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A practical nurse (PN) is preparing to irrigate an infected abdominal wound for a client on contact precautions. To protect against potential splashing of infectious body fluids, the PN will wear full personal protective equipment (PPE). After performing hand hygiene, in what sequence should the practical nurse don the personal protective equipment?

Surgical mask, face shield, isolation gown, clean gloves

Clean gloves, isolation gown, surgical mask, face shield

Isolation gown, surgical mask, face shield, clean gloves

Isolation gown, clean gloves, surgical mask, face shield

Show answer & explanation

Answer: Isolation gown, surgical mask, face shield, clean gloves

Answer

The correct sequence is to apply the isolation gown first, followed by the surgical mask, then the face shield, and finally the clean gloves.

According to standardized infection control guidelines, the correct sequence for donning personal protective equipment (PPE) begins with the isolation gown. Once the gown is secured, the healthcare worker should apply the surgical mask, followed by the face shield (or goggles). Clean gloves are always applied last so they can be pulled up over the cuffs of the gown, creating a continuous protective barrier for the wrists.

Step-by-Step Solution

Identify the required PPE components for the clinical scenario.

The PN needs an isolation gown, surgical mask, face shield, and clean gloves due to the combination of contact precautions and the high risk of splashing during wound irrigation.

Standard precautions mandate eye, face, and body protection when splashes or sprays of blood, body fluids, or secretions are anticipated.

Determine the correct standard sequence for donning the identified PPE.

The established sequence is: 1) Gown, 2) Mask or Respirator, 3) Goggles or Face Shield, 4) Gloves.

This specific order prevents the disruption of facial protection when tying the gown and ensures that gloves can be properly extended over the cuffs of the gown to create a continuous barrier.

Key Concept

Standard Sequence for Donning Personal Protective Equipment (PPE)

Question 2582Question →

A licensed practical nurse (LPN) enters the room of a client who is being treated for a hemothorax and observes that the client's chest tube has been accidentally pulled completely out of the chest wall. Arrange the following nursing actions in the correct priority sequence to manage this emergency and reduce the risk of further respiratory complications.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence prioritizes immediate prevention of air entry, followed by site closure, clinical assessment, escalation of care, and preparation for medical intervention.

In the event of an accidental chest tube dislodgement from the chest wall, the primary risk is atmospheric air entering the pleural space, leading to a tension pneumothorax. The immediate priority is stopping air entry by instructing the client to perform the Valsalva maneuver, followed instantly by applying a three-sided occlusive dressing. Only after the airway and breathing mechanics are secured should the nurse perform a thorough respiratory assessment, report the findings to the RN, and prepare for medical reinsertion.

Step-by-Step Solution

Instruct the client to exhale forcefully and bear down.

Creates positive intrathoracic pressure.

Prevents atmospheric air from instantly rushing into the negative-pressure pleural space, which could cause a tension pneumothorax.

Apply a sterile, occlusive dressing taped on three sides.

Seals the chest wall defect with a one-way flutter valve.

Taping on three sides allows trapped air to escape during exhalation but prevents new air entry during inhalation.

Assess respiratory effort, lung sounds, and oxygen saturation.

Establishes the client's current physiological stability.

Provides critical clinical data to determine if the client is developing respiratory failure after the site is secured.

Notify the supervising RN and the healthcare provider.

Escalates the clinical emergency to the appropriate level of care.

The RN and provider must intervene medically; providing them with the immediate assessment data streamlines the emergency response.

Gather sterile equipment for chest tube reinsertion.

Prepares the environment for the necessary medical procedure.

Anticipating the provider's needs reduces delays in re-establishing proper pleural drainage.

Key Concept

Emergency Management of Chest Tube Dislodgement

Question 2583Question →

An $11$ -month-old infant is admitted with acute otitis media. The infant weighs $18$ lb $12$ oz. The primary healthcare provider prescribes amoxicillin-clavulanate $45$ mg/kg/day by mouth, in equally divided doses every $8$ hours. The pharmacy supplies amoxicillin-clavulanate oral suspension with a concentration of $200$ mg/ $5$ mL.

How many milliliters will the practical nurse administer for a single dose?
*(Record your answer to the nearest tenth. Do not include units in your answer.)*

Show answer & explanation

Answer: 3.2

Answer

3.2

The correct calculation requires converting the infant's weight to kilograms accurately (including converting ounces to a fraction of a pound), calculating the weight-based daily dose, dividing by the frequency of administration to find the individual dose, and finally converting the ordered dose to a volume based on the supplied concentration, rounding only at the final step to prevent compounding rounding errors.

Step-by-Step Solution

Convert the infant's weight from ounces to pounds.

The total weight is 18.75 lb.

Standard weight conversion is required because 16 ounces equal 1 pound.

Convert the weight from pounds to kilograms.

The infant weighs 8.5227 kg.

The medication dosage is prescribed based on body weight in kilograms.

Calculate the total daily medication dose in milligrams.

The total daily dose is 383.5227 mg.

Multiplying the infant's weight in kg by the prescribed 45 mg/kg/day yields the 24-hour dose requirement.

Determine the amount of medication required for a single dose.

A single dose is 127.8409 mg.

The medication is given every 8 hours, which equals 3 divided doses per day.

Calculate the liquid volume to administer per dose based on the pharmacy supply.

The calculated volume is 3.196 mL.

Using the desired-over-have formula with the 200 mg / 5 mL concentration determines the volume.

Round the final calculated volume to the nearest tenth.

