact of the surgery guides proper postoperative care and positioning.
2
Determine the basic care intervention that mitigates this risk.
Gravity must be used to assist the compromised lymphatic system in draining fluid away from the distal part of the arm back toward the core circulation.
Edema prevention is a fundamental component of basic care and physical comfort for post-mastectomy clients.
3
Select the position that best supports this physiological goal.
Elevating the arm on a pillow achieves the necessary drainage angle while providing soft, supportive comfort.
This is the standard, evidence-based positioning technique for this specific client population.

Key Concept

Post-mastectomy arm positioning to prevent lymphedema
Question 2083Question →

During a central venous access device tubing change, the catheter accidentally disconnects. The client immediately exhibits severe dyspnea, cyanosis, and tachycardia. In what order must the nurse perform the following emergency actions to mitigate the risk of a fatal air embolism?

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Answer

The correct emergency sequence for a suspected air embolism is to clamp the catheter, position the client in left lateral Trendelenburg, administer oxygen, activate the rapid response team, and then obtain vital signs.
In a life-threatening emergency where an active hazard is present, the first priority is to stop the source of harm (clamping the catheter). The next priority is immediate physiological stabilization to prevent the complication from becoming fatal (positioning to trap the air, followed immediately by oxygen to treat hypoxia). Once these rapid, life-saving physical actions are completed, the nurse must call for advanced medical help. Finally, continuous assessment (obtaining vital signs) is performed to monitor the client's baseline and response to treatment while waiting for the rapid response team to arrive.

Step-by-Step Solution

1
Clamp the central venous catheter.
Stops further air from entering the circulatory system.
The absolute first step in any hazard is to halt the immediate source of harm.
2
Place the client in the left lateral Trendelenburg position.
Traps the air bubble in the right atrium and ventricle.
Gravity and positioning prevent the air embolus from traveling into the pulmonary circulation, which would cause a fatal obstruction.
3
Administer high-flow oxygen.
Increases blood oxygenation and accelerates nitrogen absorption.
Treats the immediate hypoxia caused by the embolism and helps shrink the size of the air bubble.
4
Activate the rapid response team.
Summons advanced medical providers.
The client requires critical care interventions that exceed the practical nurse's scope of practice.
5
Obtain vital signs.
Establishes a hemodynamic baseline.
Monitors the client's physiological stability and response to the initial emergency interventions.

Key Concept

Emergency management and prioritization of an air embolism to reduce the risk of cardiopulmonary collapse.
Question 2084Question →

A practical nurse (PN) is caring for an adult client who is receiving continuous enteral nutrition via a nasogastric (NG) tube. The client is scheduled to receive 300 mg300\text{ mg} of phenytoin. The pharmacy dispenses phenytoin oral suspension 125 mg/5 mL125\text{ mg}/5\text{ mL}. The client's morning laboratory results show a serum phenytoin level of 26 mcg/mL26\text{ mcg/mL}. During the morning assessment, the client exhibits involuntary, rapid eye movements and a noticeably unsteady gait when transferring to the chair. Which of the following actions should the PN take? Select all that apply.

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Answer: Withhold the scheduled dose of the phenytoin oral suspension.; Report the neurological assessment findings and laboratory results to the registered nurse (RN).; Implement strict fall precautions due to the client's current neurological status.

Answer

The practical nurse should withhold the dose of phenytoin, report the findings to the RN, and implement fall precautions.
The therapeutic serum level for phenytoin is 10 to 20 mcg/mL. A level of 26 mcg/mL is toxic and correlates directly with the client's clinical presentation of nystagmus (involuntary eye movements) and ataxia (unsteady gait). The practical nurse must prioritize safety by withholding the scheduled dose to prevent worsening toxicity, immediately reporting both the clinical findings and the critical laboratory value to the registered nurse, and initiating fall precautions to protect the neurologically impaired client.

