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Question 2181Question →

A practical nurse in a pediatric clinic is reinforcing teaching with caregivers about expected speech and language development from early infancy through toddlerhood. Arrange the following communication milestones in the chronological order they typically occur, from earliest to latest.

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Answer

The correct chronological sequence of communication milestones is: producing cooing sounds (earliest), babbling with consonants, using simple gestures, and finally combining words into two-word phrases (latest).
Normal speech and language development follows a predictable progression. Infants begin with simple vocalizations like cooing, progress to babbling consonant-vowel sounds, develop nonverbal communication through gestures, and eventually combine words into simple phrases as toddlers.

Step-by-Step Solution

1
Identify the earliest milestone in the first few months of life.
Produces cooing and gurgling sounds.
Cooing is one of the earliest vocalizations, typically beginning around 2 months of age.
2
Identify the next milestone in mid-infancy.
Babbles using repeating consonant-vowel combinations.
Babbling typically emerges around 6 months of age as the infant experiments with consonant sounds.
3
Identify the milestone occurring near the end of the first year.
Uses simple gestures such as waving goodbye or pointing.
Purposeful nonverbal gestures typically develop between 9 and 12 months of age.
4
Identify the milestone associated with toddlerhood.
Combines words into simple two-word phrases.
Forming simple sentences or phrases is expected around 24 months (2 years) of age.

Key Concept

Chronological progression of speech and language developmental milestones from infancy to toddlerhood
Question 2182Question →

During mealtime at a subacute care facility, a practical nurse observes a client with multiple sclerosis struggling to eat independently due to bilateral hand tremors. The client is attempting to consume a specific meal brought by their family to adhere to religious dietary laws. Which intervention best promotes the client's self-care capabilities?

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Answer: Supply the client with weighted silverware and a rimmed plate while serving the family-provided meal.

Answer

The correct action is to provide adaptive feeding equipment, such as weighted silverware and a rimmed plate, while ensuring the client receives their family-provided, culturally appropriate meal.
The correct answer emphasizes supporting the client's independence by offering specific adaptive tools designed for tremors, while concurrently respecting their religious practices by utilizing the culturally appropriate meal provided by their family.

Step-by-Step Solution

1
Assess the barrier to the client's self-care independence.
The primary barrier is impaired fine motor control (bilateral hand tremors) caused by multiple sclerosis.
Identifying the specific physical limitation helps determine the appropriate adaptive intervention.
2
Identify interventions that address the motor deficit without compromising other client needs.
Weighted silverware dampens tremors, and a rimmed plate prevents food spillage.
These adaptive devices bridge the gap between the client's functional deficit and their desire to maintain independence with ADLs.
3
Evaluate the proposed intervention against psychosocial and cultural safety requirements.
Providing the adaptive equipment allows the client to successfully eat the specific meal brought by their family.
Self-care promotion must always align with holistic care principles, including the strict observance of the client's religious and cultural dietary practices.

Key Concept

Promoting Independence in Activities of Daily Living (ADLs) through Adaptive Equipment and Cultural Competency
Question 2183Question →

A practical nurse (PN) is reviewing the electronic health record of an older adult client who is scheduled to receive a daily dose of oral warfarin. The client's morning international normalized ratio (INR) is 4.84.8. Upon entering the room, the client reports a new, severe headache. Which action should the PN take first?

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Answer: Withhold the scheduled warfarin and immediately notify the registered nurse (RN) of the laboratory result and the client's headache.

Answer

Withhold the scheduled warfarin and immediately notify the registered nurse (RN) of the laboratory result and the client's headache.
The client's INR of 4.84.8 is significantly above the standard therapeutic range of 2.02.0 to 3.03.0, indicating a severe risk of bleeding. The sudden onset of a severe headache is a critical warning sign of a potential intracranial hemorrhage. The safest and most appropriate action within the PN's scope of practice is to withhold the dose of warfarin to prevent further anticoagulation and immediately alert the RN so that emergency medical assessment can be initiated.

Step-by-Step Solution

1
Analyze the client's laboratory data.
The INR of 4.84.8 is supratherapeutic (normal therapeutic range is typically 2.02.0 to 3.03.0), placing the client at high risk for bleeding.
Recognizing critical laboratory values is essential before administering anticoagulants.
2
Evaluate the client's clinical presentation.
The client reports a new, severe headache.
A severe headache in the presence of a high INR is a clinical red flag for a potential intracranial hemorrhage.
3
Determine the appropriate nursing intervention within the PN scope of practice.
The PN must withhold the medication to prevent further bleeding and immediately report both the critical lab and the symptom to the RN.
The PN scope of practice requires reporting critical changes in condition and abnormal lab results to the supervising RN for further medical evaluation.

