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Question 201Question →

An unresponsive client requires morning oral hygiene. How should the nurse sequence the following interventions? (Arrange the steps from first to last.)

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Answer

The correct sequence is to first turn the client onto their side, then arrange the towel and basin, proceed to swab the oral cavity, and finally apply moisturizer to the lips.
The absolute priority when providing oral care to an unresponsive client is airway management. Positioning the client on their side must always occur first to allow fluids to drain out of the mouth, thereby preventing aspiration. After the airway is secure, preparation of the physical environment with a towel and basin ensures cleanliness. The actual mechanical cleaning of the oral cavity follows. Finally, applying a water-soluble moisturizer provides comfort and preserves skin integrity.

Step-by-Step Solution

1
Protect the airway
The client is placed in a side-lying position.
An unresponsive client lacks an intact gag reflex. Turning them on their side ensures fluids drain out of the mouth rather than pooling in the back of the throat, which prevents aspiration.
2
Prepare the immediate area
A towel and emesis basin are placed near the client's face.
This setup catches oral secretions and cleaning solutions, keeping the client's skin and bed linens dry and clean.
3
Perform oral hygiene
The teeth, gums, and tongue are gently cleansed.
Using a moistened sponge removes plaque, bacteria, and crusts to maintain oral health.
4
Provide skin protection
Water-soluble moisturizer is applied to the lips.
Moisturizer prevents the lips from drying, cracking, and bleeding, completing the comfort care procedure.

Key Concept

Oral Hygiene for the Unresponsive Client
Question 202Question →

A practical nurse is providing instructions to a female client who needs to collect a midstream clean-catch urine specimen for laboratory analysis. In what order should the nurse instruct the client to perform these actions? Arrange the steps in the correct chronological sequence.

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Answer

The correct sequence for a midstream clean-catch urine collection is: cleanse the perineal area, begin voiding into the toilet, place the container in the active stream, remove the container before stopping urination, and securely apply the lid.
The correct chronological sequence ensures the urine sample is as sterile as possible. Cleansing the area removes surface bacteria. Voiding a small amount flushes the urethra. Collecting the midstream sample captures urine directly from the bladder. Removing the cup before stopping prevents terminal contamination, and securing the lid safely finalizes the aseptic technique.

Step-by-Step Solution

1
Identify the first necessary action to prevent specimen contamination.
Cleanse the perineal area from front to back with the provided antiseptic wipes.
Removing external bacteria from the meatus is the essential first step before any urination begins.
2
Determine the next action to further clear potential contaminants.
Begin voiding a small amount of urine directly into the toilet.
The initial stream flushes resident bacteria out of the distal urethra.
3
Identify when to actually collect the urine sample.
Place the sterile specimen container into the active stream to collect the sample.
The midstream portion of the urine represents the most uncontaminated sample from the bladder.
4
Determine the action needed to conclude the collection safely.
Remove the specimen container from the urine stream before stopping urination.
Pulling the cup away while the stream is still strong prevents contamination from the skin as the flow dwindles.
5
Identify the final step to secure the specimen.
Securely apply the lid to the container without touching its inner surface.
Properly sealing the container maintains its internal sterility until it reaches the laboratory.

Key Concept

Specimen Collection protocols to reduce the risk of false-positive laboratory results.
Question 203Question →

A practical nurse is preparing to apply a newly prescribed transdermal clonidine patch to a client with hypertension. The client currently has an old patch in place on their right upper chest. In what order should the nurse perform the following actions?

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Answer

The correct sequence is to first don clean gloves and remove the old patch, fold it in half for disposal, cleanse and dry a new application site, apply the new patch with firm pressure, and finally label the patch with the date, time, and initials.
Applying a transdermal patch requires a systematic approach to ensure safety for both the client and the nurse. The nurse must first protect themselves with gloves and remove the old patch to prevent a medication overdose. The old patch is immediately folded and discarded safely. A new site is then cleansed and dried to prevent irritation and ensure adhesion. The new patch is applied with pressure, and finally, it is labeled so the next nurse knows when it was administered.

Step-by-Step Solution

1
Don clean gloves and remove the old patch.
The client is no longer receiving medication from the previous patch.
Gloves protect the nurse from absorbing the medication. Removing the old patch first prevents delivering a double dose.
2
Fold the old patch in half with the adhesive sides together and discard it.
The old patch is safely secured.
This prevents anyone else from accidentally coming into contact with residual medication on the patch.
3
Cleanse a new, hairless application site and allow it to dry completely.
A fresh, clean site is prepared.
Site rotation prevents tissue breakdown. Clean, dry skin is necessary for the adhesive to work properly.
4
Apply the new patch and hold it firmly in place for 10 to 15 seconds.
The new patch is securely attached.
Applying pressure ensures the edges do not peel up and the medication will be absorbed properly.
5
Write the date, time, and initials on the outside of the new patch.
The administration is clearly documented.
Proper labeling communicates with the rest of the nursing staff so they know exactly when the patch was placed.

