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A registered nurse (RN) and a practical nurse (PN) are providing team nursing for a group of clients on a gastrointestinal surgical unit. Which of the following client care tasks are most appropriate for the RN to delegate to the PN? Select all that apply.

Select all that apply

Administering a scheduled continuous enteral tube feeding to a client with a history of dysphagia

Providing the initial discharge teaching for a client who has a newly created ascending colostomy

Evaluating a client's hemodynamic response following the administration of an intravenous (IV) push analgesic

Performing a routine sterile dressing change for a client with a healing midline abdominal incision

Explaining the potential risks and complications of an upcoming procedure prior to witnessing the consent signature

Inserting a prescribed indwelling urinary catheter for a client experiencing postoperative urinary retention

Show answer & explanation

Answer: Administering a scheduled continuous enteral tube feeding to a client with a history of dysphagia; Performing a routine sterile dressing change for a client with a healing midline abdominal incision; Inserting a prescribed indwelling urinary catheter for a client experiencing postoperative urinary retention

Answer

The practical nurse (PN) can safely administer continuous enteral tube feedings, perform sterile dressing changes, and insert indwelling urinary catheters.

The correct selections represent tasks that are firmly within the legal scope of practice for a practical nurse (PN). PNs are qualified to care for stable clients with predictable outcomes. This includes administering scheduled enteral tube feedings, performing sterile procedures such as routine dressing changes on healing incisions, and inserting indwelling urinary catheters. These tasks rely on established protocols and do not require the comprehensive assessment, initial teaching, or independent clinical judgment that are exclusive to the registered nurse (RN).

Step-by-Step Solution

Identify the client care tasks that fall within the legal scope of practice for a practical nurse (PN).

Enteral feedings, sterile dressings, and catheterizations are recognized as standard PN skills.

PNs are educated and licensed to perform these stable, predictable procedures for clients whose conditions are not critical or highly complex.

Identify tasks that require the advanced knowledge, assessment skills, or teaching capabilities of a registered nurse (RN) or healthcare provider.

Initial teaching, evaluation of IV push medications, and explaining surgical risks are outside the PN scope.

These tasks require comprehensive assessment, advanced clinical judgment, or fall strictly under the provider's legal duty for informed consent.

Key Concept

Practical Nurse (PN) Scope of Practice and Delegation Principles

Estimated Time:1m 30s

Question 2602Question →

An LPN/LVN is caring for a 76-year-old client who is two days postoperative following a total hip arthroplasty. The client, who was previously alert and oriented, suddenly becomes agitated, disoriented, and attempts to climb out of bed. Which of the following is the priority action for the LPN/LVN to take?

Reassure the client's family that sudden confusion is an expected reaction to unfamiliar hospital surroundings in older adults.

Administer the prescribed as-needed (PRN) oral analgesic, assuming the sudden agitation is caused by uncontrolled surgical pain.

Obtain a complete set of vital signs, including oxygen saturation, and report the findings to the registered nurse.

Contact the healthcare provider to request a prescription for soft limb restraints to ensure the client's safety.

Show answer & explanation

Answer: Obtain a complete set of vital signs, including oxygen saturation, and report the findings to the registered nurse.

Answer

Obtain a complete set of vital signs, including oxygen saturation, and report the findings to the registered nurse.

Sudden onset of confusion, agitation, or delirium in an older adult, especially postoperatively, is often an early sign of a physiological problem such as hypoxia, infection, or hemorrhage. Obtaining a full set of vital signs, including oxygen saturation, prioritizes the Airway, Breathing, and Circulation (ABC) framework. It provides essential objective data to identify or rule out life-threatening conditions, which must then be immediately reported to the registered nurse for further clinical judgment.

Step-by-Step Solution

Analyze the client's clinical presentation.

An older adult client is exhibiting sudden onset agitation and confusion two days after major joint surgery.

Recognizing an acute change in baseline mental status is the critical first step in the clinical judgment process.

Apply prioritization frameworks (ABCs and the Nursing Process).

Assessment (gathering vital signs) must precede intervention (medication or restraints), and physiological needs (oxygenation/perfusion) take priority over assumed discomfort.

Sudden confusion is a classic early sign of hypoxia or shock in postoperative clients, which are life-threatening if missed.

Select the action that addresses the highest priority physiological need within the LPN/LVN scope.

Obtaining vital signs provides objective data to rule out hypoxia and other acute physiological changes, which can then be escalated.

This action directly aligns with reducing risk potential by identifying clinical deterioration early and safely.

Key Concept

Prioritizing Physiological Assessment in Acute Delirium

Estimated Time:1m 0s

Question 2603Question →

A practical nurse (PN) is assisting a client with collecting a sputum specimen for culture and sensitivity. To ensure an accurate diagnostic sample and reduce the risk of sample contamination, in what order should the PN instruct the client to perform these steps?