Key Concept

The practical nurse must recognize critical laboratory values, identify clinical signs of life-threatening adverse effects, and promptly escalate care to the RN while withholding contraindicated medications.
Question 2184Question →

Following a scheduled bowel resection, a 76-year-old client is recovering on the medical-surgical unit. Five hours post-procedure, the client becomes increasingly restless and reports severe, diffuse abdominal pain. The practical nurse (PN) obtains the following vital signs: heart rate 115 beats per minute, blood pressure 92/64 mm Hg, and respiratory rate 24 breaths per minute. Which actions should the PN prioritize? Select all that apply.

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Answer: Examine the surgical dressing and the linens underneath the client for signs of active bleeding; Promptly escalate the vital sign changes and the client's restlessness to the registered nurse; Confirm the patency of the client's peripheral intravenous access

Answer

The correct actions are to examine the surgical site for active bleeding, escalate the critical findings to the registered nurse, and confirm the patency of the intravenous access.
The client is demonstrating early signs of hypovolemic shock (tachycardia, hypotension, tachypnea, and restlessness) following major surgery. The practical nurse must prioritize actions that address this life-threatening circulatory compromise. Examining the surgical site helps identify the source of bleeding. Confirming intravenous access prepares the client for necessary fluid or blood resuscitation. Escalating the situation to the registered nurse is mandatory for further medical intervention and provider notification.

Step-by-Step Solution

1
Analyze the client's vital signs and clinical presentation.
The client is exhibiting tachycardia (115 bpm), borderline hypotension (92/64 mm Hg), tachypnea (24 breaths/min), and acute restlessness in the context of recent major abdominal surgery.
Identifying abnormal findings is the first step in clinical judgment.
2
Interpret the meaning of these combined physiological findings.
These findings are classic early indicators of hypovolemic shock, likely due to internal or external hemorrhage, rather than routine postoperative pain.
Connecting data points helps the nurse recognize life-threatening physiological adaptations.
3
Determine the priority interventions based on the airway, breathing, circulation (ABC) framework.
The nurse must prioritize interventions that address circulation (assessing for bleeding, ensuring IV access for fluid resuscitation) and escalate the critical situation to the RN.
Interventions must focus on resolving the most immediate threat to the client's life before addressing secondary issues like pain.

Key Concept

Early Recognition and Prioritization of Hypovolemic Shock
Question 2185Question →

A practical nurse (PN) is monitoring a 68-year-old client who had a left total hip arthroplasty earlier today. The client suddenly becomes restless and confused. The PN observes a widening circle of bright red sanguineous drainage on the surgical dressing. The client's heart rate has increased from 84 to 108 bpm, and blood pressure has changed from 122/76 to 104/88 mmHg. Identify the immediate actions the PN must include in the care of this client. Select all that apply.

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Answer: Reinforce the surgical dressing with sterile gauze pads and apply manual pressure; Immediately notify the registered nurse (RN) of the changes in the client's status; Verify the patency of the client's peripheral intravenous (IV) catheter

Answer

The correct actions are to reinforce the dressing with manual pressure, notify the RN immediately, and verify IV patency.
The client is demonstrating early signs of hypovolemic shock due to acute hemorrhage, evidenced by active bleeding, tachycardia, a significantly narrowed pulse pressure, and altered mental status. The priority actions are to apply manual pressure to the bleeding site to stem blood loss, ensure the IV line is patent for immediate fluid or blood product resuscitation, and immediately notify the RN to escalate the client's level of care.

Step-by-Step Solution

1
Analyze the clinical data provided in the scenario.
The client exhibits a narrowed pulse pressure (16 mmHg), tachycardia, acute confusion, and active surgical site bleeding, which indicate early hypovolemic shock.
Recognizing early physiological decompensation is required to properly prioritize emergency care.
2
Evaluate the correct interventions for acute hemorrhage.
The immediate physical priorities are to control the bleeding by applying pressure and to ensure vascular access for fluid resuscitation.
These actions directly support the client's circulation, which is the primary ABC priority in this scenario.
3
Determine the appropriate escalation within the PN scope of practice.
The PN must immediately notify the RN so that advanced medical interventions can occur.
The RN is responsible for initiating provider communication and overseeing advanced therapies like blood product administration.

Key Concept

Early Recognition and Prioritization of Hypovolemic Shock
Estimated Time:1m 30s
Question 2186Question →

A practical nurse is preparing to administer a prescribed transdermal nitroglycerin patch to a client with a history of angina. Arrange the following steps for applying the patch in the correct chronological order.