3.2

Standard rounding rules apply; since the hundredths place is 9, round up the tenths place.

Key Concept

Weight-Based Pediatric Dosage Calculation

Question 2584Question →

A practical nurse (PN) is providing care for several clients on a medical-surgical unit. Which actions by the PN demonstrate appropriate risk reduction strategies? (Select all that apply)

Select all that apply

Verifying the client's name and date of birth before administering a scheduled dose of oral medication.

Immediately notifying the registered nurse (RN) when a client's morning fasting blood glucose is 42 mg/dL.

Escalating to the charge nurse when a postoperative client's heart rate gradually increases to 115 beats per minute with decreasing blood pressure.

Waiting to report a critical laboratory result of a hemoglobin level at 6.5 g/dL until the healthcare provider rounds later in the afternoon.

Assuming a blood pressure of 88/50 mm Hg is a normal, expected finding for an older adult client who just returned from surgery.

Accepting a delegated task from the RN to administer an initial dose of intravenous (IV) push morphine to a client in severe pain.

Show answer & explanation

Answer: Verifying the client's name and date of birth before administering a scheduled dose of oral medication.; Immediately notifying the registered nurse (RN) when a client's morning fasting blood glucose is 42 mg/dL.; Escalating to the charge nurse when a postoperative client's heart rate gradually increases to 115 beats per minute with decreasing blood pressure.

Answer

The correct actions include verifying two distinct client identifiers before administering medication, immediately escalating a critically low blood glucose level, and promptly reporting vital sign trends that suggest early shock.

Appropriate risk reduction requires the practical nurse to strictly follow established safety protocols (such as using two identifiers for medications) and to immediately recognize and escalate life-threatening clinical changes. A blood glucose of 42 mg/dL represents critical hypoglycemia requiring immediate treatment. A rising heart rate combined with a dropping blood pressure is a classic early indicator of hypovolemic shock or hemorrhage that must be reported to the RN immediately.

Step-by-Step Solution

Evaluate the medication safety and scope of practice actions.

Verifying two identifiers is correct. Accepting an IV push medication assignment is incorrect because it is outside the PN scope of practice.

Risk reduction requires strict adherence to medication safety protocols and legal practice boundaries.

Evaluate the laboratory value management actions.

Immediately reporting a blood glucose of 42 mg/dL is correct. Delaying the report of a 6.5 g/dL hemoglobin level is incorrect.

Both values are critical. Delaying notification of critical labs directly increases client risk.

Evaluate the vital sign assessment actions.

Reporting tachycardia with hypotension is correct. Dismissing a blood pressure of 88/50 mm Hg as normal is incorrect.

Changes in vital signs postoperatively are early indicators of hemorrhage or shock and must be escalated, never ignored.

Key Concept

Reduction of Risk Potential: Safety Protocols and Escalation

Question 2585Question →

A practical nurse is supervising an unlicensed assistive personnel (UAP) who is preparing to bathe and provide oral care for a client. The client is currently on contact precautions for a multidrug-resistant organism (MDRO) wound infection. Upon assessment, the nurse notes the client has a new tracheostomy and is frequently coughing up copious amounts of thin respiratory secretions. Which instruction regarding personal protective equipment (PPE) should the nurse provide to the UAP before they enter the room?

Wear a gown and gloves, as the client is only on contact precautions.

Don a clean gown, gloves, a surgical mask, and eye protection before initiating care.

Apply an N95 respirator, a gown, and gloves due to the frequent coughing.

Use gloves and a face shield, but a gown is only required if you touch the infected wound.

Show answer & explanation

Answer: Don a clean gown, gloves, a surgical mask, and eye protection before initiating care.

Answer

The nurse should instruct the UAP to don a clean gown, gloves, a surgical mask, and eye protection before initiating care.

Standard precautions mandate that healthcare workers wear a mask and eye protection whenever there is a risk of splashes or sprays of blood, body fluids, or secretions. Because the client has a tracheostomy and is coughing up copious secretions, the UAP is at high risk for droplet exposure during bathing and oral care. Additionally, the client is on contact precautions, which specifically require a gown and gloves for any direct client care or contact with the client's environment. Combining these requirements ensures comprehensive protection.

Step-by-Step Solution

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

The client has an MDRO infection requiring contact precautions.

Contact precautions mandate the use of a gown and gloves upon entry into the room for any direct client care or interaction with the client's environment.

Assess the specific nursing task and client presentation for additional exposure risks.

The UAP will be performing a bath and oral care on a client with a tracheostomy who is coughing up copious secretions.

These factors create a high risk for splashes and sprays of body fluids (respiratory secretions) reaching the healthcare worker's face.

Apply standard precautions to the transmission-based baseline.

In addition to the gown and gloves, the UAP must wear a surgical mask and eye protection (goggles or face shield).

Standard precautions dictate that facial protection must be worn whenever a procedure is likely to generate splashes or sprays of blood, body fluids, or secretions, regardless of the isolation status.

Key Concept

Integration of Standard Precautions with Contact Precautions

Question 2586Question →

A practical nurse (PN) is managing care and evaluating mobility interventions for several clients on a medical-surgical unit. Which of the following actions by the PN demonstrate appropriate application of ergonomic principles and safe use of equipment? Select all that apply.

Select all that apply

Maintaining a wide base of support and pivoting the feet rather than twisting the spine when moving a heavy monitoring device.

Placing an out-of-service tag on a sequential compression device with a frayed cord and routing it to biomedical engineering.