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence for collecting a sputum specimen is: rinse the mouth, take deep breaths and cough, expectorate into the sterile cup, secure the lid, and place in a biohazard transport bag.

To obtain an accurate sputum culture and prevent contamination, the client must first rinse with plain water to clear resident oral flora. Next, taking deep breaths and coughing helps bring up lower respiratory secretions. The sputum is then expectorated directly into a sterile cup, which is sealed carefully to maintain sterility. Finally, it is placed in a biohazard bag to prevent transmission of infectious agents during transport.

Step-by-Step Solution

Instruct the client to rinse their mouth with water.

Clears oral flora and food.

Reduces the risk of oral bacterial contamination of the respiratory sample.

Ask the client to take several deep breaths and cough.

Mobilizes lower airway secretions.

Ensures the specimen comes from the lower respiratory tract, not just saliva from the mouth.

Have the client expectorate into the sterile cup.

Collects the sample safely.

Maintains a sterile environment for the diagnostic culture.

Secure the lid without touching the inside.

Seals the container.

Prevents accidental spills and environmental contamination.

Place the labeled cup into a biohazard bag.

Prepares for transport.

Follows standard precautions for transporting bodily fluids to the lab.

Key Concept

Proper specimen collection sequences are essential to reduce the risk of sample contamination and ensure accurate diagnostic results.

Estimated Time:1m 0s

Question 2604Question →

A practical nurse (PN) is collecting data on a client who underwent a percutaneous liver biopsy 4 hours ago. The client's baseline vital signs were blood pressure 130/82 mm Hg and heart rate 72 beats/minute. Which current assessment finding presents the highest risk for a severe complication and requires immediate escalation to the registered nurse (RN)?

A gradual increase in heart rate to 108 beats/minute and a blood pressure of 102/66 mm Hg

The client reporting a dull, aching right shoulder pain rated as 4 on a 0 to 10 scale

A post-procedure hemoglobin level of 14.2 g/dL (142 g/L) and a hematocrit of 42% (0.42)

The client asking to review the potential long-term risks of the biopsy procedure

Show answer & explanation

Answer: A gradual increase in heart rate to 108 beats/minute and a blood pressure of 102/66 mm Hg

Answer

A gradual increase in heart rate to 108 beats/minute and a blood pressure of 102/66 mm Hg

The liver is highly vascular, placing the client at significant risk for internal hemorrhage following a percutaneous biopsy. A narrowing pulse pressure, a drop in systolic blood pressure, and a compensatory increase in heart rate are classic early signs of hypovolemic shock. This finding requires immediate escalation to the RN for intervention.

Step-by-Step Solution

Identify the client's procedure and associated risks.

The client had a percutaneous liver biopsy, which carries a high risk for internal hemorrhage due to the liver's vascularity.

Recognizing high-risk procedures guides targeted post-procedure assessments.

Compare current vital signs to the established baseline.

The heart rate increased significantly from 72 to 108 beats/minute, and blood pressure dropped from 130/82 to 102/66 mm Hg.

Trend analysis is crucial for detecting subtle, early signs of physiological decline such as shock.

Evaluate the remaining findings for severity.

Right shoulder pain is an expected referred pain (phrenic nerve irritation), the hemoglobin is normal, and asking about risks is a non-emergent teaching need.

Prioritization requires differentiating between expected findings, stable data, and life-threatening crises.

Select the finding that indicates a life-threatening complication.

The changes in vital signs indicate early hypovolemic shock from internal bleeding.

Internal hemorrhage is an airway, breathing, or circulation (ABC) priority that requires immediate RN and provider intervention.

Key Concept

Post-procedure hemorrhage recognition

Question 2605Question →

An older adult client admitted with acute bronchitis has been resting comfortably. The practical nurse (PN) notes that the client has suddenly become highly restless and confused. Based on this sudden change, which of the following physiological conditions should the PN suspect first?

Decreased tissue oxygenation (hypoxia)

Normal progression of age-related dementia

Inadequate pain management

Mild systemic dehydration

Show answer & explanation

Answer: Decreased tissue oxygenation (hypoxia)

Answer

Decreased tissue oxygenation (hypoxia)

The correct answer identifies hypoxia, because the brain is highly sensitive to drops in oxygen levels. In a client with a respiratory illness like bronchitis, early signs of decreased oxygenation often present as sudden neurological changes, specifically restlessness, agitation, and acute confusion.

Step-by-Step Solution

Analyze the client's baseline and current condition

The client has a respiratory infection (bronchitis) and has experienced a sudden onset of restlessness and confusion.

Identifying acute changes from baseline is critical for recognizing physiological deterioration.

Relate the symptoms to the most immediate life-threatening physiological alteration

Restlessness and confusion are early neurological indicators that the brain is not receiving enough oxygen.

In the context of a respiratory illness, impaired gas exchange leads to hypoxia, requiring immediate assessment and intervention.