Step-by-Step Solution

1
Analyze the laboratory value.
The serum phenytoin level is 26 mcg/mL26\text{ mcg/mL}, which exceeds the normal therapeutic range of 10−20 mcg/mL10-20\text{ mcg/mL}.
Recognizing a toxic drug level is the first step in prioritizing medication safety.
2
Correlate the physical assessment findings with the medication profile.
Involuntary eye movements (nystagmus) and an unsteady gait (ataxia) are classic, direct manifestations of central nervous system toxicity from elevated phenytoin levels.
Connecting physiological symptoms to pharmacological effects determines whether a drug should be administered or withheld.
3
Determine the appropriate interventions within the practical nurse scope of practice.
The nurse must withhold the toxic medication, protect the client from physical harm (fall precautions), and communicate the critical data to the supervising RN.
Safe nursing practice requires recognizing out-of-scope tasks (like IV push meds) and prioritizing immediate patient safety and chain-of-command reporting.
4
Evaluate the mathematical calculation presented in the distractors.
Using the formula (Desired / Have) * Volume: (300 mg/125 mg)×5 mL=12 mL(300\text{ mg} / 125\text{ mg}) \times 5\text{ mL} = 12\text{ mL}. The distractor offering 24 mL24\text{ mL} is mathematically incorrect.
Identifying calculation errors prevents dangerous overdosing, reinforcing standard medication administration rights.

Key Concept

Phenytoin Toxicity and Practical Nurse Scope of Practice
Question 2085Question →

During mealtime at a long-term care facility, a practical nurse (PN) observes a resident who recently experienced a left-hemisphere stroke. The resident has been cleared to use adaptive utensils but pushes the tray away, begins to cry, and demands, 'I cannot do anything right anymore. You have to feed me!' Which action should the PN take to best support the resident's coping?

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Answer: Validate the resident's feelings of helplessness and offer to gently guide their hand for the first few bites.

Answer

The correct action is to validate the resident's feelings of helplessness and offer partial assistance to gently encourage independence.
Validating the resident's feelings acknowledges their emotional distress related to the loss of physical independence. Offering to guide their hand provides necessary support without completely taking over the task, which gently redirects the regressive behavior and promotes adaptive coping and rehabilitation.

Step-by-Step Solution

1
Analyze the resident's behavior (crying, demanding to be fed).
Identify this as a maladaptive coping response (regression and frustration) secondary to the loss of physical independence.
Understanding the underlying cause of the behavior is necessary to select a therapeutic intervention.
2
Evaluate the nursing options based on therapeutic communication and PN scope of practice.
Rule out 'why' questions, minimizing feelings with rigid grief expectations, and out-of-scope care plan modifications.
Non-therapeutic responses or out-of-scope actions can harm the therapeutic relationship or violate practice boundaries.
3
Select the intervention that balances emotional support with rehabilitation goals.
Validating the resident's feelings while offering to guide their hand provides immediate support without completely enabling the regressive behavior.
This gently shapes behavior back toward adaptive coping and utilizes the prescribed adaptive equipment.

Key Concept

Coping Mechanisms and Therapeutic Interventions
Question 2086Question →

A client who is unresponsive following a traumatic brain injury is receiving continuous enteral feedings via a gastrostomy tube. The health care provider prescribes scheduled liquid oral phenytoin for seizure prophylaxis. The practical nurse is preparing to administer the medication. Which action should the nurse take?

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Answer: Stop the continuous enteral feeding for 1 to 2 hours before administering the phenytoin dose.

Answer

The correct action is to pause the continuous enteral feeding for 1 to 2 hours prior to administering the liquid phenytoin.
The correct action is to pause the continuous enteral feeding for 1 to 2 hours before administering the medication. Enteral feeding formulas significantly decrease the absorption of oral phenytoin in the gastrointestinal tract. If the feeding is not paused, the client may develop subtherapeutic phenytoin levels, increasing the risk of breakthrough seizures. The feeding should also remain paused for 1 to 2 hours after administration to allow for complete drug absorption.

Step-by-Step Solution

1
Review the prescribed medication and the client's current nutritional therapy.
The client is prescribed oral phenytoin and is receiving continuous enteral formula via a gastrostomy tube.
Identifying concurrent therapies is essential to prevent drug-nutrient interactions.
2
Analyze the specific interactions between phenytoin and enteral feeding formulas.
Enteral formulas contain proteins and calcium that bind to phenytoin in the gastrointestinal tract, significantly decreasing drug absorption.
Understanding the pharmacokinetic interaction guides the administration protocol.
3
Implement the necessary safety intervention for administration.
The continuous enteral feeding is stopped for 1 to 2 hours before the medication is given.
Pausing the feeding creates an empty stomach environment, ensuring maximum absorption of the phenytoin to maintain therapeutic seizure prophylaxis.

Key Concept

Phenytoin Administration with Enteral Feedings
Question 2087Question →

A practical nurse is assigned to care for an older adult client admitted with mild dehydration linked to an age-related diminished thirst sensation. The healthcare provider orders the initiation of an oral rehydration protocol. In what chronological order should the nurse perform the following actions?