Elevating the head of the bed to 90 degrees and raising the knee gatch to prevent a client with a recent total hip arthroplasty from sliding down.

Delegating the initial measurement and sizing of a new set of axillary crutches to the unlicensed assistive personnel (UAP).

Raising all four side rails on the bed to safely contain a restless client who repeatedly attempts to climb out of bed without assistance.

Lowering the bed to the lowest possible level and confirming the caster locks are engaged prior to performing a stand-pivot transfer.

Show answer & explanation

Answer: Maintaining a wide base of support and pivoting the feet rather than twisting the spine when moving a heavy monitoring device.; Placing an out-of-service tag on a sequential compression device with a frayed cord and routing it to biomedical engineering.; Lowering the bed to the lowest possible level and confirming the caster locks are engaged prior to performing a stand-pivot transfer.

Answer

The correct actions include maintaining a wide base of support and pivoting feet instead of twisting, tagging and removing equipment with frayed cords, and ensuring the bed is in the lowest position with caster locks engaged before a transfer.

Applying proper ergonomic principles, such as pivoting instead of twisting and maintaining a wide base of support, protects the nurse from injury. Removing damaged electrical equipment like frayed cords protects all individuals in the environment from shock or fire hazards. Finally, locking the bed casters and lowering the bed before a transfer stabilizes the equipment, which is an essential step to prevent the bed from rolling away and causing a fall.

Step-by-Step Solution

Evaluate body mechanics during equipment handling.

Pivoting the feet and maintaining a wide base of support prevents spinal twisting and musculoskeletal injuries.

Proper ergonomics protect the nurse from work-related injuries when handling heavy medical devices.

Assess protocols for damaged electrical equipment.

Equipment with frayed cords must be tagged as out-of-service and sent for repair.

Using faulty equipment creates an immediate risk for electrical shock or fire, violating safety standards.

Identify safe parameters for client transfers.

The bed must be placed in its lowest position and caster locks firmly engaged before transferring a client.

This prevents the bed from shifting during the weight transition and reduces the distance of a potential fall.

Differentiate correct equipment use from improper clinical practices in the distractors.

Sizing crutches cannot be delegated; four side rails constitute a physical restraint; and severe hip flexion with a knee gatch is unsafe for arthroplasty clients.

Equipment use must align with the nurse's scope of practice, restraint guidelines, and specific post-operative physiological constraints.

Key Concept

Proper body mechanics, safe transfer protocols, and the immediate removal of faulty electrical devices are foundational to maintaining a safe care environment and preventing injury.

Question 2587Question →

During a midday huddle at a neurological rehabilitation center, a practical nurse (PN) collaborates with a registered nurse (RN) to organize client care activities. Based on the legal scope of practice and professional safety guidelines, which action is most appropriate for the PN to undertake?

Detailing the specific risks, benefits, and alternative treatments for a scheduled lumbar puncture before witnessing the client's signature.

Assuming responsibility for the comprehensive discharge evaluation of a client who is preparing to transition to independent home care.

Reinforcing previously taught safe swallowing strategies during mealtime for a neurologically stable individual recovering from an ischemic stroke.

Discussing a client's mobility progress with a visiting neighbor who verbally expresses deep concern for the individual's wellbeing.

Show answer & explanation

Answer: Reinforcing previously taught safe swallowing strategies during mealtime for a neurologically stable individual recovering from an ischemic stroke.

Answer

Reinforcing previously taught safe swallowing strategies during mealtime for a neurologically stable individual recovering from an ischemic stroke.

The correct answer identifies an action that aligns precisely with the practical nurse's scope of practice. PNs are authorized to care for stable clients with predictable outcomes. Furthermore, while PNs are not responsible for creating initial educational plans or providing initial teaching, they play a vital role in reinforcing teaching that has already been established by the registered nurse or interdisciplinary team, such as safe swallowing strategies.

Step-by-Step Solution

Identify the core competency being tested in the scenario.

The scenario evaluates the legal scope of practice, safe delegation boundaries, and confidentiality rules for a practical nurse.

To determine which clinical actions are safe, legal, and appropriate for the PN role.

Analyze the action regarding client education.

Reinforcing previously taught strategies for a stable client is perfectly within the PN scope.

While PNs cannot develop initial care plans or perform initial teaching, they gather data and reinforce established education for clients with predictable outcomes.

Evaluate the distractors for scope and safety violations.

The other actions involve provider responsibilities (informed consent), RN responsibilities (comprehensive assessment), or legal violations (breach of confidentiality).

To systematically eliminate options that represent unsafe, out-of-scope, or illegal nursing practice.

Key Concept

Practical Nurse Scope of Practice and Safe Client Assignment

Question 2588Question →

An older adult client admitted with a severe respiratory infection suddenly becomes highly agitated, disoriented, and repeatedly attempts to climb over the side rails of the bed. Which of the following immediate actions should the practical nurse (PN) take to prevent injury? (Select all that apply)

Select all that apply

Move the client to a room located closer to the nurses' station for increased visibility.

Apply soft limb restraints to prevent the client from exiting the bed independently.

Instruct an unlicensed assistive personnel (UAP) to remain at the bedside for continuous direct observation.

Reassure the family that the sudden onset of disorientation is an expected part of the aging process.

Activate a bed exit alarm to alert staff when the client attempts to stand up.

Direct the UAP to perform a comprehensive neurological assessment to determine the cause of the agitation.