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Answer

The correct sequence is: perform hand hygiene and don gloves, remove the old patch, label the new patch, apply the new patch to a hairless area, and finally press firmly to ensure adhesion.
Chronological adherence to safety checks is essential in transdermal medication administration. Donning gloves protects the nurse. Removing the old patch first prevents medication overdose. Labeling before application is more comfortable for the client. Finally, placing the patch on a hairless site and pressing it firmly guarantees proper absorption and adhesion.

Step-by-Step Solution

1
Perform hand hygiene and put on a pair of clean gloves.
The nurse's skin is protected.
Maintains standard precautions and prevents the nurse from absorbing the active medication during handling.
2
Remove the previously applied patch and gently wipe the old site.
The old medication source is eliminated.
Prevents medication toxicity and overdose from having multiple patches active simultaneously.
3
Write the date, time, and your initials on the outside of the new patch.
The new patch is properly documented.
Writing on the patch before applying it avoids applying uncomfortable pressure to the client's underlying tissue.
4
Apply the new patch to a clean, hairless area of the skin on the chest or upper arm.
The medication patch is placed on the client.
Hairless, clean skin ensures optimal and consistent transdermal absorption of the medication.
5
Press firmly over the new patch with the palm of the hand for about 10 seconds.
The patch is secured to the skin.
Heat and pressure from the hand help the adhesive stick properly to the skin.

Key Concept

Safe administration of transdermal medications
Question 2187Question →

A practical nurse (PN) is assessing an adult client who is 66 hours postoperative following a subtotal thyroidectomy. Which of the following assessment findings should the PN identify as indicating a potential life-threatening complication that requires immediate escalation to the registered nurse (RN)? Select all that apply.

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Answer: The client reports a new sensation of pressure at the surgical site and is frequently clearing their throat.; The client reports numbness and a tingling sensation around the mouth and fingertips.; The client's apical heart rate is 118118 beats per minute and blood pressure is 102/60102/60 mmHg.

Answer

The findings that require immediate escalation are the sensation of neck pressure with frequent throat clearing, the numbness and tingling around the mouth, and the heart rate of 118 beats per minute with a blood pressure of 102/60 mmHg.
Following a subtotal thyroidectomy, the most critical risks include airway obstruction from a hematoma, hypocalcemia from parathyroid gland damage, and internal hemorrhage. Frequent throat clearing and a sensation of neck pressure are early, subtle signs of an expanding hematoma that physically threatens the airway. Numbness and tingling around the mouth (circumoral paresthesia) are classic early manifestations of hypocalcemia, which can progress to life-threatening tetany and laryngospasm. Unexplained tachycardia (118118 bpm) paired with borderline hypotension indicates potential internal bleeding and early hypovolemic shock. All three of these findings represent potential emergencies that exceed the practical nurse's scope of independent management and require immediate escalation to the registered nurse.

Step-by-Step Solution

1
Analyze the surgical context and timeframe.
The client is 6 hours post-subtotal thyroidectomy.
Identifying the specific procedure highlights the primary risks: airway compromise (hematoma/edema), hypocalcemia (parathyroid injury), and postoperative hemorrhage.
2
Evaluate the respiratory and airway findings.
Frequent throat clearing and neck pressure indicate a potential hematoma, while mild hoarseness is an expected finding.
A rapidly expanding hematoma can compress the trachea, requiring emergency airway management, whereas intubation routinely causes temporary hoarseness.
3
Evaluate the neurological and laboratory findings.
Circumoral tingling indicates hypocalcemia (a critical complication), whereas a calcium level of 9.4 mg/dL is within normal limits.
Parathyroid gland disruption causes rapid calcium depletion, risking life-threatening tetany or seizures if not treated immediately.
4
Evaluate the hemodynamic and comfort findings.
Tachycardia (118 bpm) with borderline hypotension indicates early shock, whereas a pain level of 4/10 is expected.
Unrecognized internal bleeding leads to hypovolemic shock, requiring immediate fluid resuscitation and surgical evaluation by the RN and provider.

Key Concept

Postoperative Thyroidectomy Complications and Prioritization
Question 2188Question →

A client is transferred to the medical-surgical unit immediately after undergoing a diagnostic lumbar puncture. Which interventions should the practical nurse implement to ensure safety and promote comfort? Select all that apply.

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Answer: Maintain the client in a strictly flat, supine position for the prescribed duration.; Encourage the consumption of oral fluids unless medically contraindicated.; Collect data regarding motor strength and sensory perception in the bilateral lower extremities.