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Answer

First, evaluate swallowing safely. Second, provide the oral fluids. Third, record the intake volume. Fourth, assess physical signs of hydration improvement. Finally, provide ongoing education about scheduling fluid intake.
The correct sequence strictly follows the nursing process and safety prioritization. Safety (swallow assessment) must precede implementation (administering fluids). Implementation must be immediately followed by documentation (intake log) and then evaluation (turgor and membranes). Health promotion and teaching are reserved for when the client is physiologically stable.

Step-by-Step Solution

1
Assess the client's swallow reflex and airway safety.
Determines if the client can safely tolerate oral intake.
Airway protection and aspiration prevention take physiological priority before any oral intervention.
2
Administer the prescribed oral rehydration solution.
Begins correcting the fluid deficit.
Once safety is established, the primary acute intervention must be implemented to address the dehydration.
3
Document the fluid intake accurately.
Updates the medical record with the exact intake volume.
Immediate documentation prevents errors in total fluid calculation and guides further treatment.
4
Assess skin turgor over the sternum and check mucous membranes.
Evaluates the effectiveness of the hydration therapy.
The nurse must monitor the client's physiological response to the intervention using age-appropriate assessment sites.
5
Provide client education on scheduled fluid intake.
Equips the client with strategies to manage age-related decreased thirst.
Teaching is most effective after the client is physiologically stable and addresses the root cause of the admission.

Key Concept

Prioritization of nursing care for older adults experiencing dehydration due to age-related physiological changes.
Question 2088Question →

A practical nurse is collecting data on a client who is receiving continuous intravenous heparin therapy for a deep vein thrombosis. Which of the following findings indicate a potential complication and must be reported to the registered nurse immediately? (Select all that apply)

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Answer: Emesis that has a coffee-ground appearance; A platelet count of 60,000 /mm360,000 \text{ /mm}^3; Oozing of blood from the intravenous insertion site

Answer

The findings that must be reported immediately are coffee-ground emesis, a platelet count of 60,000 /mm360,000 \text{ /mm}^3, and oozing of blood from the intravenous site, as these all indicate active bleeding or a severe risk for hemorrhage.
Heparin is a high-alert anticoagulant that significantly increases the risk of hemorrhage. Coffee-ground emesis indicates upper gastrointestinal bleeding. A platelet count of 60,000 /mm360,000 \text{ /mm}^3 is critically low (thrombocytopenia) and predisposes the client to severe bleeding, possibly indicating heparin-induced thrombocytopenia (HIT). Oozing from the intravenous site is a direct sign of active bleeding. The practical nurse must immediately report these findings to the registered nurse for prompt intervention, which may include stopping the infusion or administering an antidote.

Step-by-Step Solution

1
Identify the medication and its primary risks.
The client is receiving continuous intravenous heparin, an anticoagulant that significantly increases the risk of bleeding.
Understanding the mechanism of the medication highlights what complications to look for during data collection.
2
Evaluate the clinical findings for signs of bleeding or shock.
Coffee-ground emesis and IV site oozing are direct signs of active bleeding. A critically low platelet count (60,000 /mm360,000 \text{ /mm}^3) predisposes the client to severe bleeding.
Active bleeding or critical thrombocytopenia requires immediate escalation to the registered nurse to prevent life-threatening hemorrhage.
3
Distinguish between expected therapeutic results and complications.
An aPTT of 60 seconds60 \text{ seconds} is an expected therapeutic response to heparin. The vital signs are completely normal.
Escalating expected or normal findings demonstrates a lack of understanding of the prescribed therapy and baseline stability.

Key Concept

Reduction of Risk Potential: Complications of Anticoagulant Therapy
Question 2089Question →

A practical nurse (PN) receives a telephone call from the laboratory reporting a critical serum potassium level of 6.26.2 mEq/L for a client. The client's morning medications, which include the potassium-sparing diuretic spironolactone, are currently due. In what order should the PN perform the following actions to minimize the risk of complications? (Arrange the steps in the correct order of priority.)

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Answer

The correct priority sequence is to first verify the lab result, withhold the contraindicated medication, assess the client's cardiac status, notify the provider, and finally document the event.
When receiving a critical laboratory value via telephone, the absolute first priority is safety and accuracy, which requires writing down and reading back the result. Next, the nurse must immediately protect the client from further harm by holding any medications that could worsen the condition (spironolactone). Before notifying the provider, the nurse must assess the client (vital signs, apical pulse) to have a complete clinical picture for the SBAR report. Notification of the RN and provider follows to secure emergency orders. Finally, all steps and communications are documented in the client's medical record.