Key Concept

Transdermal Medication Administration
Estimated Time:1m 0s
Question 204Question →

A practical nurse is preparing to perform a routine capillary blood glucose test for a client with diabetes mellitus. In what order should the nurse perform the following actions to obtain an accurate sample and minimize complications? Arrange the steps from first to last.

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Answer

The correct sequence is to first clean the site with alcohol, allow it to dry completely, puncture the side of the finger, wipe away the initial drop of blood, and then apply the second drop to the test strip.
To obtain an accurate capillary blood glucose reading and reduce the risk of potential complications, the practical nurse must follow a strict procedural sequence. First, the site is cleaned to prevent infection. Second, the alcohol must dry completely to prevent it from altering the glucose reading. Third, the puncture is made on the less sensitive side of the finger. Fourth, the first drop of blood is wiped away because it contains tissue fluid that dilutes the sample. Finally, the second drop of pure capillary blood is applied to the test strip for an accurate measurement.

Step-by-Step Solution

1
Clean the selected puncture site with an alcohol swab.
The skin surface is sanitized.
Reduces the risk of infection by removing surface pathogens before breaking the skin.
2
Allow the alcohol on the skin to dry completely.
The alcohol evaporates from the puncture site.
Prevents alcohol from mixing with the blood sample, which can cause an inaccurate glucose reading and increase stinging for the client.
3
Puncture the lateral aspect of the fingertip using a sterile lancet.
A small capillary puncture is created.
The side of the finger has a rich blood supply but fewer nerve endings, minimizing client discomfort.
4
Wipe away the first drop of blood using a dry, sterile gauze pad.
The initial blood drop is removed.
The first drop contains tissue fluids that can dilute the blood sample and skew the test result.
5
Apply the second drop of blood directly to the reagent test strip.
The sample is collected on the strip.
The second drop consists of pure capillary blood, providing the most accurate glucose measurement.

Key Concept

Proper technique for capillary blood glucose sampling ensures accurate diagnostic results and minimizes the risk of client harm or discomfort.
Question 205Question →

A practical nurse and an unlicensed assistive personnel (UAP) are preparing to move a postoperative client up in bed using a draw sheet. Arrange the following actions in the correct chronological sequence to ensure client and staff safety.

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Answer

The correct sequence is to first flatten and raise the bed, then protect the client's head with a pillow, have the client cross their arms and bend their knees, grasp the draw sheet closely on both sides, and finally execute the move on a synchronized count.
Moving a client up in bed safely requires strict adherence to body mechanics and safety protocols. Flattening the bed removes gravity as an obstacle. Placing a pillow at the headboard protects the client from head trauma. Having the client fold their arms and bend their knees minimizes friction and allows them to assist with the move. Grasping the draw sheet closely provides the necessary leverage, and moving synchronously on a count ensures smooth, safe repositioning.

Step-by-Step Solution

1
Position the bed flat and adjust the height.
Gravity resistance is minimized and working posture is optimized.
This establishes a safe starting environment that prevents musculoskeletal injuries.
2
Place a pillow against the headboard.
The headboard is padded.
This prevents trauma to the client's head if they slide up too quickly.
3
Instruct the client to cross arms and bend knees.
Friction is reduced and the client is ready to assist.
Keeping limbs compact prevents injury and bending knees provides client leverage.
4
Grasp the rolled draw sheet tightly.
A secure hold is established on the lifting device.
Holding near the client's body maximizes mechanical advantage.
5
Shift weight and move on the count of three.
The client is safely repositioned higher in the bed.
Synchronized teamwork ensures a smooth transfer without jerking motions.

Key Concept

Safe client handling, body mechanics, and mobility transfers
Question 206Question →

A client who is comatose due to a traumatic brain injury requires routine oral hygiene. Arrange the steps the practical nurse should take to safely provide mouth care in the correct sequence.

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Answer

The correct sequence prioritizes airway safety by first positioning the client laterally, followed by preparing the equipment, safely accessing the oral cavity, performing the cleaning, and finally removing the fluids with suction.
The sequencing of oral care for an unconscious client is strictly dictated by airway safety. Positioning the client laterally is always the first priority to prevent aspiration. Only after the airway is protected from gravity-induced pooling should the nurse prepare the linens, open the mouth safely with an instrument, perform the hygiene, and finally suction out the debris.

