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Question 241Question →

A practical nurse (PN) working in a rehabilitation unit observes a colleague with an unsteady gait, slurred speech, and the odor of alcohol while preparing to administer a narcotic to a client. Arrange the following actions in the chronological order the PN should perform them. All options must be used.

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Answer

The correct sequence prioritizes immediate client safety, followed by removing the risk, notifying management, and finally documenting the event.
When dealing with an impaired colleague, the absolute first priority is client safety. The PN must intervene immediately to stop care delivery. Next, the colleague must be removed from the area to secure the environment. Third, management must be notified to take official administrative action. Finally, objective documentation is completed as a permanent legal record.

Step-by-Step Solution

1
Ensure immediate client safety by stopping the medication administration.
The client is protected from a potentially dangerous medication error.
The core tenet of nursing practice is to do no harm; preventing an immediate physical threat to the client takes precedence over all other actions.
2
Remove the impaired colleague from the clinical area.
The colleague can no longer access medications or interact with clients.
This secures the environment and prevents the impaired nurse from attempting to provide care to other clients on the unit.
3
Report the situation to the nursing supervisor.
Facility leadership is activated to manage the impaired employee.
Supervisors have the authority to relieve the nurse of duty, arrange for mandatory testing, and ensure the unit remains adequately staffed.
4
Document the incident objectively.
A factual, legal record of the event is created.
Thorough documentation is legally and ethically required, but must wait until the immediate safety and administrative steps are successfully completed.

Key Concept

Reporting Impaired Practice and Prioritizing Client Safety
Question 242Question →

After providing care to a client on transmission-based precautions, a nurse prepares to exit the room and must remove all personal protective equipment (PPE). Arrange the following PPE removal steps in the correct standard sequence from first to last.

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Answer

The correct sequence for removing PPE is: gloves first, followed by protective eyewear/goggles, then the isolation gown, and finally the face mask.
The standard sequence for removing (doffing) personal protective equipment ensures that the healthcare worker does not contaminate their own skin, clothing, or mucous membranes. Gloves are typically the most contaminated and are removed first. Eyewear is removed next, followed by the gown. The mask is always removed last to provide continuous respiratory protection during the doffing process.

Step-by-Step Solution

1
Identify the most contaminated PPE.
Gloves are removed first.
To avoid spreading pathogens to the hair, face, or uniform while removing other items.
2
Identify the next contaminated item that protects the face.
Eyewear or goggles are removed second.
The outside of the goggles is contaminated and should be handled with clean hands.
3
Identify the item covering the body.
The gown is removed third.
It must be removed carefully, peeling away from the body, to prevent contamination of underlying clothing.
4
Identify the final item to remove.
The mask is removed last.
Respiratory protection must be maintained until all other contaminated items are removed and the nurse is ready to leave the room.

Key Concept

Standard Sequence for Removing (Doffing) Personal Protective Equipment
Question 243Question →

A practical nurse (PN) is preparing to remove personal protective equipment (PPE) after providing care to a client requiring airborne and contact precautions. Arrange the steps for safely removing the PPE in the correct sequence from first to last.

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Answer

The correct sequence for doffing personal protective equipment is: gloves, followed by goggles or face shield, then the gown, and finally the N95 respirator or mask.
According to standard infection control guidelines, personal protective equipment (PPE) must be removed in a specific order to minimize the risk of self-contamination. The sequence progresses from the most contaminated items to the least contaminated, prioritizing the maintenance of respiratory protection. Gloves are removed first, followed by the goggles or face shield, then the gown, and lastly the mask or respirator.

Step-by-Step Solution

1
Identify the most highly contaminated PPE item.
Gloves are identified as the most contaminated.
Gloves have direct contact with the client and environmental surfaces.
2
Determine the next piece of PPE to remove that protects the face but not the respiratory tract.
Goggles or face shield.
The front of the eyewear is contaminated and must be removed before the gown to avoid reaching up over a potentially contaminated gown later.
3
Identify the remaining large body covering.
The gown.
The gown's front and sleeves are contaminated. It is removed by touching only the inside and rolling it away from the body.
4
Determine the final piece of PPE to remove.
The N95 respirator or mask.
Airway protection must be maintained until all other contaminated items are removed and discarded safely.

Key Concept

Proper Sequence for Doffing Personal Protective Equipment (PPE)
Question 244Question →

A client informs the practical nurse (PN) that they will not take their scheduled antihypertensive medication. To respect the client's right to refuse while ensuring safe care, arrange the following nursing actions in the correct chronological order.

