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While performing data collection on a client who delivered a healthy newborn at 39 weeks of gestation 60 minutes ago, the practical nurse notes several physical changes. Which of the following findings is the highest priority and requires immediate reporting to the registered nurse?

Uterine fundus that is firm, midline, and located at the level of the umbilicus

Sudden expulsion of dark red blood when the client assists with a position change

Perineal pad completely saturated with blood within a 15-minute period

Client complaints of intense abdominal cramping while the infant is breastfeeding

Show answer & explanation

Answer: Perineal pad completely saturated with blood within a 15-minute period

Answer

A perineal pad completely saturated with blood within a 15-minute period indicates a potential emergency.

Saturating a perineal pad in 15 minutes or less is a primary indicator of postpartum hemorrhage. This is a life-threatening complication that requires immediate nursing intervention and prompt notification of the registered nurse.

Step-by-Step Solution

Evaluate the data collection findings against expected normal postpartum physiological adaptations.

The gush of blood on position change, a firm midline fundus, and breastfeeding cramping are all expected, normal findings at 1 hour postpartum.

Recognizing normal baselines prevents unnecessary interventions and helps identify true complications.

Identify the finding that indicates a potential life-threatening complication.

Saturating a perineal pad in 15 minutes indicates excessive, uncontrolled bleeding (postpartum hemorrhage).

Postpartum hemorrhage is a medical emergency that requires immediate intervention by the registered nurse and provider.

Key Concept

Expected versus unexpected postpartum findings and signs of postpartum hemorrhage

Question 2462Question →

A practical nurse (PN) is assisting an adult client in preparing for a scheduled bedside thoracentesis. The client previously signed the informed consent document with the physician. While the PN is helping the client into the correct seated position, the client becomes visibly anxious and states, "I have changed my mind. I cannot go through with this needle stick." Arrange the following PN actions in the correct chronological sequence from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct chronological sequence is to first stop the physical preparations, verify the client's intent to withdraw consent, notify the RN and physician, document the exact refusal, and finally remain with the client to provide support.

When a client revokes consent, the PN must prioritize client autonomy and safety by immediately stopping any preparations. Next, the PN verifies the client's intent to ensure it is a definitive refusal rather than just transient fear. The provider and RN must then be notified immediately because the provider is legally responsible for discussing the risks of refusal with the client. Documentation follows the clinical actions to provide an accurate legal record. Finally, the PN provides ongoing emotional support.

Step-by-Step Solution

Cease any ongoing procedural preparations and assist the client into a comfortable resting position.

The procedure is immediately halted.

Stopping the physical preparation ensures client safety and protects their legal right to refuse treatment at any time, even after initial consent was signed.

Clarify the client's statement to confirm their definitive intent to revoke the previously given consent.

The PN determines if the client is formally withdrawing consent.

The PN must assess whether the client is truly refusing the procedure or simply expressing fear that might be alleviated with therapeutic communication.

Promptly inform the supervising registered nurse (RN) and the performing physician about the client's decision.

The healthcare team is alerted to the revoked consent.

It is outside the PN's scope of practice to explain the medical consequences of refusing a procedure; the provider must be notified to fulfill this legal responsibility.

Record the client's exact words of refusal and the time of provider notification in the electronic health record.

A legal record of the event is created.

Thorough documentation protects the client and the facility, but it is prioritized after direct client care and team communication.

Provide continuous supportive presence while the client awaits the physician to discuss treatment alternatives.

The client receives ongoing psychosocial care.

Remaining with the client reduces anxiety and demonstrates advocacy while waiting for the provider to arrive.

Key Concept

A client has the legal right to revoke informed consent at any time. The practical nurse's role is to immediately halt the procedure, verify the refusal, notify the provider so they can explain the consequences, and accurately document the event.

Estimated Time:2m 0s

Question 2463Question →

At the beginning of a shift in a skilled nursing facility, a practical nurse reviews the client assignments and designated tasks. Which assigned activity falls outside the legal scope of practice and requires the practical nurse to notify the supervising registered nurse?

Conducting the comprehensive admission assessment for a client transferring from an acute care facility

Reinforcing previously taught infection control measures to the family members of a client

Serving as a witness to a client's signature on a surgical consent form after the provider's explanation

Reviewing a client's electronic health record on a secured workstation to prepare for the shift handoff

Show answer & explanation

Answer: Conducting the comprehensive admission assessment for a client transferring from an acute care facility

Answer

Conducting the comprehensive admission assessment for a client transferring from an acute care facility

The correct answer is conducting a comprehensive admission assessment. In the nursing process, comprehensive assessments, initial formulation of the care plan, and complex clinical judgments are strictly within the scope of practice for the registered nurse (RN). The practical nurse (PN) contributes to this process by collecting specific data, monitoring stability, and reporting changes, but the initial comprehensive assessment cannot be delegated to a PN.

Step-by-Step Solution

Analyze each assigned task to determine if it involves initial assessment, primary teaching, or complex clinical judgment.

Three tasks involve routine care, data collection, or reinforcement, while one involves a comprehensive admission assessment.

The National Council of State Boards of Nursing (NCSBN) delineates specific boundaries for practical nurses regarding the nursing process.

Evaluate the comprehensive admission assessment task against the practical nurse scope of practice.

The comprehensive assessment is identified as an action that requires registered nurse (RN) licensure.

Practical nurses may collect focused data and contribute to the assessment, but they cannot perform the initial comprehensive assessment or develop the initial care plan.