Answer

The correct interventions include maintaining a flat supine position, encouraging oral fluids, and collecting data on lower extremity neurological function.
Following a lumbar puncture, maintaining a flat, supine position is essential to prevent cerebrospinal fluid (CSF) leakage and subsequent spinal headaches. Encouraging oral fluids helps to quickly replenish the lost CSF volume. Additionally, collecting data on lower extremity sensory and motor function is a critical responsibility to detect potential neurological complications, such as hematoma formation compressing the spinal cord.

Step-by-Step Solution

1
Identify the primary physiological risks associated with a lumbar puncture.
The main risks are cerebrospinal fluid (CSF) leakage and subsequent spinal headaches, as well as potential spinal nerve compression.
Understanding the complications drives the appropriate comfort and safety interventions.
2
Determine the proper positioning required to minimize these risks.
The client must remain in a flat, supine position.
A flat position equalizes pressure in the central nervous system and prevents CSF from leaking through the dural puncture site.
3
Identify supportive care measures to replenish fluid volume.
Encouraging oral fluids is a necessary intervention.
Hydration assists the body in replacing the CSF that was removed during the diagnostic test.
4
Differentiate between nursing responsibilities and delegable tasks.
The nurse must personally collect neurological data and inspect the site; this cannot be delegated to assistive personnel.
Initial assessments require a licensed nurse's clinical knowledge to identify early signs of bleeding or nerve damage.

Key Concept

Post-Lumbar Puncture Care and Positioning
Question 2189Question →

A practical nurse (PN) is caring for a 72-year-old client admitted with an acute exacerbation of heart failure and a suspected lower respiratory tract infection. The client's current vital signs are: temperature 102.4°F (39.1°C), heart rate 108 bpm, respiratory rate 26 breaths/min, and blood pressure 110/70 mm Hg. The client's admission weight is documented as 75 kg. The provider's prescriptions include oral digoxin, intravenous push bumetanide, a weight-based dose of oral amoxicillin, and an influenza immunization. Which of the following actions should the PN take? Select all that apply.

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Answer: Review the client's most recent serum potassium level prior to administering the scheduled dose of oral digoxin.; Collaborate with the registered nurse to administer the intravenous bumetanide and subsequently monitor the client's fluid output.

Answer

The correct actions are to review the client's serum potassium level prior to administering the digoxin, and to collaborate with the registered nurse to administer the intravenous bumetanide while monitoring the client's fluid output.
The practical nurse demonstrates safe pharmacological practice by recognizing that loop diuretics like bumetanide deplete potassium, which requires checking serum potassium levels before giving digoxin to prevent toxicity. Furthermore, the nurse correctly identifies that intravenous push medications are outside the LPN/LVN scope of practice and collaborates with the RN for administration while monitoring therapeutic outcomes.

Step-by-Step Solution

1
Analyze the client's clinical presentation and prescribed medications.
The client has a high fever (102.4°F), requires an IV push loop diuretic (bumetanide), an oral cardiac glycoside (digoxin), a weight-based antibiotic, and an immunization.
Identifying the clinical context is essential for prioritizing care and recognizing safety contraindications.
2
Evaluate the scope of practice regarding intravenous medications.
The PN determines that administering IV push bumetanide is out of scope and must be delegated to or performed by the RN.
LPN/LVNs are generally prohibited from administering IV push medications due to the rapid systemic onset and required advanced assessment capabilities.
3
Assess pharmacological interactions between the prescribed medications.
Bumetanide is a loop diuretic that depletes potassium, which subsequently increases the risk of digoxin toxicity.
The PN must ensure the serum potassium is normal before giving digoxin to prevent fatal cardiac dysrhythmias.
4
Determine the appropriateness of the influenza immunization.
The PN recognizes that a severe acute febrile illness is a contraindication and the vaccine must be withheld.
Administering vaccines during acute febrile illness can exacerbate symptoms or mask adverse vaccine reactions.
5
Apply the rights of medication administration and basic dosage calculation rules.
The PN identifies that two active identifiers are always required, and that a weight already in kilograms should not be divided by 2.2.
Bypassing safety checks or misapplying conversion factors leads to critical medication administration errors.

Key Concept

Safe Medication Administration, Contraindications, and PN Scope of Practice
Question 2190Question →

During a home care visit, the practical nurse (PN) observes a bedbound client who spends most of the day in a dimly lit room. The client suddenly becomes agitated, attempts to pull out their indwelling urinary catheter, and yells, "Get these snakes off my legs!" The PN recognizes a perceptual alteration likely caused by sensory deprivation. In which order should the PN perform the following interventions? Arrange the actions from first to last.