Step-by-Step Solution

1
Establish a safe position for the unconscious client.
The client is placed in a lateral (side-lying) position with the head turned to the side.
Because the client cannot swallow or expectorate, this position allows fluids to drain out of the mouth, preventing pulmonary aspiration.
2
Prepare the immediate area.
A towel and emesis basin are placed under the client's chin and cheek.
This protects the bed linens and provides a direct path for fluids to drain into the basin.
3
Open the oral cavity safely.
A padded tongue blade is inserted between the upper and lower back teeth.
This ensures safe access to the oral cavity without risking injury to the nurse's fingers if the client experiences an involuntary bite reflex.
4
Perform oral hygiene.
The oral cavity is thoroughly cleaned with a moistened sponge swab or soft-bristled toothbrush.
Cleaning removes plaque, bacteria, and crusts, preventing infection and maintaining the integrity of the mucous membranes.
5
Remove excess fluids.
The mouth is suctioned using a Yankauer or standard suction catheter.
Suctioning eliminates pooling fluids and loosened secretions, completing the cleaning process while continuing to protect the airway.

Key Concept

Oral Care for the Unconscious Client (Aspiration Prevention)
Question 207Question →

A primary health care provider prescribes a deep intramuscular injection of iron dextran for an adult client with severe anemia. To prevent superficial tissue irritation and skin staining, the practical nurse must utilize the Z-track technique. Arrange the following procedural steps for preparing and administering this medication in the correct chronological order.

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Answer

The correct sequence is: draw the medication and replace the needle, displace the skin laterally, insert the needle at 90 degrees, inject slowly, wait 10 seconds, and finally withdraw the needle while releasing the skin.
The Z-track method is meticulously designed to seal highly irritating or staining medications (such as iron dextran) deep within the muscle tissue. The process begins with drawing up the medication and strictly changing the needle to ensure no residue is on the needle shaft. Next, the skin is pulled laterally to displace the tissue layers. The needle is then inserted at a 90-degree angle, and the medication is injected slowly. The nurse must wait 10 seconds before withdrawing the needle to allow the fluid to disperse and prevent backflow. Finally, withdrawing the needle and immediately releasing the skin creates a staggered track, effectively trapping the medication in the muscle layer and preventing superficial damage.

Step-by-Step Solution

1
Draw up the medication and change the needle.
A sterile needle without irritating medication residue on the outside is attached to the syringe.
Prevents tracking of the highly irritating or staining medication through superficial tissues during insertion.
2
Displace the skin and subcutaneous tissue laterally.
The superficial tissue layers are misaligned with the deeper muscle layers.
Creates the mechanical foundation required for the Z-track seal.
3
Insert the needle at 90 degrees and inject slowly.
Medication is deposited deep into the ventrogluteal muscle.
Ensures proper depth, prevents subcutaneous pooling, and minimizes tissue trauma.
4
Wait 10 seconds before needle withdrawal.
The medication begins to disperse into the surrounding muscle.
Prevents immediate backflow of the fluid into the needle track.
5
Withdraw the needle and simultaneously release the skin.
The tissue layers slide back into their natural alignment.
The staggered needle track is closed, physically sealing the medication deep within the muscle layer.

Key Concept

Safe Administration of Intramuscular Medications utilizing the Z-Track Method
Question 208Question →

A practical nurse is assisting with a community workshop for parents on childhood development. Arrange the following play behaviors in the chronological sequence in which they typically emerge, from earliest (first) to latest (last).

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Answer

The correct chronological sequence of play development is solitary play, parallel play, associative play, and finally cooperative play.
Play behavior progresses from independent, self-focused activity to complex, rule-based social interactions as a child grows. The correct chronological sequence begins with solitary play in infancy, followed by parallel play in toddlerhood, associative play in the preschool years, and finally cooperative play in school-age children.

Step-by-Step Solution

1
Identify the play behavior that corresponds to the earliest developmental stage (infancy).
Solitary play (playing independently with blocks) is the first stage to emerge.
Infants primarily focus on exploring their environment and objects on their own without actively engaging others.
2
Identify the play behavior typical of the next stage (toddlerhood).
Parallel play (playing next to, but not with, another child) emerges second.
Toddlers enjoy the company of others but are still highly egocentric and do not yet actively collaborate.
3
Identify the play behavior characteristic of the preschool years.
Associative play (sharing materials without a coordinated goal) emerges third.
Preschoolers become more social and interact during play, but they do not yet organize into structured, goal-oriented games.
4
Identify the most advanced play behavior, typical of school-age children.
Cooperative play (structured games with rules) is the final stage to develop.
School-age children have the cognitive and social maturity to follow established rules and work together toward a shared goal.