Key Concept

Scope of Practice and Delegation

Question 2464Question →

A multigravida client is recovering in the postpartum unit 6 hours after a prolonged vaginal birth. Upon assessing the client's abdomen, the practical nurse finds the uterine fundus to be soft, uncontracted, and level with the umbilicus. A heavy, continuous flow of bright red lochia is pooling on the bed linens. Which immediate action should the practical nurse implement?

Initiate continuous, firm massage of the uterine fundus while calling the registered nurse for assistance.

Administer a scheduled dose of intravenous push oxytocin to stimulate uterine involution.

Apply a fresh perineal pad and document the heavy lochia flow as an expected finding for a multiparous client.

Obtain a full set of vital signs to determine if the client is experiencing hypovolemic shock before intervening.

Show answer & explanation

Answer: Initiate continuous, firm massage of the uterine fundus while calling the registered nurse for assistance.

Answer

The practical nurse should immediately begin continuous, firm massage of the boggy uterine fundus while simultaneously calling the registered nurse for assistance.

The client is exhibiting classic signs of uterine atony, which is a leading cause of postpartum hemorrhage. The immediate priority intervention to control this active bleeding is to perform continuous, firm massage of the uterine fundus to mechanically stimulate contraction. Because the client requires emergent care that will involve intravenous fluids and medications outside the practical nurse's scope of practice, the nurse must simultaneously call the registered nurse for assistance.

Step-by-Step Solution

Analyze the clinical findings presented in the scenario.

The client has a soft, uncontracted (boggy) uterus with continuous, heavy bright red bleeding pooling on the bed.

Identifying these cues is essential to recognize uterine atony, which is the leading cause of life-threatening postpartum hemorrhage.

Determine the priority framework for the situation.

The situation involves an active circulation (bleeding) issue, requiring an immediate, direct intervention to stop the hemorrhage.

In emergency situations, addressing Airway, Breathing, and Circulation (ABC) takes precedence over further data collection or routine documentation.

Select the appropriate intervention within the practical nurse scope of practice.

The nurse must perform fundal massage to mechanically stimulate the uterus to contract while calling the registered nurse to administer fluids and medications.

Fundal massage is an independent nursing action within the PN scope that directly addresses uterine atony. Activating help is necessary because IV push medications and advanced shock management exceed the PN scope.

Key Concept

Prioritization and Scope of Practice in Postpartum Hemorrhage

Question 2465Question →

During a night shift, a practical nurse (PN) is assigned to care for an 85-year-old client who recently underwent an exploratory laparotomy. The client is experiencing acute disorientation, attempting to remove a nasogastric (NG) tube, and soft wrist restraints have been prescribed after less restrictive measures failed. Which of the following nursing actions are appropriate for this client? (Select all that apply.)

Select all that apply

Fasten the restraint straps to the movable portion of the bed frame using a quick-release knot.

Remove the restraints one at a time every 2 hours to perform range-of-motion exercises.

Request a PRN (as-needed) prescription for the restraints to allow for prompt reapplication if the client's agitation worsens.

Attribute the sudden onset of disorientation to a normal age-related cognitive change following major surgery.

Verify that two fingers can be easily inserted between the restraint and the client's skin.

Assign the unlicensed assistive personnel (UAP) to evaluate the client's ongoing need for the restraints.

Show answer & explanation

Answer: Fasten the restraint straps to the movable portion of the bed frame using a quick-release knot.; Remove the restraints one at a time every 2 hours to perform range-of-motion exercises.; Verify that two fingers can be easily inserted between the restraint and the client's skin.

Answer

The correct actions include fastening the straps to the movable bed frame using a quick-release knot, removing the restraints every 2 hours for care and assessment, and ensuring two fingers can comfortably fit between the restraint and the skin.

The correct nursing actions prioritize client safety and adherence to legal guidelines. Fastening the restraint to the movable portion of the bed frame ensures the restraint moves with the client when the bed is adjusted, preventing injury. Using a quick-release knot allows for rapid removal in an emergency. Removing the restraints every 2 hours to perform range-of-motion exercises and check skin integrity is required to prevent neurovascular compromise and skin breakdown. Verifying that two fingers can fit under the restraint ensures it is not applied too tightly, protecting circulation.

Step-by-Step Solution

Evaluate the legal and clinical requirements for restraint orders and delegation.

Identified that PRN orders are prohibited and that assessing the need for restraints cannot be delegated to a UAP.

Restraints involve strict regulations and require licensed nursing judgment to protect client rights and safety.

Determine the correct mechanical application of the physical restraints.

Confirmed that tying the straps to a movable bed frame with a quick-release knot and leaving two fingers of space is required.

These specific mechanics prevent injury during bed adjustments, allow for rapid emergency release, and ensure adequate circulation.

Identify ongoing monitoring and care needs for the client experiencing delirium.

Recognized the need to release restraints every 2 hours for skin care and range-of-motion exercises, while investigating the acute confusion rather than dismissing it as age-related.

Continuous monitoring prevents physical complications, and recognizing delirium as abnormal prompts the search for underlying causes like hypoxia or infection.

Key Concept

Use of Restraints and Safety Devices

Question 2466Question →

An adult client is admitted to an inpatient unit with suspected bacterial meningitis and an actively draining methicillin-resistant Staphylococcus aureus (MRSA) wound. Which interventions should the practical nurse (PN) implement to maintain infection control and safe care delivery? Select all that apply.

Select all that apply

Don a surgical mask, a disposable gown, and gloves before entering the client's room.

Direct the unlicensed assistive personnel (UAP) to evaluate the client's neurological status during hourly rounding.

Place a standard surgical mask on the client if transport outside the isolation room is required.

Doff the contaminated gown and gloves in the hallway immediately after exiting the client's room.