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Answer

The correct sequence is to first assess the client's reason for refusal, then reinforce education about the medication's importance, subsequently report the refusal to the RN or provider, and finally document the incident.
When a client exercises their right to refuse care, the nursing process dictates that data collection comes first. The PN must first understand the root cause of the refusal. Next, the PN ensures informed refusal by reinforcing education about the medication. Then, the PN communicates with the supervising RN or provider for continuity of care. Finally, accurate and complete documentation provides a legal record of the client's choice and the appropriate nursing response.

Step-by-Step Solution

1
Gather data regarding the refusal
Understanding the client's perspective and any underlying issues
To identify if the refusal stems from a manageable problem, such as nausea or a knowledge deficit, before escalating the situation.
2
Reinforce client education
The client makes an informed decision regarding their care
Clients have a legal right to refuse treatment, but they must be fully aware of the potential health consequences of doing so.
3
Communicate with the healthcare team
The RN and prescribing provider are made aware of the missed medication
To maintain safety and allow the provider to consider alternative treatments or evaluate the client if necessary.
4
Document the event
The client's medical record accurately reflects the refusal and nursing response
To meet legal standards of nursing practice and ensure continuity of care.

Key Concept

Client Rights: Refusal of Treatment
Question 245Question →

A practical nurse (PN) enters a client's room and observes an unlicensed assistive personnel (UAP) forcefully grabbing the client's arm and stating, "If you don't stay still, you will not get any lunch." To protect the client's rights and ensure safety, arrange the following actions the PN should take in the correct priority order.

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Answer

The PN must first intervene to stop the behavior, then assess the client for injury, report the incident to the charge nurse, and finally document the event in an incident report.
When advocating for a client whose rights are being violated (e.g., facing abuse or coercion), the nurse's primary responsibility is client safety. Intervening to stop the abuse must happen first. Once the threat is removed, the nurse assesses the client's physical and emotional status. After the client is stabilized and deemed safe, the nurse follows the chain of command to report the incident to management. Finally, formal documentation is completed via an incident report, which is an administrative task that should never delay direct client care.

Step-by-Step Solution

1
Intervene immediately to stop the behavior.
The client is protected from further physical and emotional abuse.
Immediate safety and client protection take precedence over all other actions.
2
Assess the client.
The PN identifies any injuries or distress caused by the UAP.
Determines the needed care post-incident and ensures the client's physical stability.
3
Report to the supervisor.
The chain of command is activated.
Leadership must be made aware to address the UAP's actions and ensure facility-wide safety.
4
Complete an incident report.
An official administrative record is created.
Provides factual, objective documentation of the event for risk management and legal purposes.

Key Concept

Client Rights and Advocacy: Protecting clients from abuse and proper incident reporting sequence
Question 246Question →

A practical nurse (PN) is caring for a client who suddenly packs their belongings, becomes upset, and states, 'I am leaving this hospital right now without treatment.' In which order should the PN perform the following actions? Arrange the actions in the correct sequence from first to last.

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Answer

First, the PN assesses the client's reasons for leaving. Second, the PN notifies the charge nurse and provider. Third, the PN reinforces the provider's explanation of the risks. Fourth, the PN witnesses the AMA signature. Finally, the PN documents the entire event in the medical record.
When a client wishes to leave against medical advice, the practical nurse must prioritize actions based on the nursing process and scope of practice. Assessing the client's reasons comes first to determine if a resolvable issue exists. If the client insists on leaving, the chain of command must be activated to involve the provider, who is responsible for explaining the medical risks. Following the provider's explanation, the PN reinforces the information, witnesses the legal AMA document, and concludes by thoroughly documenting the entire encounter.

Step-by-Step Solution

1
Assess the underlying reason for the client's distress.
The PN identifies exactly why the client wants to leave.
Addressing an immediate need (such as fear, anger, or pain) might resolve the underlying issue and prevent an unsafe departure.
2
Notify the healthcare provider and charge nurse.
The primary provider is alerted to intervene.
It is outside the PN's scope to provide the initial disclosure of complex medical risks; the provider must be present to fulfill this legal requirement.
3
Reinforce the provider's explanation of medical risks.
The client receives consistent information confirming the dangers of leaving.
While the PN cannot initiate the primary risk disclosure, reinforcing the provider's education falls squarely within the PN scope of practice.
4
Witness the signature on the AMA form.
The client signs the legal document refusing care.
Competent clients have the legal right to refuse treatment. Witnessing the signature validates that the client signed it voluntarily after being informed of the consequences.
5
Document the event thoroughly.
A clear legal record is created in the client's chart.
Documentation should occur after the situation is fully handled to ensure all client statements, provider notifications, and signed forms are captured accurately.