Step-by-Step Solution

1
Write down and read back the critical laboratory result.
Ensures the accuracy of the critical information received over the telephone.
Verifying verbal communication is a mandatory safety standard to prevent life-threatening errors.
2
Withhold the scheduled dose of spironolactone.
Prevents the introduction of additional potassium or retention of existing potassium.
Spironolactone is a potassium-sparing diuretic that would exacerbate the critical hyperkalemia and increase the risk of cardiac arrest.
3
Assess vital signs and apical heart rhythm.
Identifies any immediate clinical manifestations of severe hyperkalemia.
Current assessment data is required to communicate the client's immediate physiological status to the provider effectively.
4
Report the findings to the supervising registered nurse (RN) and healthcare provider.
Escalates the critical situation to the appropriate clinicians.
The provider must prescribe emergency pharmacological interventions (such as calcium gluconate, regular insulin, or sodium polystyrene sulfonate) to lower the serum potassium level.
5
Document all findings and actions in the medical record.
Creates a permanent legal and clinical record.
Documentation should always occur after the client's immediate safety is secured and care has been escalated.

Key Concept

Prioritizing nursing actions for critical laboratory values and medication safety
Question 2090Question →

An adult client on a telemetry unit is prescribed oral metoprolol for hypertension. When implementing safe medication practices for this client, which actions should the practical nurse include? Select all that apply.

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Answer: Confirm the client's identity using two distinct identifiers prior to dispensing the tablet.; Assess the client's apical heart rate and withhold the dose if it is below 60 beats per minute.; Review the electronic health record for the most recent blood pressure measurement.

Answer

The correct actions include confirming the client's identity using two identifiers, assessing the apical heart rate and withholding if below 60 beats per minute, and reviewing the most recent blood pressure measurement.
Safe administration of beta-blockers requires specific pre-administration assessments and strict adherence to medication safety rights. The practical nurse must obtain the client's current blood pressure and an apical pulse for a full minute, withholding the medication if the heart rate is less than 60 beats per minute. Furthermore, fundamental safety principles dictate that the nurse must always use at least two distinct client identifiers to ensure the right medication is given to the right person.

Step-by-Step Solution

1
Identify the classification and effects of the prescribed medication.
Metoprolol is a beta-blocker, which lowers both heart rate and blood pressure.
Understanding the drug's mechanism dictates the necessary pre-administration clinical assessments.
2
Determine the required safety assessments before administering a beta-blocker.
The nurse must check the apical pulse (withholding if < 60 bpm) and the blood pressure.
Administering the medication without these checks could cause dangerous bradycardia or hypotension.
3
Evaluate the remaining options against the standard scope of practice and medication safety rights.
Mental dosage calculations, intravenous push administration, and bypassing barcode scanning are all unsafe or out-of-scope practices.
Practical nurses must adhere strictly to their defined scope of practice and universally accepted medication safety protocols.

Key Concept

Safe medication administration involves verifying patient identity, adhering to the practical nursing scope of practice, and performing specific pre-administration assessments based on the drug's physiological effects.
Question 2091Question →

A practical nurse (PN) is gathering data from a client who is 36 hours postpartum following an uncomplicated vaginal delivery of a term neonate at 40 weeks gestation. The client reports feeling very fatigued and mentions soaking a perineal pad from front to back every 45 minutes for the past two hours. The client's vital signs are temperature 99.0°F (37.2°C), heart rate 112 beats/minute, respirations 20 breaths/minute, and blood pressure 104/64 mm Hg. Which of the following actions should the PN take? Select all that apply.

Select all that apply

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Answer: Palpate the client's abdomen to evaluate the firmness and location of the uterine fundus.; Inquire if the client has emptied her bladder within the last two hours.; Notify the registered nurse (RN) immediately regarding the client's vital signs and bleeding.

Answer

The PN should palpate the abdomen to evaluate the fundus, inquire about the client's last void, and notify the registered nurse immediately.
The client's presentation of soaking a perineal pad in less than an hour coupled with tachycardia (heart rate of 112 beats/minute) strongly suggests postpartum hemorrhage and early compensatory shock. The appropriate response for a practical nurse is to gather focused, pertinent data to identify the cause (evaluating the fundus for atony and checking if a full bladder is displacing the uterus) while concurrently escalating the critical situation to the registered nurse for advanced assessment and collaborative management.