Leave a designated stethoscope and blood pressure cuff inside the client's room for exclusive use.

Show answer & explanation

Answer: Don a surgical mask, a disposable gown, and gloves before entering the client's room.; Place a standard surgical mask on the client if transport outside the isolation room is required.; Leave a designated stethoscope and blood pressure cuff inside the client's room for exclusive use.

Answer

The correct actions include donning a surgical mask, gown, and gloves before entering; placing a surgical mask on the client during transport; and leaving designated medical equipment inside the room.

Bacterial meningitis and MRSA necessitate a combination of droplet and contact precautions. This requires donning a surgical mask, gown, and gloves before room entry, maintaining dedicated equipment in the room, and placing a surgical mask on the client during transport to contain respiratory secretions.

Step-by-Step Solution

Identify the required transmission-based precautions for the client's specific diagnoses.

Bacterial meningitis requires droplet precautions. MRSA requires contact precautions.

Different pathogens require specific personal protective equipment (PPE) to prevent transmission.

Determine the correct PPE donning and doffing procedures.

A surgical mask, gown, and gloves must be donned prior to entry. Gowns and gloves must be removed inside the room before exiting.

Correct PPE usage and removal locations are critical to preventing the spread of pathogens to the hallway and other clients.

Evaluate the delegated task for the unlicensed assistive personnel (UAP).

Evaluating neurological status is an assessment task and cannot be delegated.

UAPs cannot perform tasks that require nursing judgment or clinical assessment.

Key Concept

Clients with multiple infections require a combination of precautions (e.g., Droplet and Contact). Furthermore, proper PPE sequencing, environmental control, and safe delegation are essential components of nursing care.

Question 2467Question →

A practical nurse is preparing to administer scheduled medications to a group of clients on a medical-surgical unit. Which actions by the nurse demonstrate adherence to safe medication administration practices? Select all that apply.

Select all that apply

Scanning the barcode on the client's identification band prior to drug administration.

Asking the client to state their full name and date of birth before giving the medication.

Accepting an assignment to administer an intravenous (IV) push dose of morphine for a client in severe pain.

Withholding a scheduled dose of an antihypertensive drug for a client with a blood pressure of 88/50 mm Hg and notifying the registered nurse (RN).

Verifying the client's identity by checking the room number and bed assignment before administering a drug.

Show answer & explanation

Answer: Scanning the barcode on the client's identification band prior to drug administration.; Asking the client to state their full name and date of birth before giving the medication.; Withholding a scheduled dose of an antihypertensive drug for a client with a blood pressure of 88/50 mm Hg and notifying the registered nurse (RN).

Answer

The correct actions are scanning the barcode on the identification band, asking the client to state their full name and date of birth, and withholding the antihypertensive drug for a low blood pressure while notifying the RN.

Safe medication administration requires strict adherence to identification protocols, such as scanning the client's barcode and asking them to state their name and date of birth. These two distinct methods ensure the correct client receives the medication. Furthermore, acting safely within the practical nursing scope involves recognizing when to withhold medications—such as holding an antihypertensive drug for a client with a critically low blood pressure—and promptly reporting the finding to the supervising RN.

Step-by-Step Solution

Analyze the requirements for safe client identification prior to medication administration.

The nurse must use at least two distinct, client-specific identifiers, such as name, date of birth, or barcode scanning.

Using proper identifiers prevents medication administration to the wrong client. Room numbers are not acceptable.

Evaluate the practical nurse's scope of practice regarding medication routes.

Intravenous (IV) push medications are generally outside the practical nurse's scope of practice.

IV push medications require advanced assessment skills and the ability to manage immediate, potentially life-threatening adverse reactions, which falls under the RN role.

Assess the appropriate nursing response to abnormal clinical parameters during a medication pass.

The nurse must withhold the antihypertensive medication for a client with hypotension (88/50 mm Hg) and report this finding to the RN.

Administering the medication would further lower the client's blood pressure, potentially causing shock or decreased organ perfusion.

Key Concept

Safe Medication Administration and Scope of Practice

Question 2468Question →

An older adult client with a history of heart failure is prescribed oral furosemide daily. Upon reviewing the morning laboratory results, the nurse notes a serum potassium level of $2.8 \text{ mEq/L}$ . Which action should the nurse take first?

Administer the furosemide as prescribed and document the laboratory result.

Assess the client's blood pressure prior to giving the scheduled dose.

Withhold the furosemide dose and report the finding to the registered nurse.

Provide a potassium-rich snack and proceed with administering the medication.

Show answer & explanation

Answer: Withhold the furosemide dose and report the finding to the registered nurse.

Answer

Withhold the furosemide dose and report the finding to the registered nurse.

The client's serum potassium level of

2.8 \text{ mEq/L}

is significantly below the normal range of

3.5

5.0 \text{ mEq/L}

, indicating severe hypokalemia. Furosemide is a potassium-wasting loop diuretic. Administering this medication would further deplete the client's potassium, significantly increasing the risk of life-threatening cardiac dysrhythmias. The safest and most appropriate action to reduce client risk is to withhold the dose and notify the supervising registered nurse or healthcare provider immediately.

Step-by-Step Solution

Identify the normal range for serum potassium.

The normal serum potassium level is between

3.5

and

5.0 \text{ mEq/L}

Establishing the baseline helps determine if the client's laboratory value is abnormal.

Evaluate the client's laboratory result against the normal range.

The client's level of

2.8 \text{ mEq/L}

is significantly below normal, indicating severe hypokalemia.

Recognizing critical laboratory values is a fundamental aspect of client safety and risk reduction.