Key Concept

Stages of childhood play development (Solitary, Parallel, Associative, Cooperative)
Question 209Question →

While rounding on a clinical unit, a practical nurse discovers a client with a continuous nasogastric tube feeding who has suddenly started coughing vigorously and expelling liquid formula from the mouth. The client is visibly struggling to breathe. Drag and drop the following nursing actions into the correct priority sequence from first to last.

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Answer

The correct sequence is to halt the feeding pump, turn the client to a lateral position, suction the airway, assess vital signs, and report the event to the charge nurse.
According to the ABC (Airway, Breathing, Circulation) priority framework, the immediate focus during an active aspiration event is to remove the source of the problem and protect the airway. Halting the feeding pump stops additional formula from entering the lungs. Turning the client to a lateral decubitus position uses gravity to drain emesis and prevent further aspiration of stomach contents. Clearing the upper airway with oropharyngeal suctioning removes any residual fluid that could be inhaled. Once the airway is stabilized and the immediate life threat is resolved, assessing vital signs and pulse oximetry provides critical data about the client's physiological adaptation. Finally, the practical nurse must report the acute event and the gathered assessment data to the supervising charge nurse or registered nurse for further medical evaluation.

Step-by-Step Solution

1
Analyze the clinical presentation utilizing the Airway, Breathing, and Circulation (ABC) priority framework.
The client is experiencing an active aspiration event causing acute respiratory distress.
Immediate airway protection is the highest priority in sudden respiratory emergencies.
2
Identify the immediate intervention required to stop the cause of the emergency.
Halting the enteral feeding pump is prioritized as the first physical action.
Continuing the infusion of formula will exacerbate the aspiration and further compromise the airway.
3
Determine the physical interventions necessary to secure the airway.
Assisting the client into a lateral position and performing oropharyngeal suctioning are selected next.
The lateral position allows gravity to drain the fluid, and suctioning removes residual formula, effectively clearing the airway.
4
Select the appropriate follow-up clinical assessment and communication steps.
Vital signs are assessed, followed by reporting the incident to the charge nurse.
Once the immediate threat is mitigated, current physiological data must be collected before handing over the situation for advanced medical interventions.

Key Concept

Prioritization of airway management and aspiration precautions during an acute emergency.
Question 210Question →

A client recovering from a stroke is receiving continuous enteral nutrition via a nasogastric tube. The practical nurse is preparing to administer a scheduled dose of liquid acetaminophen through the tube. Arrange the following actions in the correct sequence to safely complete this medication administration.

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Answer

Pause the feeding pump, verify tube placement and residual volume, flush the tube with water, administer the medication, and complete a final flush before restarting the feeding.
The correct sequence ensures patient safety and tube patency. First, the feeding is paused to prevent mixing. Second, placement and residual volume are checked to confirm gastrointestinal function and prevent aspiration. Third, a pre-flush clears the tube. Fourth, the medication is administered. Finally, a post-flush delivers the full dose into the stomach and clears the tube before resuming the feeding.

Step-by-Step Solution

1
Pause the continuous enteral feeding pump.
The flow of enteral formula is stopped.
Prevents the mixing of nutritional formula with the medication, which can cause coagulation and blockages.
2
Verify tube placement and assess gastric residual volume.
Stomach placement and digestive function are confirmed.
Ensures the medication will safely enter the stomach and that the client is not at risk for aspiration due to delayed gastric emptying.
3
Flush the enteral tube with 15 to 30 mL of sterile water.
The tube is cleared of any residual formula.
Maintains tube patency and prevents chemical interactions between the enteral formula and the medication.
4
Administer the liquid medication.
The medication is instilled into the tube.
Delivers the prescribed pharmacological therapy.
5
Flush the tube with an additional 15 to 30 mL of sterile water and restart the pump.
The tube is cleared and continuous feeding resumes.
Pushes the remaining medication into the stomach, prevents tube clogging, and restores nutritional support.

Key Concept

Enteral Tube Medication Administration
Question 211Question →

A practical nurse (PN) is caring for a client who is receiving continuous enteral tube feedings via a nasogastric (NG) tube. The client suddenly begins to vomit and cough forcefully, and their oxygen saturation drops to 88%. Arrange the following nursing actions in the correct priority order from first to last.

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Answer

The correct priority order is to first stop the continuous enteral feeding pump, then turn the client to a side-lying position, next suction the oropharynx, apply supplemental oxygen, and finally notify the registered nurse (RN).
In any acute aspiration event associated with a continuous infusion, the nurse must first stop the source of the problem (the feeding pump). Next, the nurse must immediately protect the airway by utilizing gravity (side-lying position) to allow emesis to drain. Once positioned, the nurse suctions the oropharynx to actively clear residual fluid. Only after the airway is patent and clear should supplemental oxygen be applied to treat the hypoxia. Finally, after these rapid, life-saving bedside interventions are implemented, the nurse must notify the RN and healthcare provider for further assessment and orders.