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Answer

The correct sequence prioritizes immediate physical safety, followed by therapeutic communication, environmental modification, sensory distraction, and finally, collaboration with the healthcare team.
The correct sequence of actions follows the nursing priorities of safety, therapeutic communication, environmental intervention, and collaboration. The highest priority is preventing physical injury by safely guiding the client's hands away from the catheter. Next, presenting reality helps ground the frightened client. Then, the underlying sensory deprivation is addressed by increasing lighting, which removes shadows that can cause illusions. Offering a tactile distraction prevents recurrence of the unsafe behavior. Finally, the RN is notified of the acute change in the client's condition for further evaluation.

Step-by-Step Solution

1
Secure the urinary catheter.
The client is prevented from self-harm and traumatic removal of the device.
Physical safety takes precedence over all other interventions.
2
Present reality to the client.
The client's fears are validated but grounded in reality.
Therapeutic communication de-escalates the acute panic associated with hallucinations or illusions.
3
Increase room lighting.
Sensory deprivation is reduced and visual misperceptions are eliminated.
Addressing the root cause of the perceptual alteration helps clear the acute confusion.
4
Provide a distraction object.
The client's hands are safely occupied.
Tactile stimulation redirects anxious energy away from pulling at medical devices.
5
Notify the registered nurse.
The healthcare team is informed of the acute change.
Collaboration is necessary for ongoing assessment and potential changes to the care plan.

Key Concept

Prioritization of nursing care for a client experiencing perceptual alterations requires addressing immediate physical safety first, followed by reorientation, environmental modifications, and reporting.
Question 2191Question →

An older adult resident recently diagnosed with a urinary tract infection has a new prescription for oral amoxicillin. The client's medical record prominently lists a severe anaphylactic allergy to penicillin. The pharmacy has just delivered the amoxicillin to the unit. What is the most appropriate action for the practical nurse to take?

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Answer: Withhold the medication and notify the prescribing provider immediately.

Answer

The practical nurse must withhold the amoxicillin and notify the prescribing provider immediately.
Amoxicillin is a broad-spectrum antibiotic that belongs to the penicillin family. Because the client has a documented severe anaphylactic allergy to penicillin, giving amoxicillin poses an immediate, life-threatening risk. The practical nurse's primary responsibility is client safety, which requires withholding the contraindicated medication and collaborating with the provider to secure a safe alternative.

Step-by-Step Solution

1
Review the newly prescribed medication and the client's medical history.
The nurse identifies that the client is prescribed amoxicillin and has a severe allergy to penicillin.
Checking the client's chart for allergies is a critical first step in safe medication administration.
2
Correlate the prescribed medication class with the client's allergy.
The nurse recognizes that amoxicillin is a penicillin-class antibiotic.
Understanding drug classifications prevents the administration of cross-reactive allergens.
3
Determine the safest clinical action based on the findings.
The nurse decides the medication cannot be safely given.
Administering the drug could trigger life-threatening anaphylaxis.
4
Execute the appropriate nursing intervention.
The nurse withholds the dose and contacts the provider to obtain an alternative antibiotic.
The provider must be notified to ensure the client receives safe, timely, and appropriate treatment for their infection.

Key Concept

Medication Safety and Allergy Verification
Question 2192Question →

A client diagnosed with heart failure is scheduled to receive an oral dose of digoxin. During the pre-administration data collection, which of the following findings should prompt the practical nurse to withhold the medication and notify the registered nurse? Select all that apply.

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Answer: An apical heart rate of 54 beats per minute; A serum potassium level of 3.0 mEq/L; The client reports a new onset of nausea and blurred vision

Answer

The practical nurse should withhold the digoxin for an apical pulse less than 60 beats per minute (54 beats per minute), a low potassium level (3.0 mEq/L), and signs of toxicity (nausea and blurred vision).
Digoxin is a cardiac glycoside that slows the heart rate and strengthens cardiac contractility. Because of its narrow therapeutic index, the nurse must ensure the apical pulse is 60 beats per minute or greater, the potassium level is within the normal range (3.5 to 5.0 mEq/L), and the client is free from toxicity symptoms (like gastrointestinal upset or visual changes) before safely administering the dose.

Step-by-Step Solution

1
Evaluate the client's apical heart rate against safe administration parameters.
The apical rate is 54 beats per minute, which is below the safe threshold of 60 beats per minute for an adult.
Digoxin slows down the heart rate; administering it to a bradycardic client can cause severe and life-threatening dysrhythmias.
2
Analyze the client's laboratory values, specifically focusing on the potassium level.
The potassium level is 3.0 mEq/L, indicating hypokalemia.
Low potassium levels increase the binding of digoxin to cardiac muscle cells, significantly heightening the risk for toxicity even when normal doses are given.
3
Assess the client for subjective symptoms indicating medication toxicity.
The client reports experiencing nausea and blurred vision.
These are classic early subjective indicators of digoxin toxicity and require immediate clinical intervention.