Analyze the effect of the prescribed medication on the abnormal laboratory value.

Furosemide is a potassium-wasting loop diuretic, meaning it will cause the body to excrete even more potassium.

Understanding medication mechanisms prevents the administration of drugs that will worsen a client's condition.

Determine the safest nursing intervention.

The dose must be withheld and the finding escalated to the registered nurse or healthcare provider.

Prioritizing risk reduction prevents life-threatening complications, such as cardiac dysrhythmias associated with severe hypokalemia.

Key Concept

Laboratory Value Interpretation and Medication Safety

Question 2469Question →

While managing the care of a client who is two days postoperative following a right total hip arthroplasty (posterior approach), the practical nurse prepares for a bed-to-chair transfer. The client has become agitated, is attempting to climb over the bed rails, and reports unmanaged pain. An as-needed intravenous (IV) push opioid is listed on the medication administration record. Which action represents the safest integration of equipment use and clinical guidelines?

Administer the prescribed IV push opioid to calm the client's agitation prior to performing a manual pivot transfer with a gait belt.

Raise the head of the hospital bed to a 90-degree angle to assist the client into a full sitting position before pivoting them to the chair.

Apply bilateral soft wrist safety devices to prevent the client from climbing over the rails, then prepare the bedside chair for later use.

Secure an abduction pillow between the client's lower extremities and utilize a mechanical lift device with the assistance of a second staff member to complete the transfer.

Show answer & explanation

Answer: Secure an abduction pillow between the client's lower extremities and utilize a mechanical lift device with the assistance of a second staff member to complete the transfer.

Answer

The safest action is to secure an abduction pillow between the client's lower extremities and utilize a mechanical lift device with the assistance of a second staff member to complete the transfer.

The correct action integrates proper ergonomic principles by using a mechanical lift for an agitated client, preventing staff injury. It also utilizes the correct safety equipment (an abduction pillow) to adhere strictly to posterior total hip precautions, preventing joint adduction and subsequent dislocation.

Step-by-Step Solution

Evaluate the client's mobility status, cognitive state, and surgical precautions.

The client is agitated and restricted by posterior total hip precautions, making a manual transfer unsafe.

Agitation unpredictably shifts the client's center of gravity, risking falls and musculoskeletal injury to the nurse if a manual lift is attempted.

Select the appropriate transfer equipment based on the assessment.

A mechanical lift device is chosen to eliminate the need for manual lifting of an unpredictable client.

Mechanical lifts are the standard of care in ergonomics to prevent workplace injuries when a client cannot reliably assist with a transfer.

Implement specific postoperative positioning equipment during the transfer.

An abduction pillow is secured between the client's legs before and during the lift.

The abduction pillow prevents adduction and internal rotation, which are the primary causes of prosthesis dislocation following a posterior approach hip arthroplasty.

Key Concept

Ergonomics and Safe Patient Handling

Question 2470Question →

A practical nurse is providing care for a client who just returned to the nursing unit following an esophagogastroduodenoscopy (EGD) performed with conscious sedation and a local throat anesthetic. Which basic care and comfort interventions should the nurse implement? Select all that apply.

Select all that apply

Keep the client strictly NPO until the return of the gag reflex is verified.

Position the client in a side-lying or semi-Fowler's position.

Offer oral throat lozenges immediately to relieve procedural throat discomfort.

Place the client flat in a supine position to promote hemodynamic stability.

Provide an emesis basin and facial tissues within the client's easy reach.

Show answer & explanation

Answer: Keep the client strictly NPO until the return of the gag reflex is verified.; Position the client in a side-lying or semi-Fowler's position.; Provide an emesis basin and facial tissues within the client's easy reach.

Answer

The correct interventions are maintaining NPO status until the gag reflex returns, utilizing a side-lying or semi-Fowler's position, and providing an emesis basin for oral secretions.

The correct interventions prioritize protecting the client's airway while promoting basic hygiene. Because a local anesthetic was applied to the throat, the gag reflex is temporarily absent. Keeping the client NPO until the reflex returns is a critical safety measure to prevent aspiration. Positioning the client on their side or in a semi-Fowler's position uses gravity to keep the airway clear and facilitate the drainage of saliva. Providing an emesis basin gives the client a safe way to dispose of oral secretions they cannot yet swallow.

Step-by-Step Solution

Identify the procedural risks associated with an esophagogastroduodenoscopy (EGD).

Recognize that conscious sedation and local throat anesthetics depress the central nervous system and temporarily abolish the gag reflex.

Understanding the physiological effects of the procedure dictates the necessary safety and comfort interventions.

Evaluate each intervention for airway safety.

Determine that keeping the client NPO and positioning them on their side or with the head elevated protects the airway. Giving lozenges or lying flat compromises the airway.

Airway protection (ABC prioritization) is the most critical aspect of immediate post-procedure basic care.

Select the interventions that safely promote comfort and hygiene.

Select providing an emesis basin, as it allows the client to manage secretions safely without swallowing.

Basic care and comfort must be provided in a manner that does not violate primary safety protocols.

Key Concept

Post-Procedure Airway and Aspiration Precautions

Question 2471Question →

A practical nurse (PN) observes a colleague using a personal smartphone to take a photograph of a client's complex sacral pressure injury. The colleague states, "I am careful not to include the client's face or name. I plan to use this image as a case study for our upcoming unit in-service." Which action is the priority for the PN?

Notify the charge nurse about the colleague's unauthorized use of a personal device.

Verify that the colleague has obtained the client's written consent prior to capturing the image.

Remind the colleague to ensure no identifying tattoos or background details are visible.