Key Concept

Early signs of hypoxia include restlessness, agitation, and acute confusion.

Estimated Time:45s

Question 2606Question →

A client recovering from a total hip arthroplasty begins experiencing sudden confusion and repeatedly attempts to get out of bed unassisted. The client's spouse is at the bedside and asks the practical nurse to physically secure the client to the bed to prevent a fall. Which statement by the nurse best promotes client safety and adheres to standard guidelines?

We must first attempt less restrictive measures, such as using a bed alarm and frequent reorientation.

I will contact the provider to request a mild sedative to calm the client and prevent wandering.

Sudden confusion is expected for older adults in the hospital, so we will raise all four side rails.

I can apply the restraints immediately if you sign the facility's informed consent form.

Show answer & explanation

Answer: We must first attempt less restrictive measures, such as using a bed alarm and frequent reorientation.

Answer

The correct response is to explain that less restrictive measures, such as a bed alarm, must be attempted first.

The correct response demonstrates adherence to safety protocols by prioritizing less restrictive measures, such as bed alarms and reorientation, before considering restraints.

Step-by-Step Solution

Analyze the clinical situation and the spouse's request.

The client is acutely confused and at risk for falls, and the spouse is requesting physical restraints.

Understanding the exact nature of the safety risk and the requested intervention is required to formulate an appropriate response.

Recall the standard guidelines for restraint use and accident prevention.

Guidelines mandate that physical and chemical restraints are a last resort.

Restraints can cause further injury or agitation. Less restrictive alternatives must be attempted and documented first.

Evaluate the nursing responses against the guidelines.

The option prioritizing bed alarms and reorientation aligns with the requirement to use the least restrictive measures.

This approach addresses the fall risk while maintaining the client's safety and dignity without immediately resorting to restraints.

Key Concept

Restraint Alternatives and Fall Prevention

Question 2607Question →

A client is admitted to a short-stay surgical unit for a scheduled lumbar laminectomy. The neurosurgeon has discussed the procedure with the client and left the consent form at the bedside. When the practical nurse (PN) enters the room, the client states, 'I am ready to sign this paperwork.' Which actions are within the PN's scope of practice regarding the informed consent process? (Select all that apply.)

Select all that apply

Verifying that the client is signing the consent document voluntarily and without coercion.

Explaining the potential risks of nerve damage if the client asks for clarification before signing.

Witnessing the signature to confirm the identity of the person signing the document.

Assessing the client's clinical competency to ensure they legally understand the provided information.

Notifying the registered nurse (RN) or surgeon if the client expresses confusion about the planned procedure.

Show answer & explanation

Answer: Verifying that the client is signing the consent document voluntarily and without coercion.; Witnessing the signature to confirm the identity of the person signing the document.; Notifying the registered nurse (RN) or surgeon if the client expresses confusion about the planned procedure.

Answer

The practical nurse's actions should include verifying voluntary consent, witnessing the client's signature, and notifying the RN or provider if the client exhibits any lack of understanding.

In the informed consent process, the practical nurse's role is strictly limited to advocating for the client and witnessing the signature. This involves verifying that the client is the actual person signing, ensuring the signature is given voluntarily without coercion, and confirming that the client has no further questions. If the client expresses confusion or asks new questions about the procedure's risks, the PN must pause the process and notify the registered nurse or provider.

Step-by-Step Solution

Analyze the requested role of the practical nurse (PN) regarding the informed consent document.

The PN acts as a client advocate and a legal witness, but is not the primary provider of procedural or medical information.

Understanding professional scope of practice ensures legal and safe client care.

Evaluate each option against the PN's legal scope of practice.

Verifying voluntariness, witnessing the signature, and escalating client confusion are within the PN's scope. Explaining surgical risks and assessing legal competency are out of scope.

The provider must explain the procedure details, and evaluating cognitive competency requires RN or provider-level assessment.

Key Concept

The practical nurse acts solely as a witness to the informed consent process, verifying the client's identity, voluntary agreement, and basic understanding, while escalating any knowledge deficits back to the primary provider.

Question 2608Question →

A practical nurse (PN) has finished providing care for a client diagnosed with varicella. The client is placed in a negative-pressure isolation room, and the PN is currently wearing an N95 respirator, an isolation gown, and gloves. Which of the following describes the correct procedure for removing the personal protective equipment (PPE)?

Remove the isolation gown and gloves inside the client's room, and remove the N95 respirator after exiting the room and closing the door.

Remove all personal protective equipment, including the N95 respirator, inside the client's room prior to opening the door.

Keep all personal protective equipment on while exiting the room, and remove the gown, gloves, and respirator in the hallway.

Remove the gloves inside the client's room, exit into the hallway, and then remove the isolation gown and N95 respirator.

Show answer & explanation

Answer: Remove the isolation gown and gloves inside the client's room, and remove the N95 respirator after exiting the room and closing the door.