Show answer & explanation

Answer: Move the client to a room located closer to the nurses' station for increased visibility.; Instruct an unlicensed assistive personnel (UAP) to remain at the bedside for continuous direct observation.; Activate a bed exit alarm to alert staff when the client attempts to stand up.

Answer

The correct actions include moving the client closer to the nurses' station, assigning a UAP for continuous bedside observation, and activating a bed exit alarm.

Ensuring client safety requires implementing the least restrictive interventions first. Moving the client closer to the nurses' station, assigning a dedicated sitter (UAP), and using bed alarms all provide increased monitoring and fall prevention without unnecessarily restricting the client's physical movement. These actions fall appropriately within the PN scope of practice and delegation rules.

Step-by-Step Solution

Identify the primary clinical problem and risk.

The client is experiencing acute confusion (delirium) and is at an immediate, high risk for falls and physical injury due to attempts to climb out of bed.

Recognizing the immediate safety threat dictates the urgency and type of interventions required.

Select interventions that prioritize safety using the least restrictive means possible.

Selected moving the client closer for observation, assigning a sitter, and using bed alarms.

Nursing standards mandate that non-restrictive safety measures must be implemented and evaluated before any form of physical restraint is considered.

Evaluate the incorrect interventions based on scope of practice and clinical principles.

Eliminated applying restraints, delegating assessments to the UAP, and dismissing the confusion as normal aging.

Restraints are a last resort, UAPs cannot perform clinical assessments, and acute confusion indicates an underlying medical issue (delirium) requiring treatment, not a normal aging change.

Key Concept

Implementing least restrictive safety measures and appropriate delegation for clients experiencing acute delirium.

Question 2589Question →

A practical nurse (PN) is providing care at a busy outpatient pediatric clinic. Which of the following actions by the PN maintain client confidentiality and information security? (Select all that apply.)

Select all that apply

Logging out of the electronic health record (EHR) immediately before stepping away to assist a distressed child in the waiting area.

Leaving a clipboard containing the daily appointment schedule and client diagnoses face-up on the registration counter.

Verifying a caller's identity and authorized access code prior to sharing a client's laboratory results over the telephone.

Disposing of handwritten notes containing client vital signs into the standard wastebasket near the workstation.

Escorting a parent to a designated private consultation room to explain their child's newly prescribed asthma action plan.

Show answer & explanation

Answer: Logging out of the electronic health record (EHR) immediately before stepping away to assist a distressed child in the waiting area.; Verifying a caller's identity and authorized access code prior to sharing a client's laboratory results over the telephone.; Escorting a parent to a designated private consultation room to explain their child's newly prescribed asthma action plan.

Answer

The correct actions are logging out of the electronic health record before leaving the workstation, verifying caller identity with an access code before sharing results, and using a private consultation room for clinical discussions.

Maintaining client confidentiality requires a multi-faceted approach. Nurses must secure electronic records by logging out when unattended, ensure verbal disclosures over the phone are made only to verified individuals, and discuss health information in private spaces to prevent eavesdropping.

Step-by-Step Solution

Analyze the clinical scenario to identify situations involving protected health information (PHI).

The scenario involves EHR access, physical documents (clipboards and notes), telephone communication, and verbal education.

Identifying where and how PHI is being handled is the first step in assessing compliance.

Evaluate each nursing action against HIPAA and standard confidentiality guidelines.

Logging out of the EHR, verifying callers, and using private rooms align with guidelines. Leaving clipboards face-up and throwing notes in regular trash violate guidelines.

Nurses must actively protect PHI from both intentional unauthorized access and unintentional incidental disclosure.

Select the options that actively protect client data and reject those that create a vulnerability.

The appropriate actions are selected.

Answering a Select All That Apply question requires judging every option independently as either safe or unsafe practice.

Key Concept

Confidentiality and Information Security

Estimated Time:1m 30s

Question 2590Question →

A client in a subacute rehabilitation facility is scheduled for a percutaneous endoscopic gastrostomy (PEG) tube placement. The provider has previously discussed the procedure with the client. When the practical nurse brings the consent form for a signature, the client asks, "I know how the tube works, but what are my other options if I refuse this surgery?" Which action should the practical nurse take first?

Withhold the consent form and notify the provider to discuss alternative treatments with the client.

Explain the various alternative methods for receiving nutrition, such as parenteral therapy.

Ask the registered nurse (RN) to answer the client's questions about alternative nutritional options.

Have the client sign the document and note their questions in the electronic health record.

Show answer & explanation

Answer: Withhold the consent form and notify the provider to discuss alternative treatments with the client.

Answer

Withhold the consent form and notify the provider to discuss alternative treatments with the client.

Informed consent requires the client to have a clear understanding of the procedure, its risks, benefits, and any alternative treatments. Explaining alternative treatments is strictly the responsibility of the healthcare provider. If a client has unanswered questions regarding alternatives, the practical nurse must act as an advocate by withholding the consent form and notifying the provider to return and speak with the client.

Step-by-Step Solution

Analyze the client's statement to identify what information is missing.

The client understands the procedure but is lacking information regarding alternative treatments.

Understanding risks, benefits, and alternatives is a fundamental legal requirement for informed consent.

Determine whose scope of practice covers providing information about alternative treatments.

Explaining procedures, risks, and alternatives is the sole responsibility of the healthcare provider performing the procedure.

The practical nurse's role is strictly limited to witnessing the signature and verifying that the consent is given voluntarily and competently.

Formulate the priority nursing action based on the scope of practice.