Instruct the colleague to immediately delete the photograph from the smartphone.

Show answer & explanation

Answer: Notify the charge nurse about the colleague's unauthorized use of a personal device.

Answer

The correct action is to notify the charge nurse about the colleague's unauthorized use of a personal device.

The correct action involves reporting the incident to the charge nurse. Using a personal device to capture clinical images creates an immediate risk of a data breach because these devices typically sync with personal cloud storage and lack necessary enterprise-level encryption. The PN must use the chain of command so that the facility's compliance team can properly intervene and secure the data.

Step-by-Step Solution

Identify the primary issue in the scenario.

A colleague is using a personal smartphone to photograph a client's wound, which constitutes a breach of protected health information (PHI) security.

Personal devices are generally unencrypted and automatically sync to external cloud servers, creating a severe data security risk.

Evaluate the colleague's justification.

The colleague claims the image is de-identified and for educational purposes.

Even if the intent is educational and direct identifiers are excluded, the method of data capture (personal device) violates HIPAA security rules and facility policy.

Determine the PN's required action based on scope of practice and compliance guidelines.

The PN must report the incident to the charge nurse immediately.

Nurses have a mandated duty to report confidentiality breaches up the chain of command so that compliance officers can properly investigate, ensure data deletion, and mitigate risks.

Key Concept

Information Security and Mobile Device Policy

Question 2472Question →

A practical nurse (PN) is reviewing their assigned client care tasks for a shift on a general medical unit. The interprofessional team consists of a registered nurse (RN), the PN, and an assistive personnel (AP). Which of the following delegated tasks are within the PN's legal scope of practice to accept? (Select all that apply.)

Select all that apply

Administering a scheduled intramuscular (IM) injection of pain medication

Developing the initial plan of care for a client newly admitted with pneumonia

Reinforcing previously provided dietary education for a client with hypertension

Administering a prescribed intravenous (IV) push antiarrhythmic medication

Performing a sterile wet-to-dry dressing change on a client's surgical wound

Explaining the risks and benefits of an upcoming procedure to obtain informed consent

Show answer & explanation

Answer: Administering a scheduled intramuscular (IM) injection of pain medication; Reinforcing previously provided dietary education for a client with hypertension; Performing a sterile wet-to-dry dressing change on a client's surgical wound

Answer

The practical nurse should accept tasks that involve administering intramuscular injections, reinforcing established dietary education, and performing sterile dressing changes.

The correct selections represent actions that align with standard practical nursing competencies. Administering routine intramuscular medications, performing sterile procedures like dressing changes, and reinforcing previously established teaching plans do not require the comprehensive assessment, independent evaluation, or complex judgment reserved for the registered nurse.

Step-by-Step Solution

Analyze the role boundaries of the practical nurse (PN) versus the registered nurse (RN) and healthcare provider.

The RN is responsible for initial assessments, formulating care plans, initial teaching, and high-risk IV therapies. The provider handles obtaining informed consent.

Establishing professional boundaries is critical to safely accepting delegated tasks.

Evaluate each task option against the NCSBN delegation guidelines and standard PN scope of practice.

IM injections, sterile dressing changes, and reinforcement of prior teaching fall clearly within the data collection, execution, and reinforcement duties of a PN.

To ensure compliance with the legal and ethical standards of nursing practice.

Identify and exclude tasks requiring independent comprehensive assessment or provider intervention.

Developing care plans, giving IV push antiarrhythmics, and explaining procedural risks are excluded from the PN's assignment.

These actions exceed the PN's scope and present a significant safety or legal risk if accepted.

Key Concept

LPN/VN Scope of Practice and Safe Task Delegation

Question 2473Question →

While conducting hourly rounds, a practical nurse observes a client who is receiving an intravenous infusion of vancomycin for a severe bacterial infection. The infusion was initiated by the registered nurse twenty minutes ago. The client suddenly reports feeling extremely dizzy. The practical nurse notes a bright red, flushed appearance across the client's face, neck, and upper chest, and the client's blood pressure is $88/54\text{ mm Hg}$ (decreased from a baseline of $122/76\text{ mm Hg}$ ). Which of the following actions is the priority for the practical nurse?

Stop the intravenous vancomycin infusion immediately and notify the registered nurse.

Obtain a full set of vital signs and document the findings in the electronic health record.

Reassure the client that facial flushing is a harmless, expected response to this antibiotic.

Prepare to independently administer a prescribed intravenous push dose of diphenhydramine.

Show answer & explanation

Answer: Stop the intravenous vancomycin infusion immediately and notify the registered nurse.

Answer

The priority action is to immediately stop the intravenous vancomycin infusion and notify the registered nurse.

The client is experiencing Red Man syndrome, a known adverse reaction to intravenous vancomycin characterized by intense flushing, rash, and hypotension. Because this reaction can progress to severe cardiovascular collapse, the absolute priority action is to immediately stop the infusion to halt the delivery of the medication. Once the infusion is stopped, the practical nurse must promptly notify the registered nurse or health care provider, as the client will likely require fluid resuscitation or administration of an antihistamine.

Step-by-Step Solution

Analyze the client's clinical presentation.

The client has a sudden onset of dizziness, severe facial/neck flushing, and significant hypotension (

88/54\text{ mm Hg}

) shortly after starting an intravenous vancomycin infusion.

Recognizing the acute signs of an adverse medication reaction is the first step in clinical decision-making.

Identify the underlying complication.

The symptoms indicate Red Man syndrome, a potentially severe, rate-related infusion reaction associated with vancomycin.

Connecting the specific medication to the clinical manifestations determines the necessary emergency intervention.