Key Concept

Client Rights and Advocacy: Leaving Against Medical Advice (AMA)
Question 247Question →

A practical nurse (PN) is tasked with witnessing a client's signature on an informed consent form for an upcoming elective procedure. Arrange the steps the PN should take in the correct chronological order.

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Answer

The correct sequence is to first verify the client's identity, then determine their cognitive status and ensure no sedatives were given, followed by confirming their understanding of the procedure, and finally witnessing the signature.
The proper legal sequence for witnessing informed consent requires establishing identity first to prevent wrong-person errors, ensuring the client is legally competent to sign (alert and unmedicated), confirming the provider has fulfilled their duty to inform, and lastly, witnessing the actual physical signature.

Step-by-Step Solution

1
Identify the primary role of the practical nurse in the informed consent process.
The PN acts as an advocate and a witness, ensuring legal and facility requirements are met.
Understanding the PN scope of practice ensures the nurse does not overstep by attempting to explain the procedure themselves.
2
Determine the fundamental first action before initiating any procedure or legal documentation.
Verify the client's identity using two acceptable identifiers.
Accurate identification is a critical safety measure to prevent wrong-person errors.
3
Evaluate the client's legal and cognitive capacity to provide consent.
Assess the client's cognitive status to ensure they are alert and have not received sedating medications.
A consent form signed after the administration of mind-altering medications is considered legally invalid.
4
Verify that the healthcare provider has fulfilled their legal duty.
Confirm with the client that the provider has adequately explained the procedure and answered questions.
The PN must ensure the client genuinely understands the procedure before witnessing the signature.
5
Complete the legal documentation process.
Observe the client voluntarily sign the document and provide a witness signature.
This finalizes the consent process and formally documents that the client signed voluntarily.

Key Concept

The practical nurse's legal responsibilities and sequential steps when witnessing informed consent.
Question 248Question →

A practical nurse (PN) working the night shift on a medical-surgical unit observes a colleague exhibiting slurred speech, an unsteady gait, and the smell of alcohol on their breath while preparing to administer scheduled intravenous medications. Arrange the following actions the PN must take in the correct order of priority.

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Answer

The correct priority sequence is: first, intervene to stop the colleague from giving medications; second, notify the nursing supervisor; third, ensure the colleague's clients are safely reassigned; and fourth, document the incident in a facility report.
In any ethical or legal dilemma involving suspected impaired practice, the nurse's first duty is to protect the client from immediate harm. Therefore, stopping the impaired colleague from administering medications is the first mandatory step. Next, the nurse must activate the chain of command by notifying the nursing supervisor, who has the authority to formally remove the colleague from the clinical area. Once the colleague is removed, the team must ensure that the colleague's clients receive continuous, safe care through reassignment. Finally, an objective, factual incident report is completed to document the event legally.

Step-by-Step Solution

1
Prioritize immediate client safety by stopping the colleague.
The impaired colleague is prevented from administering potentially dangerous medications.
Client safety is always the first ethical and legal priority in nursing practice. Immediate intervention prevents potential sentinel events.
2
Report the observations directly to the nursing supervisor.
The chain of command is activated.
The PN must report impaired practice to management so the facility can initiate appropriate disciplinary, safety, and testing protocols.
3
Establish continuity of care for the affected clients.
Client needs continue to be met safely by competent staff.
Clients cannot be abandoned; once an impaired nurse is removed, their care must be seamlessly transitioned to safe personnel.
4
Complete an objective facility incident report.
A formal, legal record of the event is created.
Accurate, factual documentation must be completed promptly, but only after immediate safety and client care needs are resolved.

Key Concept

Mandatory reporting and management of impaired nursing practice
Question 249Question →

After performing nasotracheal suctioning on a client colonized with methicillin-resistant Staphylococcus aureus (MRSA) in the sputum, the practical nurse is standing near the room exit. The nurse is currently wearing a fluid-resistant isolation gown, disposable gloves, a surgical mask, and a protective face shield. To adhere to strict infection control protocols and prevent self-contamination, in what exact chronological sequence must the nurse execute the removal of these items?