Step-by-Step Solution

1
Analyze the client's clinical data and symptoms.
The client is soaking a pad every 45 minutes and has a heart rate of 112 beats/minute.
Identifying abnormal data points (heavy bleeding and tachycardia) differentiates between expected postpartum recovery and life-threatening complications.
2
Identify the underlying complication.
The findings indicate potential postpartum hemorrhage and early hypovolemic shock.
Tachycardia is one of the earliest signs of blood loss, and soaking a pad in under an hour is the hallmark definition of heavy lochia.
3
Select interventions appropriate for the PN scope of practice.
The PN should collect further data (fundal check, bladder check) and escalate to the RN.
The PN must recognize instability, gather essential related data to identify the cause (like atony from a full bladder), and escalate immediately without exceeding their authorized scope (e.g., avoiding IV push meds).

Key Concept

Postpartum Hemorrhage Recognition and PN Scope of Practice
Question 2092Question →

A client is admitted to the progressive care unit following a cardiac catheterization utilizing a right femoral artery approach. Four hours after the procedure, the practical nurse obtains a blood pressure of 92/58 mmHg92/58 \text{ mmHg} and a heart rate of 114 beats per minute114 \text{ beats per minute}. The client exhibits mild pallor and reports feeling dizzy, but denies any localized groin pain or chest pressure. What is the priority nursing action?

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Answer: Promptly report the current hemodynamic findings and client symptoms to the supervising registered nurse.

Answer

Promptly report the current hemodynamic findings and client symptoms to the supervising registered nurse.
The client is exhibiting early signs of hypovolemic shock or potential internal bleeding, indicated by hypotension, tachycardia, pallor, and dizziness following a femoral artery puncture. The practical nurse must prioritize circulation and patient safety by immediately reporting these abnormal findings to the registered nurse or healthcare provider for further assessment and intervention.

Step-by-Step Solution

1
Analyze the client's current vital signs and symptoms in the context of the recent invasive procedure.
The blood pressure of 92/58 mmHg and heart rate of 114 beats per minute, combined with pallor and dizziness, indicate potential fluid volume deficit.
Recognizing early signs of complications is essential for preventing severe deterioration, such as hypovolemic shock from a femoral or retroperitoneal bleed.
2
Evaluate the nursing scope of practice for the identified potential complication.
The practical nurse identifies that these unstable, deteriorating findings require immediate advanced assessment and potential medical orders.
Practical nurses must promptly report critical changes in a client's condition to the supervising registered nurse or healthcare provider.
3
Determine the priority intervention among the given choices.
Escalating the findings immediately is the safest and most appropriate action.
Timely reporting ensures the client receives prompt medical intervention to manage a potential post-procedure hemorrhage.

Key Concept

Recognizing and Escalating Early Signs of Post-Procedure Hemorrhage
Question 2093Question →

An adult client is transferred to the medical-surgical unit immediately following a diagnostic cardiac catheterization performed via a right femoral artery approach. The client reports mild lower back pain and requests a change in position to relieve the discomfort. Which action by the practical nurse is the most appropriate to ensure the client's safety and comfort?

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Answer: Maintain the client in a supine position with the head of the bed elevated no more than 15 degrees, keeping the right leg completely straight.

Answer

The practical nurse should maintain the client in a supine position with the head of the bed elevated no more than 15 degrees and the affected right leg completely straight.
Following a cardiac catheterization via the femoral artery, the client must remain strictly on bed rest in a supine position for several hours. The affected extremity must be kept completely straight to prevent tension or bending at the groin, which could dislodge the clot and precipitate severe arterial bleeding. A slight elevation of the head of the bed (usually 15 to 30 degrees maximum) is permissible for basic comfort, but the right hip must remain extended at all times.

Step-by-Step Solution

1
Assess the client's request for repositioning against post-procedure safety requirements.
The client had a right femoral artery puncture, which carries a high risk of arterial hemorrhage if the site is stressed.
Identifying the procedure access site dictates strict positioning limitations that supersede routine comfort measures.
2
Determine which comfort measures do not compromise the arterial puncture site.
Any flexion of the right hip or right knee is strictly contraindicated.
Flexion puts stress on the arterial access site, which can dislodge the internal clot and cause severe, life-threatening bleeding.
3
Implement a safe positioning strategy that balances safety with basic comfort.
The client is kept flat, or elevated minimally (under 30 degrees), with the affected leg completely extended.
This position maintains continuous, even pressure on the femoral site and prevents arterial bleeding while providing some positional relief for the back.