The nurse must stop the consent process and notify the provider to return and address the client's questions.

Advocating for the client's right to fully informed consent takes priority over obtaining a signature.

Key Concept

The practical nurse's role in informed consent is limited to witnessing the signature; answering questions about alternative treatments is the legal responsibility of the healthcare provider.

Estimated Time:1m 0s

Question 2591Question →

A practical nurse is preparing to administer morning medications to a pediatric client. The facility's barcode medication administration system is temporarily offline for maintenance. Which action demonstrates the safest practice by the nurse?

Confirm the client's identity by checking the room and bed number against the medication administration record.

Estimate the medication dosage based on the child's age rather than calculating it using the most recent weight.

Verify the client's identity by checking the identification band and asking the parent to state the child's name.

Administer a scheduled intravenous push antibiotic to ensure the client receives all morning medications on time.

Show answer & explanation

Answer: Verify the client's identity by checking the identification band and asking the parent to state the child's name.

Answer

The safest practice is to verify the client's identity by checking the identification band and asking the parent to state the child's name.

The correct action ensures the 'Right Client' by using two distinct and acceptable manual identifiers: the identification band and the parent's verbal confirmation of the name. This is a critical safety step when barcode scanning technology is unavailable.

Step-by-Step Solution

Identify the clinical challenge presented in the scenario.

The barcode medication scanner is offline, removing an automated safety check for medication administration.

Recognizing the absence of technology highlights the need for strict adherence to manual safety protocols.

Recall the Six Rights of Medication Administration.

The nurse must prioritize confirming the 'Right Client' before giving any medication.

Patient identification is the foundational step in preventing medication errors.

Determine acceptable manual identifiers for a pediatric client.

Acceptable identifiers include the client's full name, date of birth, and identification band. Verbal confirmation from a parent is appropriate for young children.

Two distinct, reliable identifiers must always be used when automated systems fail.

Evaluate the remaining options against safety protocols and scope of practice.

Room numbers are unsafe identifiers, age-based dosing is dangerous for pediatrics, and IV push medications are outside the practical nurse scope of practice.

Eliminating unsafe or out-of-scope actions confirms the correct choice.

Key Concept

Safe medication administration requires the use of at least two acceptable client identifiers (such as name and date of birth) prior to administering any medication, especially when automated systems are unavailable.

Question 2592Question →

While caring for a hospitalized client, a practical nurse prepares to initiate an intermittent intravenous (IV) antibiotic infusion. As the electronic infusion pump is plugged into the wall outlet, a spark flashes from the receptacle, a faint smell of smoke develops, and the device fails to power on. Which action should the nurse take first?

Unplug the device immediately, attach a defective tag, and remove it from the patient care area.

Assess the client's airway, breathing, and vital signs before addressing the malfunctioning equipment.

Administer the medication via direct intravenous (IV) push so the client does not miss the scheduled dose.

Hang the infusion via gravity drip and administer it without completing the electronic barcode scanning process.

Show answer & explanation

Answer: Unplug the device immediately, attach a defective tag, and remove it from the patient care area.

Answer

Unplug the device immediately, attach a defective tag, and remove it from the patient care area.

The correct action prioritizes equipment safety by dictating that any malfunctioning biomedical device must be immediately disconnected, labeled as defective, and removed from the patient environment. This protocol eliminates the immediate risk of electrical shock or fire and prevents accidental use by other staff members.

Step-by-Step Solution

Identify the immediate environmental hazard presented by the situation.

The nurse recognizes that a sparking electrical device with the smell of smoke poses an imminent risk of electrocution or fire.

Electrical malfunctions threaten the immediate physical safety of both the client and the healthcare team.

Determine the priority intervention to mitigate the hazard.

The nurse unplugs the pump to stop the electrical current.

Neutralizing the source of a potential fire or electrical shock is the primary step in environmental emergency response (similar to the 'Rescue' phase in RACE).

Secure the equipment to prevent accidental use by others.

The device is tagged as defective and physically removed from the room.

Proper equipment safety protocols require removing broken devices from clinical areas so they are not mistakenly used on patients.

Key Concept

Biomedical Equipment Safety and Environmental Hazard Management

Estimated Time:1m 0s

Question 2593Question →

A practical nurse (PN) is collecting data on an adult client who is receiving continuous intravenous (IV) fluid therapy. Which of the following findings should the PN identify as physiological signs of fluid volume excess (hypervolemia)? Select all that apply.

Select all that apply

Jugular vein distention

Bounding peripheral pulses

Bilateral crackles in the lung bases

Urine specific gravity of 1.032

Postural hypotension

Flat neck veins when supine

Show answer & explanation

Answer: Jugular vein distention; Bounding peripheral pulses; Bilateral crackles in the lung bases

Answer

The correct physiological signs of fluid volume excess are jugular vein distention, bounding peripheral pulses, and bilateral crackles in the lung bases.

Fluid volume excess (hypervolemia) occurs when there is an abnormal retention of water and sodium in the extracellular fluid compartment. This increased volume directly raises hydrostatic pressure in the blood vessels, leading to bounding peripheral pulses and distended jugular veins. As pressure builds in the pulmonary circulation, fluid is forced into the alveoli, resulting in respiratory manifestations such as shortness of breath and bilateral crackles upon auscultation.

Step-by-Step Solution

Analyze the client's clinical situation.

The client is receiving continuous IV fluid therapy, placing them at risk for receiving too much fluid, leading to fluid volume excess (hypervolemia).