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Answer

The correct sequence for doffing full personal protective equipment is to first remove the gloves, followed by the face shield, then the gown, then the surgical mask, and finally concluding with hand hygiene.
According to standardized infection control guidelines, the removal of personal protective equipment must proceed from the most contaminated item to the least, protecting the respiratory tract until the very end. The exact sequence is: gloves, goggles/face shield, gown, mask/respirator, and hand hygiene. This specific order ensures that contaminated items are not brought near the unprotected face and that any airborne particles disturbed during gown removal do not enter the respiratory tract.

Step-by-Step Solution

1
Remove and discard the disposable gloves.
The hands are freed from the most heavily soiled barrier.
This prevents transferring gross contamination to the face, neck, or uniform during the subsequent removal steps.
2
Remove the face shield by handling only the back straps.
Eye protection is safely taken off without touching the contaminated front surface.
This eliminates splash hazards while keeping the nurse's respiratory tract protected during the next steps.
3
Unfasten and remove the isolation gown by rolling it inside out.
The gown is safely contained in an inside-out bundle and discarded.
Rolling the gown inside out prevents pathogens on the exterior from transferring to the nurse's uniform or skin.
4
Remove the surgical mask by handling only the ear loops or ties.
The respiratory barrier is taken off as the final piece of apparel.
The mask must remain on during gown removal in case any pathogens become aerosolized while manipulating the contaminated gown fabric.
5
Perform thorough hand hygiene.
The hands are completely sanitized.
This eradicates any microorganisms that may have incidentally contacted the bare skin during the doffing procedure.

Key Concept

Standardized CDC Sequence for Doffing Personal Protective Equipment (PPE)
Estimated Time:1m 30s
Question 250Question →

After completing a wound dressing change for a client with disseminated herpes zoster, the practical nurse prepares to leave the airborne infection isolation room (AIIR). The nurse is currently wearing an N95 respirator, a face shield, an isolation gown, and gloves. What is the correct sequence for safely removing the personal protective equipment (PPE) and exiting the area?

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Answer

The correct sequence is to first remove the gloves, then the face shield, followed by the gown. After removing these items, the nurse must exit the room and close the door. Once outside in the clean hallway, the nurse removes the N95 respirator and finally performs hand hygiene.
The correct sequence prioritizes removing the most contaminated items first (gloves), followed by the face shield and gown, all while remaining inside the client's room. Because the client has disseminated herpes zoster (requiring airborne and contact precautions), the N95 respirator must be kept on until the nurse has fully exited the negative-pressure room and closed the door. Furthermore, safely removing the N95 requires pulling the bottom strap first. Finally, hand hygiene is universally performed immediately after all PPE is removed.

Step-by-Step Solution

1
Identify the most contaminated items to remove first.
The gloves are removed.
Gloves have directly touched the client and environmental surfaces, making them the most contaminated item. Removing them first prevents transferring pathogens to the head or face during other doffing steps.
2
Protect the mucous membranes while maintaining body protection.
The face shield is removed by the back strap.
The traditional CDC doffing sequence dictates removing eyewear before the gown. Touching only the back strap ensures the hands remain clean.
3
Remove the remaining body protection.
The gown is untied, pulled away, and rolled inside out.
Rolling the gown inside out contains the contaminated front and sleeves, protecting the nurse's uniform and the environment.
4
Maintain the integrity of the airborne isolation environment.
The nurse exits the AIIR and closes the door.
To prevent inhalation of airborne particles (like aerosolized varicella-zoster virus), respiratory protection must remain firmly in place until the nurse is outside the negative pressure environment.
5
Remove respiratory protection safely.
The N95 respirator is removed using the straps, starting with the bottom strap.
Removing the bottom strap first prevents the contaminated front of the mask from falling against the nurse's body. Touching only the straps prevents hand contamination.
6
Eradicate any residual pathogens.
Hand hygiene is performed.
This is the universal final step of standard precautions to ensure hands are safe for the next client interaction.

Key Concept

Standard CDC PPE doffing sequence for combined Airborne and Contact precautions
Question 251Question →

A client is scheduled for an elective cardiac catheterization in 30 minutes and has previously signed the informed consent document. The client suddenly appears highly anxious and tells the practical nurse (PN), "I changed my mind and do not want to go through with this, but my daughter insists that I have to." The daughter is standing at the bedside. In what order should the PN perform the following interventions? (Arrange the actions from first to last.)