Key Concept

Post-Cardiac Catheterization Positioning (Femoral Approach)
Question 2094Question →

A practical nurse is assisting a client who is postoperative from abdominal surgery to transfer from the bed to a chair for the first time. Arrange the following actions in the correct sequence to ensure a safe transfer.

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Answer

The correct order is to first secure and lower the bed, second assist the client to sit on the edge of the bed, third apply a transfer belt, and fourth guide the client to stand and pivot into the chair.
The correct sequence prioritizes client safety and fall prevention during a postoperative transfer. First, the bed must be secured in the lowest position with wheels locked to prevent movement. Second, the client should sit on the edge of the bed to prevent orthostatic hypotension. Third, a transfer belt is applied to provide a secure handhold. Finally, the client is assisted to stand, pivot, and sit in the chair.

Step-by-Step Solution

1
Secure the environment
The bed is lowered to its lowest height and the wheels are locked.
This prevents the bed from moving during the transfer and minimizes the distance to the floor.
2
Position the client
The client is assisted to sit on the edge of the bed.
Allowing the client to dangle their legs stabilizes blood pressure and prevents dizziness.
3
Apply safety equipment
A transfer belt is applied around the client's waist.
The belt provides a secure handhold to support the client's weight safely.
4
Execute the transfer
The client stands, pivots, and sits in the chair.
This completes the safe transfer from the bed to the chair.

Key Concept

Safe postoperative mobility requires environmental safety, prevention of orthostatic hypotension, and the use of assistive devices like a transfer belt.
Question 2095Question →

During the evening shift on a surgical unit, a practical nurse receives handoff report on a client recovering from a subtotal thyroidectomy performed earlier that day. The client reports mild incisional pain, is permitted a clear liquid diet, and strictly follows cultural dietary practices that prohibit consuming beef and pork products. Which care measures should the nurse implement? Select all that apply.

Select all that apply

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Answer: Maintain the bed in a semi-Fowler's position to facilitate breathing and decrease neck edema.; Apply a prescribed ice collar lightly over the anterior neck to relieve pain and reduce swelling.; Place both hands behind the client's neck to provide manual support when assisting the client to sit upright.

Answer

The correct actions include maintaining a semi-Fowler's position, applying an ice collar to the neck, and manually supporting the back of the neck during movement.
Appropriate care after a subtotal thyroidectomy focuses on minimizing airway edema and protecting the surgical site. Maintaining a semi-Fowler's position and applying an ice collar both work to reduce swelling and promote venous drainage. Manually supporting the head and neck during position changes prevents tension on the suture line, reducing pain and the risk of wound dehiscence.

Step-by-Step Solution

1
Analyze the client's postoperative surgical needs.
The client requires interventions that prevent airway obstruction from edema and protect the neck incision.
Thyroidectomy incisions are in close proximity to the trachea, making airway patency the highest clinical priority.
2
Identify appropriate positioning and comfort measures.
Semi-Fowler's positioning, cold application, and manual neck support are selected.
These actions directly decrease local swelling and prevent mechanical tension on the surgical sutures.
3
Evaluate the remaining options against safety standards and cultural constraints.
The supine position, beef broth, and IV push medication are rejected.
They represent improper positioning, cultural dietary ignorance, and an out-of-scope practice violation, respectively.

Key Concept

Postoperative care for neck surgery prioritizes airway maintenance through head elevation, prevention of incisional tension, and adherence to safe practice boundaries and cultural preferences.
Question 2096Question →

A practical nurse (PN) is collecting data from a client at a primary care clinic. The client's adult child died unexpectedly eight months ago. The client tearfully states, 'I was functioning okay for a while, but this week I am just so angry and I can't stop crying. I feel like I am not making any progress.' Which response by the PN is the most appropriate?

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Answer: Grieving does not always follow a straight line, and it is normal to experience returning waves of intense emotion.

Answer

The most appropriate response is to validate the client's feelings by explaining that grief is an individualized, non-linear process and that experiencing returning waves of emotion is a normal expectation.
The correct answer provides validation and reassurance by acknowledging that grief is a dynamic, individualized journey. It avoids placing the client's experience into a rigid framework and normalizes the fluctuating emotions the client is experiencing, which is a key component of therapeutic communication.