Key Concept

Reduction of Risk Potential: Preventing Digoxin Toxicity
Question 2193Question →

A practical nurse (PN) in a rehabilitation unit is planning care for an older adult client with severe rheumatoid arthritis who experiences significant morning joint stiffness in the hands. The goal is to promote the client's independence with activities of daily living (ADLs). Which of the following actions should the PN include in the plan of care? Select all that apply.

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Answer: Provide adaptive clothing with hook-and-loop closures instead of traditional buttons.; Supply foam-built-up handles on eating utensils and toothbrushes to reduce strain on the finger joints.; Schedule self-care activities later in the morning to allow time for morning stiffness to decrease and pain medications to take effect.

Answer

The correct actions include providing adaptive clothing with hook-and-loop closures, supplying foam-built-up handles for utensils, and scheduling self-care activities later in the morning.
Clients with severe rheumatoid arthritis experience pronounced joint stiffness, particularly in the morning, which impairs fine motor skills and grip strength. Supplying adaptive clothing with hook-and-loop closures and built-up handles on utensils compensates for these deficits, allowing the client to dress and eat without exacerbating joint pain. Furthermore, scheduling ADLs later in the morning ensures that prescribed pain and anti-inflammatory medications have reached peak effect, maximizing the client's physical capability to participate in their own care.

Step-by-Step Solution

1
Identify the primary physiological barrier to the client's independence.
The client has severe rheumatoid arthritis causing significant morning joint stiffness and reduced grip strength in the hands.
Understanding the specific physical limitations allows the nurse to select appropriate adaptive interventions.
2
Evaluate each action based on its ability to safely promote independence within the PN scope of practice.
Adaptive closures, built-up handles, and strategic scheduling directly accommodate the client's joint stiffness. Ignoring acute confusion, delegating initial assessments, and bypassing cultural dietary checks are unsafe or inappropriate.
Nursing interventions must be legally sound, culturally sensitive, and tailored to the client's current clinical profile to effectively support self-care.

Key Concept

Promoting Self-Care and Independence in Clients with Chronic Joint Stiffness
Question 2194Question →

A newborn who is preparing for discharge requires a routine neonatal metabolic screening test via heel stick. Arrange the following procedural actions the nurse should take to obtain the capillary blood sample in the correct chronological sequence.

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Answer

The correct sequence is to first warm the heel, cleanse and dry the site, puncture the appropriate outer edge, wipe away the first drop of blood, collect the specimen on the filter paper, and finally apply pressure to stop the bleeding.
Following this specific sequence ensures the infant's safety by avoiding bone injury, prevents infection, and guarantees an uncontaminated, high-quality blood sample necessary for accurate metabolic screening.

Step-by-Step Solution

1
Warm the heel
Increases local perfusion
Promotes adequate blood flow to avoid milking or squeezing the foot, which can cause hemolysis.
2
Cleanse and air-dry the site
Skin is sanitized
Prevents introduction of pathogens and avoids alcohol contamination of the blood sample.
3
Puncture the outer edge of the heel
Capillary bed is accessed safely
Targeting the lateral or medial aspects avoids the calcaneus bone to prevent osteomyelitis.
4
Wipe away the first blood drop
Removes tissue fluid
Ensures the collected specimen is pure capillary blood, not diluted by interstitial fluid.
5
Collect the blood drops on filter paper
Circles are fully saturated
Provides a sufficient and unsmeared sample for the laboratory to run the metabolic assays.
6
Apply pressure to the site
Hemostasis is achieved
Prevents ongoing bleeding and localized bruising.

Key Concept

Newborn Capillary Blood Sampling (Heel Stick) Sequence
Question 2195Question →

A client is recovering on the surgical floor one day after undergoing an open laparotomy. Which interventions should the nurse include to promote comfort and prevent complications? Select all that apply.

Select all that apply

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Answer: Show the client how to hold a firm cushion against the abdomen when coughing.; Help the client change positions frequently throughout the shift.; Administer a prescribed mild analgesic prior to planned ambulation sessions.

Answer

The correct actions include showing the client how to splint the abdomen with a cushion, helping the client change positions frequently, and administering prescribed analgesics prior to ambulation.
Splinting the abdomen with a cushion provides external support to the surgical incision, which significantly reduces pain during coughing or deep breathing. Frequent position changes are essential basic care actions that prevent skin breakdown, promote circulation, and improve lung aeration. Administering an analgesic before ambulation ensures the client is comfortable enough to participate in mobility exercises, which are critical for preventing postoperative complications.