Identifying the primary risk factor helps anticipate the specific physiological changes associated with that condition.

Recall the systemic effects of fluid volume excess.

Excess intravascular fluid increases blood pressure, engorges veins, and can lead to fluid shifting into the lungs (pulmonary edema).

Understanding the pathophysiology of fluid overload is necessary to correctly identify the associated clinical signs.

Evaluate each finding to determine if it indicates fluid excess or deficit.

Jugular vein distention, bounding pulses, and lung crackles indicate excess. A high urine specific gravity, postural hypotension, and flat neck veins indicate deficit.

Differentiating between signs of excess and deficit ensures accurate data collection and reporting.

Key Concept

Recognition of fluid volume excess (hypervolemia) involves identifying signs of increased intravascular volume and pulmonary congestion.

Question 2594Question →

An older adult client is admitted to the medical-surgical unit immediately after undergoing a diagnostic cardiac catheterization using the right femoral approach. Which action must the practical nurse (PN) implement to decrease the risk of a post-procedural hemorrhage?

Maintain the client on bed rest while keeping the right leg completely straight.

Elevate the head of the client's bed to a 60-degree angle to promote comfort.

Document a gradually rising heart rate as an expected response to the dye.

Apply a warm, moist compress directly over the right groin area.

Show answer & explanation

Answer: Maintain the client on bed rest while keeping the right leg completely straight.

Answer

Maintain the client on bed rest while keeping the right leg completely straight.

Following a femoral cardiac catheterization, the insertion site is at a high risk for arterial bleeding. Keeping the affected leg straight and maintaining bed rest prevents unnecessary pressure, flexion, and movement at the puncture site, ensuring the arterial clot remains stable and intact.

Step-by-Step Solution

Identify the procedure and its primary immediate complication risk.

The procedure is a femoral cardiac catheterization, which carries a high risk of arterial bleeding at the groin insertion site.

Understanding the procedural risks guides prioritizing the most appropriate protective nursing intervention.

Determine how physical positioning impacts the femoral artery.

Bending the hip or moving the leg puts mechanical stress on the puncture site, which can disrupt clot formation.

Maintaining the structural integrity of the newly formed clot is essential to prevent hemorrhage.

Select the nursing action that mitigates this specific risk.

Keeping the right leg entirely straight on bed rest minimizes hip flexion and protects the puncture site.

This is the standard evidence-based intervention to prevent post-catheterization bleeding.

Key Concept

Post-procedure Positioning and Risk Reduction

Estimated Time:45s

Question 2595Question →

A practical nurse is preparing to administer a scheduled dose of liquid phenytoin suspension via a percutaneous endoscopic gastrostomy (PEG) tube to a client who is receiving continuous enteral feedings. To ensure therapeutic drug levels and maintain tube patency, arrange the following actions in the correct chronological order.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first stop the feeding pump, wait 1 to 2 hours, verify placement and flush, administer the phenytoin, and finally flush again while delaying the restart of the feeding for another 1 to 2 hours.

Phenytoin has a significant drug-nutrient interaction with enteral feeding formulas. The proteins and calcium in the formula bind tightly to phenytoin, significantly reducing its gastrointestinal absorption and potentially leading to subtherapeutic serum levels and breakthrough seizures. Therefore, the continuous feeding must be stopped 1 to 2 hours prior to administration. After this waiting period, standard safe medication administration requires verifying tube placement and flushing the tube to confirm patency and clear any residual formula. The liquid phenytoin is then administered by gravity, followed by another flush to ensure the full dose reaches the stomach and to prevent tube occlusion. Finally, the feeding must remain paused for an additional 1 to 2 hours to allow the drug to be fully absorbed before the formula is reintroduced.

Step-by-Step Solution

Stop the continuous enteral feeding pump.

The flow of enteral formula into the gastrointestinal tract is halted.

Phenytoin binds strongly to the proteins and calcium in enteral formulas, which significantly reduces the bioavailability of the drug and can lead to subtherapeutic levels and seizures.

Allow 1 to 2 hours to elapse.

The stomach is given time to empty the existing enteral formula.

A waiting period ensures the gastrointestinal tract is free of formula that could bind to the administered phenytoin.

Verify enteral tube placement and flush with 30 mL of water.

Tube placement is confirmed and patency is established.

Placement verification prevents accidental administration into the respiratory tract. Flushing clears the tube of any residual formula.

Administer the liquid phenytoin suspension by gravity.

The medication is safely delivered into the stomach.

Administering by gravity prevents excessive pressure that could damage the PEG tube.

Flush the tube with 30 mL of water and delay restarting the feeding for 1 to 2 hours.

The medication is cleared from the tube and absorption is protected.

The post-flush ensures the entire dose reaches the stomach and prevents tube occlusion. Delaying the restart of the feeding prevents the formula from interacting with the freshly administered phenytoin.

Key Concept

Phenytoin has a significant drug-nutrient interaction with enteral feeding formulas. The feeding must be stopped 1 to 2 hours before and 1 to 2 hours after administration to ensure adequate absorption and maintain therapeutic drug levels.

Question 2596Question →

A client with a history of generalized seizures is prescribed phenytoin $5$ mg/kg/day PO divided into $2$ equal doses. The client weighs $176$ lb. The available medication is phenytoin oral suspension $125$ mg / $5$ mL. How many mL should the practical nurse administer per dose? (Record answer to the nearest whole number. Do not include units in the answer.)