Step-by-Step Solution

1
Analyze the client's statement.
The client is expressing distress over feeling angry and tearful again after a period of functioning well.
Identifying the client's core concern (feeling like they are failing at the grieving process) is necessary to formulate a supportive response.
2
Evaluate the principles of normal grief.
Grief is a highly individualized, dynamic process that does not follow a strict linear timeline; regressions or 'waves' of grief are expected.
Understanding normal versus complicated grief helps the nurse provide accurate reassurance.
3
Select the most therapeutic communication technique.
The response that normalizes the non-linear nature of grief without giving advice, asking 'why', or imposing rigid stages is the best choice.
Therapeutic communication focuses on validating the client's experience and encouraging expression without judgment.

Key Concept

Normal grief is a dynamic, fluctuating process rather than a linear progression of stages, and therapeutic communication requires validating the client's individualized experience.
Question 2097Question →

A practical nurse (PN) is providing morning care for an older adult resident in a long-term care facility. The PN observes several distinct, thumb-shaped bruises on the resident's inner arms. When asked about the bruises, the resident looks down and whispers, "The night aide squeezed me too hard when I wouldn't go to sleep." Which action must the PN take first to advocate for this resident?

Show answer & explanation

Answer: Document the resident's exact statement and immediately notify the charge nurse or facility administration.

Answer

Document the resident's exact statement and immediately notify the charge nurse or facility administration.
Practical nurses are legally designated as mandated reporters. When a vulnerable adult presents with suspicious injuries and alleges abuse, the nurse's immediate priority is to ensure the client's safety and report the suspicion to the designated facility authority (such as the charge nurse or administrator). The nurse must objectively document the physical findings and the client's exact words without attempting to investigate the matter independently.

Step-by-Step Solution

1
Assess the resident for any immediate physical danger or need for urgent medical treatment.
The resident is determined to be safe in the current moment, as the alleged abuser is no longer present.
Client safety is always the primary and immediate priority in any suspected abuse situation.
2
Listen to the resident's statement and observe physical findings without asking leading questions.
The PN gathers the resident's direct quote regarding the incident and notes the specific location and shape of the bruises.
Preserving the resident's exact words and maintaining objective physical descriptions ensures accurate documentation and aids in the subsequent official investigation.
3
Report the suspected abuse to the immediate supervisor (charge nurse or administrator).
The chain of command is activated to begin a formal investigation, notify authorities, and protect the resident.
Practical nurses are mandated reporters; they are legally obligated to report suspicions of abuse immediately, without waiting for definitive proof.

Key Concept

Mandatory Reporting of Suspected Abuse
Question 2098Question →

Three days after moving into a residential care community, an 82-year-old client suddenly becomes highly restless, exhibits disorganized thinking, and cannot recognize the facility staff. The client's family assumes this is just the stress of the major life change. Which action should the practical nurse prioritize?

Show answer & explanation

Answer: Obtain a complete set of vital signs and immediately notify the supervising nurse of the acute changes.

Answer

The practical nurse should obtain a complete set of vital signs and immediately notify the supervising nurse of the acute changes.
Sudden onset of confusion, restlessness, and disorganized thinking are classic signs of delirium, an acute and potentially life-threatening medical condition often caused by infections, hypoxia, or metabolic imbalances. In older adults, these symptoms should never be dismissed as normal aging or stress from a life transition. The practical nurse's priority is to collect baseline data, such as vital signs, and report the acute change in condition to the supervising nurse or provider immediately.

Step-by-Step Solution

1
Analyze the client's clinical presentation and the family's concerns.
The client is exhibiting sudden, acute changes in cognition and behavior (restlessness, disorganized thinking, failure to recognize staff), which the family mistakenly attributes to the stress of moving.
Recognizing the difference between expected transition stress and acute pathology is essential for client safety.
2
Determine if the symptoms align with a normal developmental or life transition.
Sudden onset confusion is a classic presentation of delirium, an acute medical emergency often triggered by infection, hypoxia, or medication changes, not a normal transition.
Normalizing acute confusion delays critical medical interventions and can lead to severe client harm.
3
Identify the appropriate nursing action within the practical nurse's scope of practice.
The nurse must collect baseline physical data (vital signs) and report the findings to the RN or provider for a comprehensive medical assessment.
Immediate communication ensures the client receives prompt evaluation for underlying physiological causes of the delirium.