Step-by-Step Solution

1
Analyze the client's postoperative status.
The client had an open abdominal surgery one day ago and needs basic care measures.
Understanding the procedure helps identify appropriate comfort and safety interventions.
2
Evaluate the safety of the proposed positioning techniques.
Actions such as placing a blanket behind the knees or keeping the bed completely flat are identified as hazardous.
These specific positions increase the risk of deep vein thrombosis and respiratory compromise.
3
Select interventions that actively promote comfort without causing harm.
Incision splinting, frequent repositioning, and preemptive pain management are chosen.
These basic care strategies safely reduce postoperative pain while encouraging vital mobility and respiratory function.

Key Concept

Postoperative basic care, safety, and positioning
Question 2196Question →

A practical nurse is caring for a client who is two days post-operative following a total hip arthroplasty. The client is prescribed subcutaneous enoxaparin 40 mg40\text{ mg} once daily. While reviewing the client's electronic health record prior to the morning medication administration, the nurse notes the following data:

- Hemoglobin: 11.5 g/dL11.5\text{ g/dL}
- Hematocrit: 34%34\%
- Platelet count: 78,000/mm378,000/\text{mm}^3 (baseline on admission: 225,000/mm3225,000/\text{mm}^3)

Which action should the practical nurse take first?

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Answer: Withhold the scheduled dose of enoxaparin and immediately notify the registered nurse.

Answer

The correct action is to withhold the scheduled dose of enoxaparin and immediately notify the registered nurse.
The client has developed severe thrombocytopenia, a potential sign of heparin-induced thrombocytopenia (HIT). Administering enoxaparin is strictly contraindicated. The practical nurse must prioritize safety by immediately withholding the medication and reporting the critical laboratory finding to the registered nurse.

Step-by-Step Solution

1
Analyze the morning laboratory results.
The platelet count is 78,000/mm378,000/\text{mm}^3, representing a severe drop from the baseline.
Identifying critical abnormalities is required before medication administration.
2
Correlate the findings with the prescribed medication.
Enoxaparin can cause heparin-induced thrombocytopenia, making administration dangerous.
Nurses must recognize adverse effects to ensure safe pharmacological therapy.
3
Determine the priority action within the practical nursing scope.
The medication must be withheld and the registered nurse notified immediately.
Preventing harm takes precedence over routine administration or secondary assessments.

Key Concept

Heparin-Induced Thrombocytopenia (HIT) and Practical Nurse Scope
Question 2197Question →

A practical nurse is preparing to administer an intramuscular injection of iron dextran to a client with iron-deficiency anemia using the Z-track method. Arrange the following steps of the administration procedure in the correct chronological sequence.

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Answer

The correct sequence is: pull the skin laterally, insert the needle at a 90-degree angle, inject the medication slowly, wait 10 seconds, and finally withdraw the needle while simultaneously releasing the retracted skin.
The Z-track method is essential for medications that cause tissue irritation or staining. The procedure begins by pulling the skin laterally to displace the tissue planes. While holding the skin in this position, the needle is inserted at a 90-degree angle and the medication is injected slowly. The nurse then waits 10 seconds to allow the medication to disperse within the muscle. Finally, the needle is withdrawn and the skin is released simultaneously, creating a zig-zag path that effectively seals the medication within the muscle belly.

Step-by-Step Solution

1
Pull the overlying skin and subcutaneous tissue laterally 1 to 1.5 inches.
The skin and subcutaneous tissue are displaced from the underlying muscle.
This creates an offset pathway that will seal the needle track after the injection is complete.
2
Insert the needle smoothly and swiftly at a 90-degree angle.
The needle reaches the deep muscle tissue.
A 90-degree angle ensures the medication is deposited directly into the muscle belly rather than the subcutaneous layer.
3
Inject the medication slowly and steadily into the muscle.
The medication is deposited into the muscle tissue.
A slow injection rate minimizes tissue trauma and pain while allowing the muscle fibers to accommodate the fluid volume.
4
Wait 10 seconds before removing the needle.
The medication begins to disperse deeply into the muscle.
This pause prevents the medication from tracking back up the needle pathway immediately following the injection.
5
Withdraw the needle and immediately release the retracted skin.
The tissue planes slide back into their original, unretracted positions.
Releasing the skin breaks the alignment of the needle track, permanently trapping the medication in the muscle layer and preventing superficial staining or irritation.