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Answer

The correct sequence is to first halt the preparation, then reassure the client of their rights, inquire about their specific concerns, notify the healthcare provider, and finally document the event.
In any situation involving the withdrawal of informed consent and potential family coercion, the nursing process dictates that immediate harm or unwanted intervention must be stopped first (halting preparation). Next, the nurse addresses the psychosocial threat by advocating for the client's rights (reassuring the client). Once the client is safe and supported, the nurse collects data (inquiring about fears) to understand the root cause. This information is then communicated to the primary healthcare provider, who is responsible for the medical management of the refusal. Finally, the entire sequence of events is legally documented.

Step-by-Step Solution

1
Halt any further preoperative preparation and delay the transport process.
The immediate progression toward the procedure is stopped.
The fundamental right to refuse treatment requires the immediate cessation of any interventions leading up to the procedure to prevent battery and respect client autonomy.
2
Reassure the client that they retain the right to withdraw informed consent without penalty.
The client feels supported and their legal rights are validated.
Because the client is experiencing family coercion, the nurse must immediately act as an advocate to empower the client and neutralize the external pressure.
3
Ask open-ended questions to determine the client's specific fears about the procedure.
The practical nurse gathers relevant clinical data about the refusal.
The PN must collect data regarding the cause of the refusal (e.g., fear of pain, misunderstanding of the procedure) to report an accurate and complete clinical picture to the provider.
4
Contact the primary healthcare provider to report the client's decision to revoke consent.
The provider is made aware of the situation and the client's concerns.
Only the primary healthcare provider can formally address complex medical concerns, explain alternative treatments, and officially cancel the procedure.
5
Document the client's exact verbal refusal and the subsequent notifications in the health record.
A permanent, legal record of the event is created.
Accurate, objective documentation of the client's quotes, family dynamics, and provider notifications provides legal protection and ensures continuity of care.

Key Concept

The practical nurse's role in client advocacy and informed consent withdrawal involves prioritizing immediate safety, validating client autonomy, collecting preliminary data, escalating to the provider, and maintaining accurate legal documentation.
Question 252Question →

A practical nurse (PN) is working the night shift on a medical-surgical unit. The PN observes the charge nurse (a registered nurse) stumbling, slurring words, and smelling faintly of alcohol. The registered nurse is preparing to administer an intravenous (IV) push medication to a client. In what order should the PN perform the following actions? (Arrange from first action to last).

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Answer

The correct sequence is to first intervene to stop the medication administration, remove the nurse from the area, notify the supervisor, collaborate on reassigning client care, and finally complete an incident report.
When encountering an impaired colleague, the correct sequence prioritizes immediate client safety (stopping the medication administration and removing the impaired nurse), followed by initiating the chain of command (notifying the supervisor). Because the PN cannot independently reassign the RN's clients, they must collaborate with the supervisor to ensure continuity of care. Finally, an objective incident report is completed to document the event for administrative and legal purposes.

Step-by-Step Solution

1
Intervene immediately to stop the registered nurse from administering the medication.
The client is protected from a potentially dangerous medication error.
Client safety is the highest priority. The PN must stop the unsafe action before taking any other steps.
2
Remove the registered nurse from the client care area to a private location.
The RN is no longer a threat to other clients on the unit.
This protects all clients on the unit and maintains the confidentiality of the impaired coworker.
3
Notify the nursing supervisor on duty about the objective observations.
The formal chain of command is activated to handle the impaired employee.
The PN does not have the authority to dismiss or formally discipline the RN; leadership must intervene immediately.
4
Collaborate with the nursing supervisor to ensure continuous care is arranged for the clients.
The RN's assigned clients continue to receive necessary nursing care.
The PN cannot independently reassign clients, but must ensure they are not abandoned while the RN is removed.
5
Submit an objective incident report detailing the registered nurse's behavior.
The facility has a formal, written administrative record of the event.
Factual documentation of the event is required for risk management, legal protection, and potential regulatory reporting.

Key Concept

Prioritization in impaired practice reporting: Immediate client safety first, followed by chain of command notification, continuity of care, and documentation.
Estimated Time:2m 0s
Question 253Question →

Following the shift handoff, a practical nurse (PN) must organize the morning workflow for a newly assigned group of clients. Prioritize the order in which the PN should evaluate the following clients, from most urgent (first) to least urgent (last).