Show answer & explanation

Answer: 8

Answer

To find the correct volume to administer, the practical nurse must complete a multi-step calculation. First, convert the weight to kilograms:

176 \text{ lb} \div 2.2 = 80

kg. Next, calculate the total daily dose:

80 \text{ kg} \times 5 \text{ mg/kg} = 400

mg. Because the medication is divided into two equal doses, divide the daily dose by

2

, yielding

200

mg per dose. Finally, use the available concentration (

125

mg in

5

mL) to find the volume:

\frac{200 \text{ mg}}{125 \text{ mg}} \times 5 \text{ mL} = 8

mL. The practical nurse will administer

8

mL per dose.

Step-by-Step Solution

Convert the client's weight from pounds (lb) to kilograms (kg).

176 \div 2.2 = 80

Weight-based medication prescriptions require the client's weight to be in metric units (kilograms).

Calculate the total daily medication dosage.

80 \text{ kg} \times 5 \text{ mg/kg} = 400

mg/day

The prescription specifies

5

mg of phenytoin per kilogram of body weight for the entire day.

Determine the amount of medication required for a single dose.

400 \text{ mg/day} \div 2 \text{ doses} = 200

mg/dose

The total daily dose must be divided into

2

equal doses as prescribed.

Calculate the liquid volume to administer using the available concentration.

\frac{200 \text{ mg}}{125 \text{ mg}} \times 5 \text{ mL} = 1.6 \times 5 \text{ mL} = 8

Using the dimensional analysis or desired-over-have method ensures the correct volume of the oral suspension is administered.

Key Concept

Weight-based oral medication dosage calculation

Question 2597Question →

A practical nurse is providing basic care for a client who is 48 hours postoperative following a right above-the-knee amputation (AKA). The client reports muscle spasms and discomfort in the affected limb. Which of the following nursing actions should the nurse implement to promote comfort and prevent complications? Select all that apply.

Select all that apply

Assist the client into a prone position for 20 to 30 minutes several times a day.

Elevate the right residual limb on a pillow while the client is resting in bed.

Wrap the residual limb with an elastic compression bandage using a figure-eight pattern.

Encourage the client to sit upright in a bedside chair for 4 continuous hours daily.

Place a trochanter roll alongside the outer aspect of the right thigh and hip.

Show answer & explanation

Answer: Assist the client into a prone position for 20 to 30 minutes several times a day.; Wrap the residual limb with an elastic compression bandage using a figure-eight pattern.; Place a trochanter roll alongside the outer aspect of the right thigh and hip.

Answer

The correct actions are to assist the client into a prone position, wrap the limb with an elastic compression bandage using a figure-eight pattern, and place a trochanter roll alongside the outer aspect of the hip.

After a lower extremity amputation, preventing hip flexion contractures and managing edema are critical priorities for the practical nurse. Assisting the client into a prone position extends the hip joint and stretches flexor muscles. Applying a figure-eight compression bandage minimizes swelling, reduces spasm-related pain, and shapes the limb. Using a trochanter roll prevents improper external rotation of the affected leg, ensuring comfortable and correct anatomical alignment.

Step-by-Step Solution

Analyze the client's postoperative time frame and surgical procedure.

The client is 48 hours post-above-the-knee amputation (AKA).

Interventions change based on the postoperative timeline, particularly regarding safe limb positioning.

Evaluate the risk of complications associated with AKA.

The primary mobility complication is a hip flexion contracture, and the primary comfort issue is edema and muscle spasms.

Identifying risks guides the selection of safe and effective basic care measures.

Select interventions that prevent contractures and reduce edema while avoiding contraindicated positions.

Prone positioning, figure-eight compression, and trochanter rolls are safe. Pillow elevation and prolonged sitting are contraindicated.

Evidence-based positioning ensures comfort without compromising future mobility and prosthesis fitting.

Key Concept

Postoperative positioning and comfort measures for lower extremity amputation

Question 2598Question →

A client arrives at the surgical step-down unit after undergoing a left modified radical mastectomy with axillary node dissection. When planning the client's basic comfort and safety measures for the current shift, which actions should the nurse include? Select all that apply.

Select all that apply

Elevate the client's left arm on a soft cushion.

Reposition the client to rest directly on the left side to reduce incisional tension.

Adjust the head of the bed to a forty-five-degree angle.

Guide the client to use a small pillow against the chest wall while performing deep breathing exercises.

Maintain the client in a flat, supine posture to minimize postoperative dizziness.

Show answer & explanation

Answer: Elevate the client's left arm on a soft cushion.; Adjust the head of the bed to a forty-five-degree angle.; Guide the client to use a small pillow against the chest wall while performing deep breathing exercises.

Answer

The correct actions include elevating the left arm, adjusting the head of the bed to a forty-five-degree angle, and guiding the client to splint the chest wall during deep breathing.

Appropriate basic care for a postoperative mastectomy client focuses on preventing lymphedema, reducing incisional pain, and optimizing respiratory status. Elevating the affected arm uses gravity to drain lymphatic fluid. Placing the client in a semi-Fowler's position allows the diaphragm to drop, improving lung expansion. Splinting the incision with a pillow provides mechanical support, reducing pain during coughing and deep breathing.

Step-by-Step Solution

Analyze the client's surgical procedure (left modified radical mastectomy with axillary node dissection).

Identified the need to prevent lymphedema on the left side and promote respiratory function.

Axillary node removal disrupts lymphatic drainage, requiring specific positioning and comfort measures to prevent fluid accumulation.