Key Concept

The Z-track method is an intramuscular injection technique designed to prevent irritating or staining medications from leaking back into the subcutaneous tissue.
Question 2198Question →

During morning care, a practical nurse reviews the electronic health record of a client receiving chemotherapy. The latest complete blood count reveals a white blood cell (WBC) count of 1,200/mm31,200/\text{mm}^3 (1.2×109/L1.2 \times 10^9/\text{L}). What is the priority nursing action?

Show answer & explanation

Answer: Inform the supervising registered nurse about the abnormal blood count

Answer

The correct action is to immediately inform the supervising registered nurse about the abnormal blood count so that protective measures can be initiated.
The normal white blood cell (WBC) count is typically between 5,0005,000 and 10,000/mm310,000/\text{mm}^3. A count of 1,200/mm31,200/\text{mm}^3 indicates severe leukopenia, which places the client at a critical risk for infection. Within the practical nurse scope of practice, any critical laboratory value must be immediately escalated to the registered nurse or healthcare provider so that protective measures can be initiated.

Step-by-Step Solution

1
Analyze the client's laboratory result.
The WBC count is 1,200/mm31,200/\text{mm}^3, which is significantly below the normal range of 5,0005,000 to 10,000/mm310,000/\text{mm}^3.
Identifying abnormal values is the first step in recognizing potential complications.
2
Determine the appropriate action based on the practical nurse's scope of practice.
The practical nurse must communicate critical findings to the registered nurse.
The registered nurse must assess the client and collaborate with the provider to implement necessary medical interventions, such as neutropenic precautions.

Key Concept

Escalation of Critical Laboratory Values
Question 2199Question →

A client is resting in bed on the telemetry unit 4 hours after a diagnostic cardiac catheterization performed via the right femoral artery. During routine data collection, the client complains of a new, persistent ache in the lower back. Current vital signs show a blood pressure of 102/64 mm Hg and a pulse of 112 beats per minute, compared to a pre-procedure baseline of 134/78 mm Hg and 76 beats per minute. Which action should the practical nurse (PN) take first?

Show answer & explanation

Answer: Notify the registered nurse (RN) immediately about the assessment findings.

Answer

Notify the registered nurse (RN) immediately about the assessment findings.
Following a femoral cardiac catheterization, the onset of new lower back pain combined with tachycardia and a dropping blood pressure are hallmark indicators of retroperitoneal hemorrhage. This is a critical circulatory emergency. Within the practical nurse scope of practice, recognizing these signs of hypovolemic shock necessitates immediate escalation to the registered nurse (RN) or healthcare provider for rapid medical intervention.

Step-by-Step Solution

1
Analyze the client's post-procedure symptoms and vital sign trends.
The client has new lower back pain, hypotension, and tachycardia compared to baseline.
Identifying deviations from baseline is critical for recognizing early postoperative complications.
2
Correlate the findings with potential complications of a femoral arterial puncture.
These combined findings strongly suggest retroperitoneal bleeding, a severe circulatory compromise.
Blood leaking backward into the retroperitoneal space causes back pain and subsequent hypovolemia.
3
Determine the priority nursing intervention within the PN scope of practice.
The PN must immediately escalate these critical, unstable findings to the RN.
Life-threatening emergencies require rapid RN or provider intervention for fluid resuscitation and medical management.

Key Concept

Recognizing early signs of hemorrhage and hypovolemic shock post-procedure
Question 2200Question →

A client recovering from a systemic infection on a medical-surgical unit becomes suddenly distressed at dusk. The client points toward the shadowed window curtains and shouts, "Who are those strangers trying to get inside? Make them go away!" Which action should the practical nurse (PN) take first?

Show answer & explanation

Answer: Stay with the client, turn on the room lights to reduce shadows, and offer calm reassurance.

Answer

Stay with the client, turn on the room lights to reduce shadows, and offer calm reassurance.
The client is experiencing a visual illusion, a sensory misperception triggered by the dim lighting and shadows of dusk, which is common in clients at risk for delirium. The priority nursing action is to modify the environment by turning on the lights to eliminate the shadows. Staying with the client ensures safety and provides therapeutic reassurance without arguing about their perceived reality.

Step-by-Step Solution

1
Analyze the client's behavior and potential triggers.
The client is experiencing a sensory misperception (an illusion) likely exacerbated by the dim lighting at dusk and the underlying systemic infection.
Identifying the root cause of the perceptual alteration helps determine the most effective and least restrictive intervention.
2
Determine the priority nursing action based on safety and environmental modification.
The nurse must prioritize immediate safety by staying present and modifying the environment to remove the trigger.
Turning on the lights eliminates the shadows that are causing the visual illusion, directly addressing the sensory alteration while maintaining a safe, therapeutic presence.

Key Concept

Sensory Alteration Management and Therapeutic Environment
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