Answer

The correct procedure is to remove the isolation gown and gloves inside the client's room, and remove the N95 respirator after exiting the room and closing the door.

Varicella requires both airborne and contact precautions. To prevent environmental cross-contamination, the PPE used for contact precautions (the gown and gloves) must be removed inside the client's room prior to leaving. To protect the healthcare worker from airborne particles, the N95 respirator must remain securely in place until the nurse has exited the negative-pressure room and the door is completely closed.

Step-by-Step Solution

Identify the required isolation precautions for a client diagnosed with varicella (chickenpox).

Varicella requires a combination of both airborne and contact precautions.

The virus is transmitted through airborne infectious droplet nuclei as well as direct contact with skin lesions.

Determine the proper location for removing contact precaution PPE (the isolation gown and gloves).

Gowns and gloves must be removed inside the client's room before exiting.

Removing contact PPE inside the room prevents the spread of pathogens from the contaminated garments to the external hospital environment.

Determine the proper location for removing airborne precaution PPE (the N95 respirator).

The N95 respirator must remain on until the nurse has exited the room and the door is completely closed.

Airborne droplet nuclei can remain suspended in the air of the negative-pressure room. Removing the respirator inside would expose the nurse to these particles.

Key Concept

PPE Removal Sequence and Location for Combined Airborne and Contact Precautions

Question 2609Question →

An older adult client with a history of chronic obstructive pulmonary disease (COPD) and heart failure is receiving a continuous intravenous infusion of 0.9% sodium chloride. The practical nurse is preparing to administer scheduled morning medications, which include oral levofloxacin, oral furosemide, and subcutaneous enoxaparin. During the pre-administration assessment, the client appears restless. Vital signs are: heart rate 112 beats/min, blood pressure 90/58 mm Hg, and oxygen saturation 88% on 2 L/min via nasal cannula. The morning laboratory report shows a platelet count of 95,000/mm³ ( $95 \times 10^9$ /L). Based on these findings, which action should the practical nurse take first?

Administer the levofloxacin and furosemide, withhold the enoxaparin due to the platelet count, and recheck the blood pressure in one hour.

Increase the supplemental oxygen to 4 L/min to address the hypoxia, administer the furosemide, and document the client's restlessness.

Withhold all scheduled medications and immediately notify the registered nurse of the client's vital signs and laboratory results.

Administer the medications rapidly due to the client's declining status, bypassing the standard barcode scanning procedure to expedite care.

Show answer & explanation

Answer: Withhold all scheduled medications and immediately notify the registered nurse of the client's vital signs and laboratory results.

Answer

The correct action is to withhold all scheduled medications and immediately notify the registered nurse of the assessment findings and laboratory results.

The client is experiencing acute clinical deterioration evidenced by restlessness, tachycardia, hypotension, and hypoxia, alongside a critical laboratory finding (thrombocytopenia). Administering furosemide will exacerbate the hypotension, and enoxaparin poses a severe bleeding risk due to the low platelets. The practical nurse must recognize this complex, unstable presentation, withhold the potentially dangerous pharmacological therapies, and immediately report the findings to the registered nurse for urgent collaborative intervention.

Step-by-Step Solution

Analyze the client's vital signs and clinical presentation.

The client is restless with tachycardia (112 beats/min), borderline hypotension (90/58 mm Hg), and hypoxia (88%), indicating acute hemodynamic and respiratory deterioration.

Recognizing signs of acute decline is the first step in determining if scheduled medications are safe to administer.

Evaluate the laboratory results against the prescribed medications.

The platelet count of 95,000/mm³ indicates thrombocytopenia. Enoxaparin is an anticoagulant and is contraindicated when platelet counts are critically low due to severe bleeding risk.

Medications must be correlated with current diagnostic data to prevent adverse drug events.

Synthesize data to determine the safety of the remaining medications.

Furosemide is a loop diuretic that decreases fluid volume. Administering it to a client with a blood pressure of 90/58 mm Hg will worsen the hypotension and decrease perfusion further.

Pharmacological principles dictate holding medications that will exacerbate abnormal physiological parameters.

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

The nurse must withhold all medications and escalate the situation immediately to the registered nurse or primary healthcare provider for urgent medical intervention.

The practical nurse must recognize when a client's condition exceeds the stability required for routine medication administration and requires higher-level clinical judgment.

Key Concept

Pre-administration Assessment and Safe Scope of Practice

Estimated Time:2m 0s

Question 2610Question →

While performing a postoperative assessment, a licensed practical nurse (LPN) evaluates a client who underwent a percutaneous coronary intervention via the right femoral artery 4 hours ago. The client reports a new, continuous dull ache in the lower back. Inspection of the right groin reveals a dry surgical dressing with no localized swelling. Bilateral pedal pulses are palpable and symmetric. The client's baseline vital signs were blood pressure 144/82 mm Hg and heart rate 70 bpm. Current vital signs are blood pressure 104/62 mm Hg, heart rate 116 bpm, and respirations 20/min. Based on these findings, which action should the LPN take first?