Step-by-Step Solution

1
Stop the continuous enteral feeding pump immediately.
The infusion of formula into the stomach is halted.
Removing the ongoing source of potential aspiration is the absolute first priority to prevent worsening of the respiratory compromise.
2
Turn the client into a side-lying position.
The airway is protected via gravity.
Allowing emesis to drain out of the mouth prevents fluid from pooling into the trachea. This must be done before suctioning if the client is actively vomiting.
3
Suction the oropharynx to clear emesis and secretions.
The airway is actively cleared of residual fluid.
Ensuring a patent airway is required before any oxygen therapy can be effective.
4
Apply supplemental oxygen to address the hypoxia.
Oxygen saturation levels improve.
Treats the acute hypoxia (88% SpO2) caused by the aspiration event now that the airway is clear.
5
Notify the registered nurse (RN) regarding the aspiration event.
The healthcare team is alerted.
Escalates the situation for further medical assessment, respiratory therapy involvement, and provider orders after the client is initially stabilized.

Key Concept

Airway Protection and Emergency Prioritization in Enteral Feeding
Estimated Time:2m 0s
Question 212Question →

A practical nurse is tasked with collecting an aerobic wound culture from a client's healing surgical incision. To ensure an accurate specimen and minimize the risk of sample contamination, in what chronological order should the nurse perform the following actions?

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Answer

The correct sequence for collecting a wound culture is to first remove the dressing and assess the wound, then cleanse the area with sterile saline, collect the specimen from clean granulation tissue, insert the swab into the transport tube, and finally label the container for transport.
To collect a clinically accurate wound culture and reduce the risk of sample contamination, the nurse must follow a strict sequential protocol. First, the wound is exposed by removing the old dressing. Second, it is critical to irrigate or cleanse the wound with sterile saline to remove surface exudate and resident skin flora. Third, the nurse swabs clean, viable granulation tissue rather than pus or necrotic tissue to capture the true pathogen. Fourth, the swab is immediately secured in the transport tube to maintain sterility. Finally, the container is labeled at the bedside to ensure accurate client identification before it leaves the room.

Step-by-Step Solution

1
Remove the existing dressing and visually assess the wound bed.
The wound is exposed and ready for preparation.
Assessment dictates the exact location for sample collection and reveals the condition of the surgical site.
2
Cleanse the wound gently with sterile normal saline.
Surface exudate and colonizing skin flora are washed away.
Culturing uncleaned exudate will yield inaccurate results that do not reflect the true infecting pathogen.
3
Rotate a sterile swab over an area of clean granulation tissue.
The pathogen responsible for the deeper infection is collected on the swab.
Granulating tissue provides the most accurate representation of the wound's microbial environment.
4
Insert the swab into the appropriate transport tube without touching the outer edges.
The specimen is safely contained within a sterile environment.
This maintains the sterility of the sample and prevents the introduction of outside environmental microbes.
5
Secure the cap, label the specimen container, and prepare it for laboratory transport.
The specimen is properly identified and secured for diagnostic evaluation.
Immediate labeling at the bedside prevents specimen mix-ups and ensures safe transport.

Key Concept

Proper wound culture technique requires cleansing the wound prior to swabbing to isolate the true infectious pathogen and prevent sample contamination.
Question 213Question →

The practical nurse (PN) is observing a client in a long-term care facility's busy dining room. The client, who was recently fitted with new bilateral hearing aids, suddenly becomes visibly agitated, covers their ears with their hands, and attempts to leave the room quickly. In which order should the PN perform the following nursing actions? Arrange the actions from first to last.

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Answer

The PN must first approach the client calmly, then remove the client from the overstimulating environment, adjust the hearing aids in a quiet space, and finally document the event.
For a client experiencing acute sensory overload, the nursing priority is safety and stimulus reduction. The PN must first approach the client safely, remove them from the overwhelming environment, correct the direct cause of the overload, and conclude with proper documentation.

Step-by-Step Solution

1
Approach the client calmly from the front.
The client sees the nurse and is not startled.
Establishes a non-threatening, therapeutic presence during a moment of acute distress.
2
Guide the client to a quiet, low-stimulus environment.
The client is removed from the excessive noise.
Sensory overload requires immediate reduction of environmental stimuli to prevent escalation of agitation.
3
Assist the client with adjusting the hearing aid volume.
The direct source of auditory amplification is controlled.
Addressing the physical equipment is easier and more effective once the client is in a calmer setting.
4
Document the incident in the client's chart.
The healthcare team is informed of the client's intolerance to the current hearing aid settings in loud environments.
Evaluation and documentation must occur after the client is physically and emotionally stabilized.