Determine the priority intervention based on ABCs (Airway, Breathing, Circulation) and scope of practice.

The immediate threat to circulation (hypotension) must be halted by stopping the infusion. This action is safely within the practical nurse's scope.

Stopping the offending agent prevents further cardiovascular collapse and must precede additional assessment, documentation, or out-of-scope interventions.

Key Concept

Recognizing and prioritizing immediate interventions for adverse medication reactions (such as Red Man syndrome) within the practical nursing scope of practice.

Estimated Time:1m 0s

Question 2474Question →

A practical nurse is collecting data on a newborn who was delivered at 38 weeks of gestation and is currently 16 hours old. Which of the following findings require immediate notification to the registered nurse (RN)? Select all that apply.

Select all that apply

Respiratory rate of 68 breaths per minute while resting quietly

Substernal retractions and nasal flaring during inspiration

Yellowish discoloration of the skin on the face and upper chest

Bluish appearance of the hands and feet

Apical pulse of 135 beats per minute while awake

Audible mucus secretions pooling in the oral cavity

Show answer & explanation

Answer: Respiratory rate of 68 breaths per minute while resting quietly; Substernal retractions and nasal flaring during inspiration; Yellowish discoloration of the skin on the face and upper chest

Answer

The findings that require immediate notification to the registered nurse are a resting respiratory rate of 68 breaths per minute, substernal retractions with nasal flaring, and yellowish discoloration of the skin.

A normal newborn respiratory rate is 30 to 60 breaths per minute; a rate of 68 at rest indicates tachypnea. Substernal retractions and nasal flaring are distinct indicators of respiratory distress. Both of these respiratory findings require immediate RN evaluation. Additionally, jaundice appearing within the first 24 hours of life is considered pathologic (often due to hemolysis) and requires immediate RN notification and further medical evaluation.

Step-by-Step Solution

Identify the normal vital signs and physiological expectations for a 16-hour-old newborn.

Normal respiratory rate is 30 to 60 breaths per minute, normal heart rate is 110 to 160 beats per minute, acrocyanosis is expected, and jaundice before 24 hours of age is abnormal.

Establishing normal baselines helps differentiate expected physiological findings from those requiring escalation.

Evaluate each assessment finding to determine if it is abnormal or a sign of complications.

The respiratory rate of 68, retractions, nasal flaring, and early-onset jaundice are abnormal findings.

Recognizing complications early ensures prompt intervention and prevents newborn deterioration.

Determine the appropriate practical nursing action for each abnormal finding.

The signs of respiratory distress and early jaundice require RN notification. Audible mucus requires immediate independent suctioning by the practical nurse before reporting.

The practical nurse must prioritize immediate airway clearance independently while escalating findings that require RN or provider assessment.

Key Concept

Prioritization of abnormal newborn assessment findings and boundary of practical nurse independent action.

Question 2475Question →

A practical nurse (PN) is completing client care on a busy medical-surgical unit. Which actions by the PN demonstrate adherence to client confidentiality and information security protocols? Select all that apply.

Select all that apply

Logging off the electronic health record (EHR) immediately after documenting a nursing intervention.

Confirming a client's admission status to a caller who identifies themselves as the client's employer.

Placing printed daily care schedules into a designated secure shredding bin before leaving the facility.

Sharing a personal computer password with a temporary agency nurse who is having trouble accessing the system.

Lowering the voice to a hushed tone when conducting bedside shift handoff in a semi-private room.

Show answer & explanation

Answer: Logging off the electronic health record (EHR) immediately after documenting a nursing intervention.; Placing printed daily care schedules into a designated secure shredding bin before leaving the facility.; Lowering the voice to a hushed tone when conducting bedside shift handoff in a semi-private room.

Answer

The correct actions are logging off the EHR after use, placing printed schedules in a secure shredding bin, and lowering the voice during handoff in a semi-private room.

Protecting protected health information (PHI) requires active measures in electronic, physical, and verbal domains. Logging off the computer prevents unauthorized digital access, utilizing secure shredding bins prevents physical data breaches from printed handoffs, and speaking quietly in shared spaces minimizes incidental verbal exposure.

Step-by-Step Solution

Evaluate each action for compliance with HIPAA and facility confidentiality policies.

Identify whether the action protects or compromises protected health information (PHI).

The PN must differentiate between secure practices and potential breaches.

Analyze the electronic security actions.

Logging off the EHR protects data, while sharing passwords violates security protocols.

Digital security requires individual accountability and preventing unauthorized access.

Analyze the physical and verbal security actions.

Shredding documents and lowering one's voice protect PHI, whereas confirming admission status to an unauthorized caller is a breach.

PHI exists in paper, verbal, and electronic formats, all of which require safeguarding.

Key Concept

Safeguarding Protected Health Information (PHI)

Question 2476Question →

A practical nurse is assisting with the care of a client who is 12 hours postoperative following a lumbar laminectomy with spinal fusion. The client reports severe lower back stiffness from remaining supine and requests assistance to turn onto their side. Which technique should the practical nurse implement to safely reposition this client?

Place a pillow between the client's legs and work with a second staff member to turn the client's entire body simultaneously using a draw sheet.

Instruct the client to reach across their chest to grasp the opposite side rail and gently pull their upper body over.

Elevate the head of the bed to 45 degrees to reduce lumbar strain before assisting the client to roll onto their side.

Ask the client to cross their arms over their chest while the nurse shifts their pelvis first, followed by their shoulders.

Show answer & explanation

Answer: Place a pillow between the client's legs and work with a second staff member to turn the client's entire body simultaneously using a draw sheet.