Immediately notify the registered nurse of the vital sign trends and the client's back pain.

Reassess the client's vital signs in one hour since the insertion site exhibits no visible bleeding.

Administer the prescribed as-needed (PRN) acetaminophen and apply a warm compress to the lower back.

Elevate the head of the bed to a 60-degree angle to reduce strain on the client's lower back muscles.

Show answer & explanation

Answer: Immediately notify the registered nurse of the vital sign trends and the client's back pain.

Answer

The LPN should immediately notify the registered nurse of the vital sign trends and the client's back pain.

The correct action is to immediately notify the registered nurse. After a femoral artery procedure, blood can leak internally into the retroperitoneal space. Because the bleeding is internal, the external groin dressing often remains dry and intact. The classic presentation of a retroperitoneal hemorrhage includes new-onset lower back or flank pain, accompanied by hemodynamic instability (tachycardia and hypotension). The LPN must recognize these subtle shock signs and escalate care immediately to prevent severe hypovolemia.

Step-by-Step Solution

Analyze the client's procedure and current symptoms.

The client had a right femoral artery puncture and is now experiencing new-onset lower back pain.

Back or flank pain after a femoral catheterization is a primary indicator of retroperitoneal bleeding, where blood pools in the retroperitoneal cavity rather than at the visible groin site.

Evaluate the vital sign trends against the baseline.

Blood pressure has dropped significantly (144/82 to 104/62) and heart rate has increased (70 to 116).

Tachycardia and hypotension are compensatory mechanisms indicating early hypovolemic shock due to internal blood loss.

Determine the priority nursing intervention within the LPN scope of practice.

The LPN must escalate these findings to the RN immediately.

A retroperitoneal hemorrhage is a life-threatening complication that requires rapid fluid resuscitation, potential blood transfusions, and possible surgical intervention, all of which require RN and provider collaboration.

Key Concept

Recognizing early signs of retroperitoneal hemorrhage (internal bleeding) following a femoral artery procedure.

Estimated Time:1m 30s

Question 2611Question →

A practical nurse (PN) is caring for a postpartum client. During the admission assessment, the client explicitly requests that no information regarding her hospitalization or the newborn be shared with anyone. Later in the shift, an individual calls the nursing station, identifies themselves as the client's parent, provides the client's full name and room number, and asks for a brief medical update. Which of the following is the most appropriate response by the PN?

I have no information available regarding an individual by that name.

The client is currently resting, but she has instructed us not to share any details.

Since you already have the room number, I will transfer your call directly to her room.

I cannot share medical updates over the telephone, but visiting hours end at 8:00 PM.

Show answer & explanation

Answer: I have no information available regarding an individual by that name.

Answer

The most appropriate response is to state that there is no information available regarding an individual by that name.

When a client requests that no information be shared regarding their admission, they are essentially opting out of the facility directory. Under these privacy regulations, nurses must maintain strict confidentiality and cannot acknowledge or confirm the individual's presence at the facility to anyone, including family members. The most appropriate response is to state that no information is available.

Step-by-Step Solution

Analyze the client's specific privacy request.

The client opted for complete privacy, meaning her presence in the facility cannot be confirmed to outside callers.

Healthcare privacy laws mandate that providers respect a competent client's right to control who knows about their hospitalization.

Evaluate the caller's request and provided information.

Despite the caller having accurate identifying information (name and room number), the PN cannot confirm the client is there.

Possessing a room number or knowing a client's full name does not override the client's explicit request for non-disclosure.

Select the response that best protects the client's privacy.

The PN must use standard phrasing to deny the request without confirming the client's admission status.

Stating that no information is available protects confidentiality without providing false information to the caller.

Key Concept

Client Privacy and Directory Opt-Out

Question 2612Question →

The nursing team is planning to move a restless, older adult client from the bed to a geriatric chair using a full-body mechanical lift. The client has a history of dementia and frequently grabs at equipment. Which of the following interventions should the practical nurse (PN) implement to ensure a safe transfer? Select all that apply.

Select all that apply

Verify that the client's documented weight is within the safe operating capacity of the mechanical lift.

Open the base legs of the mechanical lift to the widest position before elevating the client from the mattress.

Apply soft wrist restraints to prevent the client from pulling on the lift straps during the transfer.

Assure the client by stating, 'Do not worry about falling; this machine is perfectly safe and cannot tip over.'

Enlist the assistance of at least one other staff member to help guide the client and operate the device.

Assign an unlicensed assistive personnel (UAP) to assess the client's skin for breakdown while rolling them onto the sling.

Show answer & explanation

Answer: Verify that the client's documented weight is within the safe operating capacity of the mechanical lift.; Open the base legs of the mechanical lift to the widest position before elevating the client from the mattress.; Enlist the assistance of at least one other staff member to help guide the client and operate the device.