Key Concept

Management of Sensory Overload
Question 214Question →

The healthcare provider prescribes an aerobic wound culture for a client with a pressure injury on the sacrum. To obtain the specimen accurately and reduce the risk of contaminated diagnostic results, in what order should the practical nurse perform the following actions? Arrange the steps from first to last.

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Answer

The correct sequence is to first remove the dressing and evaluate the wound, then cleanse the wound with normal saline, next swab the viable granulation tissue, place the swab in the transport tube, and finally label the container at the bedside.
The correct sequence ensures the integrity of the diagnostic specimen, which is a critical risk reduction strategy. The wound must first be exposed and assessed. Next, it MUST be cleansed with sterile saline to remove surface contamination. Once clean, the swab is rotated on viable granulation tissue where the active pathogen resides. The swab is then safely secured in the transport tube to maintain sterility. Finally, labeling at the bedside prevents specimen mix-ups and ensures accurate diagnostics.

Step-by-Step Solution

1
Remove the existing dressing and evaluate the status of the wound bed.
The wound is exposed for care.
This is necessary to access the site and determine the appropriate area for sampling.
2
Cleanse the wound thoroughly using sterile 0.9% sodium chloride.
Surface exudate and colonizing skin flora are removed.
This prevents contamination of the culture with non-pathogenic surface bacteria, ensuring an accurate diagnostic result.
3
Rotate a sterile swab gently over an area of healthy-looking granulation tissue.
The specimen is collected from actively infected viable tissue.
This provides the most accurate representation of the underlying pathogen.
4
Place the swab into the sterile culture transport tube without touching the edges.
The specimen is secured in its sterile container.
This maintains sterility and prevents environmental contamination of the sample.
5
Apply the completed identification label to the specimen container at the bedside.
The specimen is accurately linked to the client.
This prevents misidentification and medical errors, standardizing safe laboratory transport.

Key Concept

When obtaining a wound culture, the nurse must cleanse the wound with sterile saline before swabbing to ensure the specimen contains the actual pathogen from viable tissue rather than surface colonization or old exudate.
Question 215Question →

While performing morning rounds, a practical nurse discovers that a client's intravenous tubing has disconnected from their central venous catheter hub. The client is suddenly gasping for air, extremely anxious, and cyanotic. To reduce the risk of a life-threatening complication, place the following nursing actions in the correct priority sequence.

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Answer

The correct priority sequence is to clamp the catheter, position the client in the left lateral Trendelenburg position, administer oxygen, activate the emergency response team, and finally obtain vital signs.
In the event of a disconnected central venous catheter accompanied by sudden respiratory distress, the nurse must suspect an air embolism. The immediate priority is risk reduction by stopping the source of harm. Clamping the catheter prevents more air from entering the heart. Positioning the client on their left side with the head down (Durant's maneuver) traps the air in the right ventricle, preventing it from blocking the pulmonary artery. Oxygen is then applied to treat severe ischemia. Only after these immediate physical stabilization steps are complete should the nurse call for emergency assistance and gather vital signs.

Step-by-Step Solution

1
Clamp the central venous catheter.
Stops further entrainment of room air into the vascular system.
Air embolism is a mechanical obstruction; stopping the source is always the immediate first step.
2
Place in left lateral Trendelenburg.
Displaces the air away from the right ventricular outflow tract.
Gravity causes the lighter air to rise to the apex of the right ventricle, keeping the pulmonary artery clear for blood flow.
3
Administer oxygen.
Reverses hypoxemia and promotes nitrogen washout.
The client is showing signs of severe respiratory distress due to impaired perfusion.
4
Activate emergency response.
Brings advanced providers and equipment to the bedside.
The client requires critical care, but the nurse must secure the airway and circulation with basic measures first.
5
Assess vital signs.
Provides quantitative data on the client's hemodynamic status.
This establishes a baseline for the arriving code team but is the lowest priority among these emergency actions.

Key Concept

Emergency management and risk reduction for suspected air embolism via central line.
Question 216Question →

During a shift on a medical-surgical unit, a practical nurse (PN) is caring for an adult client who begins to deteriorate rapidly, exhibiting severe respiratory distress. As the PN prepares to intervene, the client's sibling presents a handwritten document they claim is a valid living will refusing all mechanical ventilation. Simultaneously, the client's legally separated spouse arrives, demands that all life-saving measures be initiated immediately, and claims to be the client's designated healthcare proxy. In what order should the PN take the following actions? (Arrange the actions from first to last.)