Evaluate each intervention for safety and appropriateness in promoting comfort and preventing complications.

Selected elevation of the affected arm, semi-Fowler's positioning, and incisional splinting.

These actions directly address basic comfort, airway management, and circulation without compromising the surgical site.

Identify and reject contraindicated actions.

Rejected laying on the operative side and maintaining a flat supine position.

These positions increase pressure on the surgical site, impede drainage, and limit optimal lung expansion.

Key Concept

Basic care and comfort positioning following a mastectomy

Question 2599Question →

A 76-year-old client with chronic obstructive pulmonary disease (COPD) is receiving continuous oxygen therapy via nasal cannula. The client abruptly becomes highly combative, rips off the oxygen tubing, and begins thrusting their legs over the lowered side rails. To prevent immediate injury and manage the situation safely, which action is the priority for the practical nurse (PN)?

Remain at the bedside to provide direct supervision, call for staff assistance, and prioritize the assessment of the client's respiratory status.

Promptly apply soft bilateral wrist restraints to protect the client from self-injury and ensure the oxygen therapy remains intact.

Secure the client by raising all four side rails, attributing the sudden disorientation and combativeness to an expected manifestation of advanced age.

Focus immediately on physically pinning the client's limbs to the bed to prevent a fall, delaying the evaluation of the client's airway and breathing.

Show answer & explanation

Answer: Remain at the bedside to provide direct supervision, call for staff assistance, and prioritize the assessment of the client's respiratory status.

Answer

The priority action is to remain at the bedside for immediate direct supervision, request assistance, and promptly assess the client's respiratory status.

The correct action prioritizes both immediate client safety and physiological stability. By remaining at the bedside and calling for assistance, the PN implements a less restrictive safety measure (direct supervision) to prevent a fall. Concurrently, by prioritizing the assessment of the client's respiratory status, the PN addresses the most probable cause of the sudden agitation (acute hypoxia), adhering to the ABCs (Airway, Breathing, Circulation) of nursing care.

Step-by-Step Solution

Analyze the client's clinical presentation.

The client is exhibiting sudden, acute combativeness and has removed their oxygen supply, presenting both an immediate fall risk and a severe respiratory threat.

Identifying the simultaneous safety and physiological risks is essential for accurate prioritization.

Correlate the behavioral change with potential physiological causes.

Sudden agitation and confusion in a client with a history of COPD is a primary indicator of acute hypoxia (delirium), not an expected age-related cognitive decline.

Understanding the root physiological cause prevents the inappropriate use of physical restraints for a medical problem.

Evaluate the proposed interventions against safety guidelines.

Physical restraints, including raising all four side rails or pinning the client's limbs, are interventions of last resort and can increase the risk of injury if the client struggles.

Nurses must always attempt less restrictive alternatives first to maintain a safe environment.

Select the optimal priority action.

Remaining at the bedside provides an immediate, non-restrictive safety measure, while calling for help allows the nurse to concurrently assess the ABCs (Airway, Breathing, Circulation).

This action simultaneously addresses immediate injury prevention and the critical physiological deficit.

Key Concept

Prioritizing less restrictive restraint alternatives while simultaneously addressing acute physiological needs (ABCs) to prevent client injury.

Estimated Time:1m 30s

Question 2600Question →

A practical nurse (PN) is assigned to care for a client admitted with seasonal Influenza A who also has an infected leg ulcer positive for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following infection control actions should the PN implement? (Select all that apply)

Select all that apply

Wear a surgical mask when providing direct care within 3 feet of the client.

Don a clean isolation gown and gloves prior to entering the client's room.

Leave a dedicated stethoscope and blood pressure cuff inside the client's room.

Remove the isolation gown and gloves in the hallway immediately after exiting the room.

Accept the task of administering a newly prescribed intravenous (IV) push antiviral medication to the client.

Doff the surgical mask prior to removing the contaminated gown and gloves when finishing care.

Show answer & explanation

Answer: Wear a surgical mask when providing direct care within 3 feet of the client.; Don a clean isolation gown and gloves prior to entering the client's room.; Leave a dedicated stethoscope and blood pressure cuff inside the client's room.

Answer

The correct actions are wearing a surgical mask within 3 feet, donning a gown and gloves prior to entering the room, and leaving dedicated assessment equipment inside the room.

The correct infection control actions address both Droplet Precautions (requiring a surgical mask within 3 feet) for Influenza A and Contact Precautions (requiring an isolation gown, gloves, and dedicated equipment) for MRSA. These interventions effectively interrupt the specific chains of transmission for both pathogens.

Step-by-Step Solution

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

Influenza A requires Droplet Precautions, and MRSA requires Contact Precautions.

Different pathogens transmit via distinct routes, dictating the necessary protective measures.

Determine the correct personal protective equipment (PPE) required for Droplet and Contact Precautions combined.

A surgical mask is needed for droplet exposure, while an isolation gown and gloves are needed for contact exposure.

Simultaneous precautions must fulfill the combined requirements of both transmission categories to protect the nurse.

Evaluate the correct sequence and location for donning and doffing PPE, as well as the PN scope of practice.

PPE must be doffed in the correct order inside the room, and the PN must decline out-of-scope tasks such as IV push medications.

Adhering to strict doffing protocols prevents self and environmental cross-contamination, while staying within scope ensures client safety.

Key Concept

Implementation of combined Droplet and Contact Precautions and adherence to proper PPE sequencing and PN scope of practice.

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