Answer

The correct interventions are verifying the lift's weight capacity, opening the base legs to the widest position, and enlisting the assistance of at least one other staff member.

Safe use of a full-body mechanical lift requires adherence to strict equipment protocols. The nurse must verify that the client does not exceed the weight limit to prevent equipment failure. Widening the base of the lift lowers its center of gravity, providing maximum stability to prevent it from tipping over. Finally, because the equipment is complex and the client is restless, at least two healthcare personnel must be present to operate the controls and safely guide the client's body.

Step-by-Step Solution

Analyze the clinical scenario.

The situation involves transferring a restless, confused client using a complex piece of equipment (full-body mechanical lift).

Identifying patient-specific risks (restlessness, dementia) dictates the necessary safety and communication protocols.

Identify mandatory equipment safety standards.

Safe lift operation requires confirming weight capacity, widening the base for stability, and utilizing a multi-person team.

These actions directly prevent structural failure, tipping hazards, and physical injury to both the client and staff.

Evaluate the remaining options against legal and ethical nursing standards.

Restraints, false reassurance, and inappropriate delegation are recognized as unsafe nursing practices.

Adhering to the PN scope of practice, exploring restraint alternatives, and using therapeutic communication are required components of safe care.

Key Concept

Ergonomics and proper operation of mechanical patient-handling equipment.

Question 2613Question →

A client who underwent a right above-the-knee amputation 48 hours ago reports lower back stiffness and requests assistance with repositioning. Which action should the practical nurse take to promote comfort and prevent postoperative complications?

Support the residual limb in a continuously elevated position using stacked pillows.

Assist the client to turn onto their abdomen for 20 to 30 minutes.

Maintain the head of the bed in a high Fowler's position to stretch the lumbar spine.

Position a trochanter roll along the inner aspect of the affected thigh to maintain alignment.

Show answer & explanation

Answer: Assist the client to turn onto their abdomen for 20 to 30 minutes.

Answer

Assist the client to turn onto their abdomen for 20 to 30 minutes.

Assisting the client into a prone position for 20 to 30 minutes several times a day helps stretch the hip flexor muscles. This therapeutic position prevents hip flexion contractures, which are a major complication following an above-the-knee amputation, while simultaneously relieving the lower back stiffness caused by prolonged supine positioning.

Step-by-Step Solution

Assess the client's postoperative timeline and current positioning needs.

The client is 48 hours post-amputation and requires relief from back stiffness.

Understanding the time elapsed since surgery dictates which positioning interventions are safe and therapeutic.

Identify the primary complication associated with above-the-knee amputations.

Hip flexion contractures are a major risk that can hinder future prosthetic use.

Preventive care is a core component of basic nursing interventions.

Select the position that relieves back tension while counteracting hip flexion.

The prone position is selected and implemented.

Lying prone extends the hip joint fully, combating the continuous flexion experienced when sitting or lying supine.

Key Concept

Postoperative positioning for amputation to prevent contractures

Question 2614Question →

A practical nurse is reviewing the electronic health record of a client admitted with an exacerbation of chronic obstructive pulmonary disease and generalized edema. The provider has prescribed oral furosemide and oral levofloxacin. The morning chemistry panel reveals a serum potassium level of 2.8 mEq/L (normal: 3.5-5.0 mEq/L). During data collection, the practical nurse notes the client's blood pressure is 102/60 mm Hg and heart rate is 115 beats/min. The registered nurse is occupied with another admission and asks the practical nurse to administer all scheduled morning medications. Which action should the practical nurse take?

Administer the scheduled medications, then document the potassium level of 2.8 mEq/L in the electronic health record for the provider to review.

Administer the furosemide because the client's borderline blood pressure and tachycardia are expected findings with an acute exacerbation.

Withhold the furosemide and immediately report the laboratory findings and vital signs to the registered nurse.

Give the medications based on the registered nurse's instruction, bypassing the barcode scan since the registered nurse has already identified the client.

Show answer & explanation

Answer: Withhold the furosemide and immediately report the laboratory findings and vital signs to the registered nurse.

Answer

The practical nurse should withhold the furosemide and immediately report the laboratory findings and vital signs to the registered nurse.

Furosemide is a potassium-wasting loop diuretic. Administering it to a client with a critically low potassium level (2.8 mEq/L) can precipitate life-threatening cardiac dysrhythmias, which may already be developing given the client's tachycardia. The practical nurse's priority is client safety, requiring the medication to be withheld and the findings escalated to the registered nurse immediately.

Step-by-Step Solution

Analyze the morning laboratory results and vital signs.

The potassium level is 2.8 mEq/L, which is critically low. The client has borderline hypotension (102/60 mm Hg) and tachycardia (115 beats/min).

Data collection and identifying abnormal findings are essential practical nursing responsibilities before any medication administration.