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Answer

The correct order requires the PN to first stabilize the client physiologically, obtain the disputed legal documents from the family, escalate the emergency to the provider and charge nurse, place the documents in the medical record for formal review, and finally document the event in the nursing notes.
In acute emergencies complicated by conflicting legal claims, nursing prioritization dictates that physiological stability (Airway/Breathing) is always the first action. Nurses cannot independently interpret disputed legal documents to withhold care. After initiating basic stabilizing measures, the nurse gathers the necessary data (the documents), escalates the issue to the provider who holds the authority to resolve the conflict, ensures the documents are available for review, and completes the nursing documentation last.

Step-by-Step Solution

1
Maintain the client's airway and apply supplemental oxygen.
Basic physiological safety is maintained during a critical event.
Life preservation supersedes unverified or disputed legal directives. Emergency care cannot be withheld based on verbal claims or unreviewed documents.
2
Request that the family members provide their respective legal documents.
Crucial legal data is gathered directly from the involved parties.
The PN must have the physical documents in hand to accurately report the situation to the healthcare provider.
3
Notify the primary healthcare provider and the charge nurse.
The chain of command and medical decision-makers are activated.
Resolving proxy disputes and officially altering a client's code status requires a provider's assessment and legal/ethics team involvement.
4
Place the documents into the client's medical record.
The advance directives become accessible to the entire interdisciplinary team.
Formal evaluation of the documents by the provider and hospital administration requires them to be part of the official chart.
5
Document the clinical interventions and family statements in the nursing notes.
A complete, factual legal record of the dispute and clinical changes is created.
Thorough documentation protects the nurse and the facility, but is an administrative task that must follow direct client care and escalation.

Key Concept

Prioritization of Care amidst Disputed Advance Directives
Question 217Question →

A practical nurse (PN) is assisting a female client with collecting a midstream clean-catch urine specimen for a culture and sensitivity test. In which order should the PN perform or instruct the client to perform the following steps? (Arrange from first to last)

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Answer

The correct sequence is: cleanse the perineum, begin voiding into the toilet, collect the midstream urine, and finally secure and label the container.
To obtain an uncontaminated midstream clean-catch urine specimen, the urethral meatus must first be cleansed from front to back to remove external bacteria. The client then initiates the urine stream into the toilet to flush the distal urethra of any remaining flora. The sterile container is then introduced into the midstream flow to capture the most representative bladder sample. Finally, the container is sealed to prevent leaks and properly labeled for accurate processing.

Step-by-Step Solution

1
Identify the first action required to prevent contamination.
Cleanse the perineal area from front to back.
Reduces the number of bacteria surrounding the urethral meatus.
2
Determine the next step to further clear bacteria.
Begin voiding a small amount of urine into the toilet.
Flushes the distal urethra of remaining resident bacteria.
3
Identify when to collect the actual specimen.
Pass the sterile container into the urine stream.
The midstream portion contains the most accurate sample of bladder urine.
4
Determine the final steps for specimen handling.
Secure the lid and apply the client label.
Maintains specimen integrity and ensures correct client identification.

Key Concept

Specimen Collection: Midstream Clean-Catch Urine
Question 218Question →

An older adult client recovering from a stroke has residual left-sided weakness. The licensed practical nurse is preparing to help the client move from the bed into a wheelchair. Arrange the following actions in the correct chronological sequence to ensure a safe transfer.

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Answer

The correct sequence is to first position the wheelchair on the strong side, lock all brakes, assist the client to a dangling position, apply the transfer belt, and finally have the client pivot using their strong arm.
Safe transfer of a client with hemiplegia requires systematic preparation and execution. First, the environment must be prepared by placing the wheelchair on the client's strong side and locking all wheels. Next, the client's physiological readiness is ensured by allowing them to dangle and stabilize their blood pressure. Then, safety equipment (a transfer belt) is applied before any weight-bearing begins. Finally, the client uses their strong side to pivot and safely lower themselves into the chair.

Step-by-Step Solution

1
Position the wheelchair on the client's right side.
The equipment is properly aligned on the client's unaffected side.
Transferring toward the strong side allows the client to bear weight and pull themselves safely into the chair.
2
Engage the locking mechanisms on the bed and wheelchair.
Both the bed and the wheelchair are completely immobilized.
This prevents accidental movement of equipment that could lead to unexpected falls.
3
Assist the client to sit on the edge of the bed.
The client is upright with their legs dangling over the side of the mattress.
Promotes equilibrium and prevents a sudden drop in blood pressure (orthostatic hypotension) prior to standing.
4
Apply a transfer belt around the client's waist.
The nurse has a secure and safe point of contact.
Provides a designated handhold to control the client's center of gravity and protect both the client and nurse from injury.
5
Instruct the client to grasp the armrest with their right arm and pivot.
The client safely transitions from a standing position into the wheelchair.
Utilizes the client's remaining strength on the unaffected side to control the descent and stabilize the body.