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Answer

The correct sequence prioritizes the acute physiological emergency (shortness of breath) first, followed by urgent symptom management (pain), routine clinical maintenance (dressing change), and finally administrative tasks (discharge).
Safe client care assignments require the nurse to prioritize based on the ABCs (Airway, Breathing, Circulation) and Maslow's Hierarchy of Needs. The client with shortness of breath has an acute breathing compromise and must be evaluated first. The client experiencing post-operative pain requires urgent symptom management, making them the second priority. The routine dressing change is a necessary clinical task but is not immediately urgent, placing it third. Finally, the client awaiting an afternoon discharge is stable and requires only administrative preparation, making them the lowest priority.

Step-by-Step Solution

1
Identify any clients with life-threatening airway, breathing, or circulation (ABC) issues.
The client with sudden shortness of breath and wheezing is identified as the highest priority.
Airway and breathing are the most critical physiological needs because failure can lead to rapid systemic deterioration.
2
Evaluate the remaining clients for urgent but non-life-threatening physiological needs.
The client requesting post-operative pain medication is identified as the second priority.
Unrelieved pain is an urgent physiological and psychological need that impacts recovery, taking precedence over routine scheduled tasks.
3
Differentiate between routine clinical care and non-clinical or administrative tasks.
The client needing a routine dressing change is prioritized over the client awaiting an afternoon discharge.
Clinical maintenance tasks must take precedence over administrative tasks for stable clients.

Key Concept

Prioritization of Care Assignments
Question 254Question →

A licensed practical nurse (LPN) in a rehabilitation facility is planning to delegate morning ambulation for a medically stable client to an unlicensed assistive personnel (UAP). Place the following steps of the delegation process in the correct chronological order.

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Answer

The correct chronological sequence is: Assess the client, determine UAP competency, provide clear instructions, verify understanding, and finally evaluate the outcome.
According to the NCSBN National Guidelines for Nursing Delegation, the delegation process must follow a logical sequence. The nurse must first assess the client to ensure stability (Right Circumstance). Next, the nurse verifies the competence of the delegatee (Right Person). After matching the person to the task, the nurse must communicate clear expectations and parameters (Right Direction/Communication). The nurse then verifies that the delegatee understands and accepts the task. Finally, the nurse must follow up to evaluate the client's response and the outcome of the task (Right Supervision/Evaluation).

Step-by-Step Solution

1
Prioritize client safety by performing a clinical assessment.
The nurse confirms the client is stable and suitable for delegation.
Delegation must always begin with evaluating the client's current condition.
2
Match the task to the appropriate healthcare team member.
The nurse verifies the UAP is competent to perform the ambulation.
The delegatee must have the demonstrated knowledge and skills to perform the task safely.
3
Communicate the specific requirements of the task.
The nurse provides exact parameters, such as distance to walk and specific signs to report.
Clear communication prevents errors and sets concrete expectations.
4
Confirm two-way communication.
The UAP acknowledges understanding and accepts the task.
This ensures the delegatee is confident and prepared to proceed without confusion.
5
Perform supervision and evaluation.
The nurse follows up on the client's status after the ambulation is completed.
The delegating nurse retains accountability for the outcome and must evaluate the results.

Key Concept

The National Council of State Boards of Nursing (NCSBN) delegation process follows a sequential framework: assessing the client, verifying delegatee competency, providing clear communication, confirming understanding, and evaluating the final outcome.
Question 255Question →

A licensed practical nurse (LPN) on a medical-surgical unit receives simultaneous requests for assistance regarding four assigned clients. Arrange the clients in the order the LPN should evaluate them and report findings to the supervising registered nurse (RN), from first (highest priority) to last (lowest priority).

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Answer

The correct priority sequence evaluates airway/breathing first, then circulation, then metabolic needs, and finally comfort needs. The order is: 1) Asthma with retractions, 2) Postoperative client with saturated dressing, 3) Diabetic client with hypoglycemia signs, 4) Client with bladder spasms.
The correct sequence utilizes the ABC (Airway, Breathing, Circulation) prioritization framework and Maslow's Hierarchy of Needs. The client with asthma is experiencing severe respiratory distress (airway/breathing), making them the absolute highest priority. The postoperative client has an active hemorrhage (circulation), which is the second priority. The client with signs of hypoglycemia has an urgent metabolic need, placing them third. Finally, the client with bladder spasms has a comfort/pain issue, which is the lowest priority among this group. The LPN must evaluate them in this order, implement immediate basic interventions, and rapidly collaborate with the RN.