Answer

The nurse must use the logrolling technique with the assistance of another staff member, turning the client's body as a single unit with a pillow between the legs.

The correct approach for repositioning a client after a spinal fusion is logrolling. This technique requires at least two staff members using a draw sheet (friction-reducing sheet) to turn the client's head, shoulders, spine, and pelvis simultaneously as a single unit. Placing a pillow between the client's legs prevents adduction of the upper leg, which helps maintain the spine in neutral alignment during the turn.

Step-by-Step Solution

Identify the client's surgical procedure and the specific postoperative precautions required.

The client had a lumbar laminectomy with spinal fusion, which requires keeping the spine in strict neutral alignment.

Spinal fusion involves bone grafts and hardware that must remain completely stable during the initial healing phase to prevent injury or failure of the fusion.

Evaluate each repositioning technique for its impact on spinal alignment.

Only turning the body simultaneously as a single unit (logrolling) prevents spinal torsion. Other methods cause twisting of the shoulders relative to the pelvis.

Logrolling distributes movement equally across the entire spine, whereas independent movement or segmented rolling bends or twists the vertebral column.

Key Concept

Postoperative mobility and positioning following spinal surgery requires the logrolling technique to maintain neutral spinal alignment and prevent injury to the surgical site.

Question 2477Question →

While coordinating care on a progressive neurological unit, a practical nurse (PN) prepares to assign routine mobility assistance to an assistive personnel (AP). To comply with the National Guidelines for Nursing Delegation, arrange the PN's actions in the required chronological order.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct chronological sequence aligns with the Five Rights of Delegation: 1) Review client acuity and stability, 2) Confirm AP competency, 3) Direct the AP with specific parameters, 4) Observe performance periodically, and 5) Obtain a final report on client tolerance.

The delegation process must follow a strict chronological sequence to ensure safety. The PN must first confirm the client is stable enough for delegation (Right Circumstance). Next, the PN verifies the AP is competent to perform the care (Right Person). Then, the PN gives specific instructions and reporting limits (Right Direction). While the task is occurring, the PN monitors the AP (Right Supervision). Finally, the PN follows up to determine how the client responded (Right Evaluation).

Step-by-Step Solution

Determine the right task and right circumstances.

The PN reviews the clients' acuity and neurological stability.

Delegation is only safe when the client's condition is stable and predictable.

Ensure the right person is selected.

The PN confirms the AP has the training to manage mobility equipment.

The AP must possess documented competency before a task is assigned.

Provide the right direction and communication.

The PN provides exact ambulation distances and parameters for reporting.

Clear, two-way communication ensures the AP understands exactly what to do and what findings require immediate escalation.

Implement the right supervision.

The PN observes the AP periodically during the task execution.

The PN retains accountability and must monitor the AP to ensure safe care delivery.

Conduct the right evaluation.

The PN obtains a comprehensive report on client tolerance.

The delegation loop is closed by evaluating the outcome of the task and documenting the results.

Key Concept

The National Guidelines for Nursing Delegation require a sequential application of the Five Rights: Right Task, Right Circumstances, Right Person, Right Direction/Communication, and Right Supervision/Evaluation.

Estimated Time:1m 30s

Question 2478Question →

An older adult client with a history of asthma and atrial fibrillation is admitted to a medical unit. The health care provider prescribes several new daily medications. Which actions by the practical nurse demonstrate safe pharmacological management? Select all that apply.

Select all that apply

Verify the client's identity using their full name and date of birth before giving oral digoxin.

Withhold the prescribed oral propranolol and notify the registered nurse after assessing audible wheezing.

Administer the scheduled dose of warfarin despite a morning international normalized ratio (INR) of 4.8.

Accept a verbal order during rounds to administer an intravenous push dose of metoprolol.

Confirm the client's room number and bed assignment as the second identifier when the barcode system is offline.

Reinforce previous instructions to rinse the oral cavity with water after using a prescribed budesonide inhaler.

Show answer & explanation

Answer: Verify the client's identity using their full name and date of birth before giving oral digoxin.; Withhold the prescribed oral propranolol and notify the registered nurse after assessing audible wheezing.; Reinforce previous instructions to rinse the oral cavity with water after using a prescribed budesonide inhaler.

Answer

The correct actions are to verify identity using the client's name and date of birth, withhold the propranolol due to active wheezing, and reinforce instructions to rinse the mouth after using the budesonide inhaler.

Safe pharmacological management encompasses strict adherence to the rights of medication administration, including using two acceptable client identifiers (like name and date of birth). Practical nurses must also recognize critical contraindications, such as the danger of administering a non-selective beta-blocker (propranolol) to an asthmatic client who is actively wheezing, as it can worsen bronchospasm. Finally, reinforcing prior teaching regarding self-care measures, such as rinsing the mouth after using an inhaled corticosteroid to prevent candidiasis, is an essential and appropriate component of the practical nurse's scope of practice.

Step-by-Step Solution

Evaluate each action against the standard rights of medication administration.

Using full name and date of birth is correct; using a room number is incorrect and violates safety protocols.

Two unique, client-specific identifiers are required to prevent medication errors.

Analyze the prescribed medications against the client's medical history and current assessment findings.

Propranolol must be withheld in an asthmatic client with audible wheezing.

Non-selective beta-blockers like propranolol can trigger severe bronchospasms in clients with a history of asthma.

Determine if the actions align with the practical nurse's scope of practice.

Reinforcing teaching about budesonide is within the scope; accepting and giving IV push medications is outside the scope. Additionally, administering warfarin with a critically high INR represents a failure to escalate critical data.