Key Concept

Safe client transfer techniques for unilateral weakness
Question 219Question →

A practical nurse is caring for a conscious client with diabetes mellitus who suddenly reports feeling shaky and weak. The client's skin is cool and clammy, and their capillary blood glucose is 58 mg/dL. In what order should the practical nurse implement the following actions?

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Answer

The correct sequence is to administer a simple carbohydrate, wait 15 minutes, reassess the blood glucose, and finally provide a complex carbohydrate and protein snack.
The standard protocol for treating a conscious client with hypoglycemia is the 'Rule of 15'. The sequence begins with administering 15 grams of a fast-acting simple carbohydrate to rapidly raise the blood glucose. The nurse then waits 15 minutes for the sugar to absorb before reassessing the capillary blood glucose. Once the blood glucose is stabilized above 70 mg/dL, a snack containing a complex carbohydrate and protein is provided to sustain the blood glucose level and prevent a rebound hypoglycemic event.

Step-by-Step Solution

1
Administer 15 grams of a fast-acting simple carbohydrate.
Provides an immediate source of glucose to treat the hypoglycemia.
The client is symptomatic with a blood glucose of 58 mg/dL; immediate intervention is required to prevent neurological deterioration.
2
Wait 15 minutes to allow the body to absorb the sugar.
Allows time for the simple carbohydrate to enter the bloodstream.
Checking the blood glucose too soon will not accurately reflect the effect of the intervention.
3
Reassess the client's capillary blood glucose level.
Evaluates the effectiveness of the simple carbohydrate administration.
The nurse must verify that the blood glucose has risen to a safe level (typically above 70 mg/dL) or determine if another 15 grams of carbohydrate is needed.
4
Provide a complex carbohydrate and protein snack.
Maintains the blood glucose level.
Simple carbohydrates are metabolized quickly. Providing a complex carbohydrate and protein prevents a subsequent drop in blood sugar.

Key Concept

Hypoglycemia Management (Rule of 15)
Question 220Question →

A practical nurse is changing a dressing for a client who is 3 days postoperative following abdominal surgery. The client coughs forcefully, and the nurse observes loops of intestine protruding through the surgical incision. In what order should the nurse perform the following actions? (Arrange the actions from first priority to last priority.)

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Answer

The correct sequence is: 1) Remain with the client and call for immediate assistance, 2) Place the client in a low Fowler's position with the knees flexed, 3) Cover the protruding bowel with sterile, saline-moistened dressings, 4) Measure the client's vital signs, and 5) Document the evisceration event.
In an acute wound evisceration, the primary goal is to prevent further injury and stabilize the client. The practical nurse must first call for help while staying with the client to ensure continuous monitoring. Next, placing the client in a low Fowler's position with flexed knees immediately reduces intra-abdominal pressure. Once supplies arrive, the nurse covers the wound with sterile, moist dressings to preserve tissue viability. Only after the organs are protected from necrosis should the nurse assess vital signs to monitor for shock. Documentation is always the final administrative step, completed once the client is safe.

Step-by-Step Solution

1
Remain with the client and call for immediate assistance.
Assistance is secured without compromising client safety.
The client must never be left alone during an acute surgical emergency. Calling for help allows others to bring required sterile supplies and notify the provider.
2
Place the client in a low Fowler's position with the knees flexed.
Intra-abdominal pressure is reduced.
This specific positioning relaxes the abdominal muscles, reducing tension on the incision and preventing further protrusion of the internal organs.
3
Cover the protruding bowel with sterile, saline-moistened dressings.
The exposed intestinal tissue is protected.
Exposed bowel can quickly dry out, leading to tissue necrosis. Sterile, moist dressings preserve the tissue and reduce the risk of severe infection.
4
Measure the client's vital signs to assess for shock.
The client's hemodynamic status is evaluated.
Evisceration can precipitate hypovolemic shock. Once the physical site is protected, assessing vital signs guides further emergency medical interventions.
5
Document the evisceration event and the nursing interventions provided.
An accurate medical record is maintained.
Administrative tasks and documentation must always occur after the client is physically stabilized and the immediate life threat is managed.

Key Concept

Prioritization of nursing care during wound evisceration requires immediate protection of the client, reduction of abdominal tension, and preservation of the exposed organs, followed by physiological monitoring.
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