Evaluate the pharmacological action of the prescribed medications against the client's data.

Furosemide is a loop diuretic that causes potassium excretion, which will worsen the client's severe hypokalemia.

Understanding medication actions and contraindications ensures client safety and prevents adverse events.

Determine the appropriate nursing intervention within the practical nurse's scope of practice.

The practical nurse must withhold the dangerous medication and immediately escalate the findings to the registered nurse.

The practical nurse is responsible for reporting critical data and withholding medications that pose an immediate risk to the client.

Key Concept

Recognizing critical laboratory values and medication contraindications to ensure safe administration.

Question 2615Question →

A licensed practical nurse (LPN) is assigned to obtain a sterile urine culture specimen from a client who has a continuous indwelling urinary catheter. To ensure accurate diagnostic results and reduce the risk of client complications, arrange the following procedural steps in the correct chronological sequence. All steps must be used.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first clamp the tubing to collect fresh urine, then scrub the port with an antiseptic, aspirate the urine with a sterile syringe, transfer it to a sterile container, and finally unclamp the tubing to prevent bladder distension.

To safely collect a sterile urine specimen from an indwelling catheter, the LPN must first clamp the tubing to allow fresh urine to collect. Once collected, the port must be disinfected to prevent infection. The urine is then aspirated with a sterile syringe and safely transferred to a sterile cup. Finally, unclamping the tubing is critical to prevent bladder distension and associated complications.

Step-by-Step Solution

Clamp the drainage tubing just below the collection port for 15 to 30 minutes.

Fresh urine accumulates in the tubing above the clamp.

Urine collected from the drainage bag is not sterile and cannot be used for a culture. Clamping ensures a fresh sample is available at the port.

Scrub the catheter aspiration port with an approved antiseptic wipe.

The port surface is disinfected.

Cleaning the port eliminates surface pathogens, reducing the risk of introducing bacteria into the closed urinary system (CAUTI).

Attach a sterile syringe to the aspiration port and withdraw the required volume of urine.

A sterile specimen is safely extracted from the tubing.

Using a sterile syringe maintains the sterility of both the specimen and the closed drainage system.

Transfer the aspirated urine into a sterile specimen container without contaminating the rim.

The specimen is secured in the transport container.

Preventing contact between the syringe and the rim of the cup ensures the culture will only grow organisms present in the client's urine.

Unclamp the drainage tubing to restore the free flow of urine.

Continuous urinary drainage resumes.

Failing to unclamp the tubing is a significant risk factor that can lead to urinary retention, severe bladder distension, and retrograde flow to the kidneys.

Key Concept

Reduction of Risk Potential

Question 2616Question →

During the morning medication pass, a client with pulmonary edema is scheduled to receive a $40$ mg oral dose of furosemide. The medication drawer contains $20$ mg scored tablets. The client's most recent basic metabolic panel reveals a serum potassium concentration of $2.8$ mEq/L ( $2.8$ mmol/L). Which action should the practical nurse (PN) take?

Withhold the furosemide and immediately report the laboratory findings to the registered nurse (RN).

Administer

2

tablets of furosemide after scanning the client's identification band.

Administer

0.5

tablets of the medication to adjust for the client's current laboratory values.

Administer a prescribed intravenous push dose of potassium chloride to correct the electrolyte deficit.

Show answer & explanation

Answer: Withhold the furosemide and immediately report the laboratory findings to the registered nurse (RN).

Answer

The correct action is to withhold the furosemide and immediately report the laboratory findings to the registered nurse (RN).

Furosemide is a loop diuretic that promotes the renal excretion of potassium. A serum potassium level of

2.8

mEq/L indicates severe hypokalemia, as the normal reference range is generally

3.5

5.0

mEq/L. Administering a potassium-wasting medication to a client in this state could precipitate life-threatening cardiac dysrhythmias. Safe nursing practice dictates that the PN must recognize this critical finding, withhold the scheduled dose, and promptly notify the supervising RN or healthcare provider to ensure client safety.

Step-by-Step Solution

Evaluate the client's prescribed medication and corresponding laboratory values.

The client is scheduled to receive furosemide, a loop diuretic known to deplete potassium, while having a critically low serum potassium level of

2.8

mEq/L.

Safe medication administration requires understanding the drug's mechanism of action and its potential impact on the client's current physiological state.

Determine the safety risk of administering the medication.

Administering a potassium-wasting diuretic to a client with severe hypokalemia increases the risk of life-threatening cardiac dysrhythmias.

Preventing adverse drug events is a primary responsibility in nursing care.

Select the appropriate intervention within the PN scope of practice.

The PN must withhold the unsafe medication and communicate the critical laboratory findings to the RN or provider for further orders.

The PN plays a vital role in data collection and patient safety but must escalate findings that require changes to the medical plan of care.

Key Concept

Pre-administration assessment and recognizing critical laboratory values within the practical nursing scope of practice.