The PN must practice within legal boundaries, which excludes IV push administration and requires reporting abnormal physiological findings before proceeding.

Key Concept

Safe medication administration requires adherence to the rights of medication administration, understanding contraindications (such as beta-blockers in asthma), and functioning within the practical nurse scope of practice.

Estimated Time:1m 30s

Question 2479Question →

A practical nurse is caring for a pediatric client who weighs $22\text{ lbs}$ ( $10\text{ kg}$ ) and has a tympanic temperature of $102.1^\circ\text{F}$ ( $38.9^\circ\text{C}$ ). The health care provider's prescription reads: "Ibuprofen $100\text{ mg}$ PO every $6\text{ hours}$ PRN for temperature greater than $101.5^\circ\text{F}$ ( $38.6^\circ\text{C}$ )." The pharmacy dispenses an oral suspension containing $100\text{ mg}/5\text{ mL}$ . The client's caregiver reports administering a dose of oral acetaminophen at home $2\text{ hours}$ prior to arrival. Which action by the nurse is the most appropriate?

Administer

5\text{ mL}

of the ibuprofen suspension to the client using a calibrated oral syringe.

Withhold the ibuprofen because it should not be administered within

4\text{ hours}

of the caregiver's acetaminophen dose.

Administer

11\text{ mL}

of the ibuprofen suspension to match a weight-based calculation using the client's weight in pounds.

Notify the health care provider to increase the dose because

100\text{ mg}

is below the therapeutic range for a

22\text{ lb}

client.

Show answer & explanation

Answer: Administer $5\text{ mL}$ of the ibuprofen suspension to the client using a calibrated oral syringe.

Answer

The correct action is to administer

5\text{ mL}

of the ibuprofen suspension to the client using a calibrated oral syringe.

The correct action is to administer

5\text{ mL}

of the medication. The prescribed dose of

100\text{ mg}

is safe for a

10\text{ kg}

child, as the standard pediatric dose for ibuprofen is

5

10\text{ mg/kg}

per dose (

10\text{ kg} \times 10\text{ mg/kg} = 100\text{ mg}

). To determine the correct volume, the nurse divides the desired dose by the available concentration:

(100\text{ mg} / 100\text{ mg}) \times 5\text{ mL} = 5\text{ mL}

. Acetaminophen and ibuprofen belong to different medication classes, so they can be safely administered within two hours of each other to manage a persistent high fever. A calibrated oral syringe ensures precise measurement.

Step-by-Step Solution

Verify the client's weight in kilograms.

The client weighs

10\text{ kg}

Pediatric medication dosing is strictly based on kilograms to prevent potentially fatal overdosing or underdosing.

Determine if the prescribed dose is within the safe pediatric range.

The standard dose is

5

10\text{ mg/kg}

. For a

10\text{ kg}

child, the maximum safe single dose is

100\text{ mg}

, which exactly matches the prescription.

Nurses must independently verify that a prescribed dose is safe before administration, even if the order is written clearly.

Calculate the required liquid volume to administer.

Using the formula

(\text{Desired} / \text{Have}) \times \text{Volume}

(100\text{ mg} / 100\text{ mg}) \times 5\text{ mL} = 5\text{ mL}

This calculation determines the exact physical amount of liquid to draw into the syringe.

Evaluate drug interactions and administration timing.

The administration is safe. Ibuprofen (an NSAID) and acetaminophen (a non-opioid analgesic/antipyretic) have different mechanisms of action.

Because they are metabolized differently, they can be safely alternated or given within two hours of each other for high fevers without compounding toxicity.

Key Concept

Pediatric Dosage Calculation and Antipyretic Administration

Estimated Time:2m 0s

Question 2480Question →

A practical nurse is caring for a client who is three hours postpartum following a rapid vaginal delivery of a large-for-gestational-age infant. The nurse palpates the uterine fundus and notes it is firm, midline, and at the level of the umbilicus. However, the nurse observes a continuous, steady trickle of bright red blood from the vagina. Which action is the priority for the nurse to take?

Notify the registered nurse of the assessment findings.

Document the observation as an expected lochia pattern.

Initiate vigorous massage of the client's uterine fundus.

Independently increase the rate of the client's intravenous fluids.

Show answer & explanation

Answer: Notify the registered nurse of the assessment findings.

Answer

Notify the registered nurse of the assessment findings.

A continuous trickle of bright red blood despite a firm, midline fundus strongly suggests a genital tract laceration (such as a cervical or vaginal tear) rather than uterine atony. Because evaluating and repairing a laceration is outside the practical nurse's scope of practice, the priority is to immediately notify the registered nurse for further assessment and intervention.

Step-by-Step Solution

Analyze the clinical findings.

The fundus is firm and midline, indicating the uterus is contracted. However, there is a continuous trickle of bright red blood.

Differentiating the source of postpartum bleeding is essential for determining the appropriate intervention.

Correlate findings with potential complications.

A firm uterus with active bleeding suggests a trauma-related cause, such as a laceration of the cervix or vagina, which is a known risk following a rapid delivery of a large infant.

Understanding the pathophysiology of postpartum hemorrhage guides safe clinical decision-making.

Determine the practical nurse's scope of practice.

Identifying and repairing a vaginal or cervical laceration requires advanced assessment by a registered nurse or healthcare provider.

Practical nurses must operate within their legal scope of practice and safely delegate or report complex situations.

Select the priority action.

The nurse must immediately notify the registered nurse to ensure the client receives timely medical evaluation.

Prompt communication of abnormal findings prevents clinical deterioration.

Key Concept

Postpartum Hemorrhage and Scope of Practice

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