Step-by-Step Solution

1
Apply the primary ABC (Airway, Breathing, Circulation) framework.
Identify the client with asthma exhibiting retractions and wheezing as having an immediate airway and breathing threat.
Airway and breathing compromise is the most rapid cause of deterioration and death. This client must be evaluated and reported to the RN first.
2
Evaluate the remaining clients for severe circulatory threats.
Identify the postoperative client with a blood-saturated dressing as having active hemorrhage.
Circulatory collapse from severe bleeding is the next most immediate threat to life after airway issues, making this the second priority.
3
Assess the remaining clients for urgent metabolic or systemic needs.
Identify the client with diabetes experiencing diaphoresis and jitteriness as having symptomatic hypoglycemia.
Hypoglycemia is a critical metabolic state that can lead to neurological damage if untreated, but physiological survival (ABCs) must be secured first.
4
Assign the lowest priority to non-life-threatening comfort or routine needs.
Identify the client with bladder spasms as the final priority.
While pain requires management and catheter troubleshooting is necessary, it is a physiologically stable condition compared to the other emergencies.

Key Concept

Prioritization of Client Care Assignments using the ABC and Maslow's Frameworks
Estimated Time:1m 30s
Question 256Question →

Prior to initiating care for a newly admitted client placed on contact and droplet precautions, the practical nurse must don appropriate protective gear. In what sequence should the nurse apply the following items? Arrange the steps in the correct order from first to last.

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Answer

The correct sequence for donning personal protective equipment is: gown, mask, goggles or face shield, and finally gloves.
The standardized sequence for donning personal protective equipment maximizes protection and minimizes the risk of contamination. The gown is applied first to cover the torso and arms. Next, the mask is secured to protect the respiratory tract. Eye protection is then added. Finally, gloves are donned and extended over the gown cuffs to complete the protective barrier.

Step-by-Step Solution

1
Put on the isolation gown.
The nurse's torso and clothing are protected.
The gown forms the largest barrier and must be secured before other facial PPE is applied.
2
Apply the surgical mask.
The nurse's respiratory tract is protected from large droplets.
The mask must be placed and adjusted before eye protection to ensure a proper fit over the bridge of the nose.
3
Place goggles or a face shield.
The nurse's eyes are protected from potential splashes or sprays.
Eye protection is placed over the mask and face to complete mucous membrane coverage.
4
Don clean gloves.
The nurse's hands are protected, and the wrist area is sealed.
Gloves are put on last so they can be pulled up securely over the cuffs of the gown, creating a continuous barrier.

Key Concept

The sequence for donning personal protective equipment (PPE) moves systematically from the largest body coverage to the face, ending with the hands.
Question 257Question →

A client in a rehabilitation facility tells the practical nurse (PN) that they are packing their bags and leaving immediately, despite not being medically discharged. Arrange the following actions the PN should take in the correct priority order, from first to last.

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Answer

The correct sequence is to first listen to the client's concerns, then notify the supervising RN and provider, reinforce the risks of leaving, request a signature on the AMA form, and finally document the event.
When a client decides to leave against medical advice, the practical nurse's first priority is to advocate for the client by exploring their concerns. If the client insists on leaving, the PN must utilize the chain of command by notifying the RN and provider so the medical risks can be officially explained. The PN then reinforces this education, asks the client to sign the AMA form to legally acknowledge the risks, and completes thorough, objective documentation of the entire departure process.

Step-by-Step Solution

1
Assess the situation by listening to the client.
The PN understands why the client wants to leave.
Advocacy begins with understanding the client's perspective and attempting to resolve immediate concerns.
2
Notify the RN and healthcare provider.
The healthcare team is alerted to the situation.
The provider must be informed so they can explain the specific medical risks of leaving against medical advice.
3
Reinforce the provider's explanation of the risks.
The client fully understands the potential consequences.
The PN reinforces education provided by the RN or physician, ensuring informed decision-making.
4
Present the AMA form for signature.
The client's informed refusal is formally captured.
The AMA form provides legal documentation that the client was informed of risks but chose to leave anyway.
5
Document the entire incident.
The medical record reflects a complete account of the event.
Thorough documentation is legally required to show that the facility and nursing staff provided safe, appropriate care and advocacy.

Key Concept

Client Rights and Advocacy
Question 258Question →

A practical nurse (PN) in a long-term care facility enters a resident's room and witnesses an assistive personnel (AP) roughly pulling the resident by the arm and yelling at them. Arrange the following actions the PN should take in the correct priority order, from first to last.