Key Concept

Differentiating acute pathological changes (such as delirium) from expected developmental and transition-related stress in older adults.
Question 2099Question →

A practical nurse (PN) is reviewing psychosocial data for several clients on a medical-surgical unit. Match each client statement or behavior to the specific ego defense mechanism being demonstrated.

Click a left item, then click its matching right item

Items

A client diagnosed with severe emphysema continues to smoke, stating, 'My grandfather smoked two packs a day until he was 90 and never had lung problems.'
A client who is terrified of their upcoming open-heart surgery calmly reads medical journals and explains the exact anatomical steps of the procedure to visitors.
A client gets into a heated, shouting argument with the physical therapist, then later that afternoon offers to buy the therapist a coffee from the cafeteria.
A client experiencing intense grief after a sudden pregnancy loss smiles brightly and tells everyone on the unit, 'I am just so incredibly joyful today!'

Matches

Show answer & explanation

Answer

The client justifying smoking matches Rationalization; the client reading surgical steps matches Intellectualization; the client offering coffee after an argument matches Undoing; and the grieving client expressing extreme joy matches Reaction Formation.
Each behavior specifically aligns with the psychiatric definitions of these defense mechanisms. Identifying these mechanisms allows the practical nurse to understand the root of the client's anxiety and plan therapeutic communication strategies to support their coping process.

Step-by-Step Solution

1
Analyze the first scenario regarding the client with emphysema.
The client is making excuses for continuing a harmful habit. This matches Rationalization.
Rationalization involves justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations.
2
Analyze the second scenario regarding the client awaiting open-heart surgery.
The client is using excessive logic and reading medical journals to avoid fear. This matches Intellectualization.
Intellectualization is a process in which events are analyzed based on remote, cold facts and without passion, rather than incorporating feeling and emotion.
3
Analyze the third scenario regarding the client who argued with the therapist.
The client tries to make up for a bad action by doing a good deed. This matches Undoing.
Undoing is performing an action to make up for a previous behavior or thought that was considered unacceptable.
4
Analyze the fourth scenario regarding the grieving client.
The client is demonstrating an emotion that is the exact opposite of what they actually feel. This matches Reaction Formation.
Reaction formation occurs when unacceptable feelings or behaviors are controlled and kept out of awareness by developing the opposite behavior or emotion.

Key Concept

Adaptive and Maladaptive Ego Defense Mechanisms
Question 2100Question →

A practical nurse is preparing to assist a client with their lunch. The client is 48 hours postoperative following a right carotid endarterectomy and experienced a perioperative right-hemisphere ischemic stroke. This complication resulted in left-sided hemiplegia, left homonymous hemianopsia, and mild dysphagia. Which sequence of basic care and positioning actions should the nurse implement?

Show answer & explanation

Answer: Place the client in a high-Fowler's position, set the meal tray on the client's right side, and instruct the client to tuck their chin to their chest when swallowing.

Answer

Place the client in a high-Fowler's position, set the meal tray on the client's right side, and instruct the client to tuck their chin to their chest when swallowing.
This sequence addresses all of the client's specific physiological needs safely. The high-Fowler's position and chin-tuck maneuver are essential dysphagia precautions that protect the airway and prevent aspiration. Placing the meal tray on the right side accommodates both the left-sided paralysis and the left homonymous hemianopsia, allowing the client to see the food and feed themselves using their intact right arm.

Step-by-Step Solution

1
Analyze the client's visual and motor deficits based on the right-hemisphere stroke.
A right-hemisphere stroke causes left-sided hemiplegia (paralysis) and left homonymous hemianopsia (loss of the left visual field in both eyes).
Understanding the specific neurological deficits dictates where objects should be placed to promote the client's safety and independence.
2
Determine the optimal placement for the meal tray.
The tray must be placed on the client's right side.
Placing the tray on the right side aligns with the client's intact visual field and allows them to use their functional right arm to eat.
3
Identify the safest positioning for a client with dysphagia.
The client must be positioned fully upright in a high-Fowler's position (90 degrees).
An upright position uses gravity to help food travel down the esophagus and prevents accidental aspiration into the lungs.
4
Determine the appropriate swallowing technique to protect the airway.
The client should use the chin-tuck maneuver during swallowing.
Tucking the chin toward the chest narrows the airway opening (larynx), significantly reducing the risk of food or liquid entering the trachea.

Key Concept

Basic care and positioning for a client with stroke-induced neurological deficits and dysphagia requires absolute airway protection (high-Fowler's position, chin tuck) and environmental adaptation (approaching and placing items on the unaffected side).
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