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Answer

The correct sequence is to first intervene to stop the action, then assess the resident, next report the incident to the supervisor, and finally document the objective findings.
In any situation involving client abuse or an immediate safety threat, the nurse must prioritize actions based on immediate client safety. The very first action must always be to intervene and stop the active harm. Immediately following intervention, the nurse must assess the client for injuries. Once the client is safe and stable, the nurse must act as a mandatory reporter by notifying the supervisor. Finally, the nurse completes the ethical and legal requirement of factual, objective documentation.

Step-by-Step Solution

1
Intervene immediately to stop the assistive personnel's actions.
The immediate threat to the resident's safety is removed.
According to safety principles, protecting the client from active harm is always the primary nursing responsibility.
2
Assess the resident for physical injuries and signs of distress.
The resident's physical and emotional condition is evaluated.
The nurse must determine if the resident sustained any injuries that require immediate medical treatment or further monitoring.
3
Report the incident to the charge nurse or nursing supervisor.
Facility management is informed of the suspected abuse.
Nurses are mandatory reporters. The chain of command must be notified promptly so that the AP can be removed from client care and formal investigations can begin.
4
Document the objective observations and the resident's condition in the medical record.
A legal, factual record of the event is created.
Objective documentation must be completed according to facility policy to ensure a legal record exists, but only after immediate safety, assessment, and reporting steps are complete.

Key Concept

Mandatory Reporting and Client Safety Prioritization
Question 259Question →

A practical nurse (PN) working in a long-term care facility enters the medication preparation area and observes a coworker consuming a client's prescribed liquid opioid medication. Arrange the actions the PN must take in the correct chronological order of priority.

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Answer

The correct sequence is to first prevent the coworker from providing care, then report to the supervisor, followed by ensuring continuity of care for the clients, and finally documenting the incident.
In situations involving impaired practice, the nursing process dictates that client safety is the paramount concern. The PN must first intervene to stop the impaired individual from providing care. Immediately following this, the PN must report up the chain of command so leadership can address the employee. Ensuring that the affected clients receive their care from an alternative nurse follows next. Finally, a factual incident report must be completed to legally document the event.

Step-by-Step Solution

1
Prioritize immediate client safety.
The impaired coworker is prevented from interacting with clients.
Client safety is always the primary concern in nursing practice; an impaired nurse cannot safely administer care.
2
Activate the chain of command.
The nursing supervisor is notified of the objective findings.
Management must handle the impaired employee, arrange for drug testing if appropriate, and secure the facility.
3
Maintain continuity of care.
Another qualified nurse is assigned to the coworker's clients.
Clients must continue to receive their scheduled medications and safe care without interruption.
4
Document the event.
An objective incident report is filed.
Factual documentation provides a legal record of the observation, which must be completed after the situation is stabilized.

Key Concept

Impaired Practice and Mandatory Reporting Procedures
Question 260Question →

A practical nurse is preparing to enter the room of a client who requires contact and droplet precautions. Arrange the following steps for donning personal protective equipment (PPE) in the correct sequence.

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Answer

The correct sequence for donning PPE is: Gown, Mask, Goggles or Face Shield, then Gloves.
According to standard infection control protocols, personal protective equipment must be donned in a specific sequence to ensure a proper fit and a continuous protective barrier. The gown is put on first to cover the torso and arms. Next, the mask is applied to protect the nose and mouth. Then, eye protection (goggles or face shield) is added. Finally, gloves are put on last so they can be pulled up over the cuffs of the gown, preventing any skin exposure at the wrists.

Step-by-Step Solution

1
Identify the standard guidelines for donning personal protective equipment.
The nurse recognizes that the sequence is designed to build protective layers from the most comprehensive to the most specific.
Following standard guidelines ensures maximum protection and prevents self-contamination during the donning process.
2
Select the gown as the first item.
The torso and arms receive a foundational barrier.
It is easiest to tie and secure the gown behind the back before the hands are gloved or vision is potentially restricted by eyewear.
3
Select the mask as the second item.
The respiratory tract and mouth are protected.
Applying the mask before eyewear ensures the mask's upper edge sits properly under the goggles or face shield to prevent fogging.
4
Select the goggles or face shield as the third item.
The eyes are protected from droplets.
Eye protection is placed over the mask to complete facial coverage.
5
Select the gloves as the final item.
The hands are protected and the barrier is sealed.
Gloves are put on last so they can be stretched over the cuffs of the gown, leaving no exposed skin at the wrists.

Key Concept

The standard sequence for donning personal protective equipment is Gown, Mask, Goggles/Face Shield, then Gloves to ensure proper fit and a continuous barrier.
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