Question 2617Question →

A practical nurse is reviewing the morning laboratory results for a client who receives a daily dose of furosemide. Which of the following laboratory findings presents the greatest physiological risk to the client and requires immediate notification to the registered nurse?

Serum potassium of

2.8

mEq/L (

2.8

mmol/L)

Blood urea nitrogen (BUN) of

16

mg/dL (

5.7

mmol/L)

Serum sodium of

139

mEq/L (

139

mmol/L)

Serum magnesium of

1.9

mEq/L (

0.78

mmol/L)

Show answer & explanation

Answer: Serum potassium of $2.8$ mEq/L ( $2.8$ mmol/L)

Answer

Serum potassium of 2.8 mEq/L (2.8 mmol/L)

Furosemide is a potassium-wasting loop diuretic. A serum potassium level of 2.8 mEq/L is significantly below the normal range of 3.5 to 5.0 mEq/L. Hypokalemia can lead to severe muscle weakness and life-threatening cardiac dysrhythmias, making this the highest priority finding that must be immediately reported to the registered nurse for prompt intervention.

Step-by-Step Solution

Identify the primary mechanism and risks associated with the client's prescribed medication.

Furosemide is a loop diuretic known to cause the excretion of water, sodium, and significantly, potassium.

Understanding the medication's expected side effects guides the nurse on which specific laboratory values to monitor most closely.

Evaluate each laboratory option against expected normal adult reference ranges.

The potassium level of 2.8 mEq/L is well below the normal range (3.5-5.0 mEq/L). The BUN, sodium, and magnesium levels are all within their respective normal limits.

The practical nurse must be able to rapidly differentiate between normal expected findings and abnormal critical values to ensure client safety.

Determine the required nursing action for the abnormal finding.

The abnormally low potassium level (hypokalemia) must be reported to the registered nurse immediately.

Severe hypokalemia can trigger lethal cardiac dysrhythmias, making it the highest priority finding that requires urgent medical intervention.

Key Concept

Identifying critical laboratory values and escalating abnormal findings associated with high-risk medications to reduce client harm.

Question 2618Question →

An interdisciplinary team is managing client care on a cardiovascular step-down unit. Which action performed by the practical nurse (PN) demonstrates a correct understanding of their legal scope of practice and safe assignment principles?

Administering scheduled oral antihypertensive medications to a clinically stable client who is two days post-myocardial infarction.

Formulating the initial discharge teaching plan for a client who is preparing to return home with a newly implanted permanent pacemaker.

Describing the potential complications of an upcoming cardiac catheterization to a client before witnessing the informed consent signature.

Filing a laboratory report showing a serum potassium level of

2.8 \text{ mEq/L}

(

2.8 \text{ mmol/L}

) for review during the upcoming shift handoff.

Show answer & explanation

Answer: Administering scheduled oral antihypertensive medications to a clinically stable client who is two days post-myocardial infarction.

Answer

Administering scheduled oral antihypertensive medications to a clinically stable client who is two days post-myocardial infarction.

The correct answer involves providing routine care to a clinically stable client. Administering scheduled oral medications to a client who is two days post-myocardial infarction and stable is entirely within the recognized legal scope of practice for a practical nurse.

Step-by-Step Solution

Analyze each proposed action to determine if it falls within the legal and safe scope of practice for a practical nurse.

Three actions are identified as unsafe or outside the PN scope, while one is a standard PN task.

Safe delegation and assignment require adherence to legal practice boundaries and prompt recognition of critical client changes.

Evaluate the educational and consent-related tasks.

Formulating an initial teaching plan is an RN responsibility, and explaining procedural risks is a provider responsibility.

The PN scope allows for reinforcement of teaching and witnessing consent signatures, but not initial complex education or obtaining informed consent.

Evaluate the clinical data task.

A potassium level of

2.8 \text{ mEq/L}

is identified as a critical laboratory value.

Normal potassium is

3.5

5.0 \text{ mEq/L}

. Hypokalemia can cause severe arrhythmias, necessitating immediate escalation rather than delaying for shift handoff.

Verify the remaining action.

Administering routine oral medications to a stable client is confirmed as the correct action.

This task does not require complex initial assessment or intervention, making it perfectly suited for the PN scope of practice.

Key Concept

Practical Nurse Scope of Practice and Task Delegation

Question 2619Question →

Prior to an elective hernia repair, a client who has already signed the surgical consent form suddenly states to the practical nurse (PN), "I have changed my mind. I do not want to go through with this operation today." Which action should the PN take first?

Notify the operating surgeon and the charge nurse immediately regarding the client's decision.

Explain the potential health complications that may occur if the hernia is left untreated.

Ask the client why they are suddenly refusing the procedure after already agreeing to it.

Independently cancel the surgical procedure order in the electronic health record.

Show answer & explanation

Answer: Notify the operating surgeon and the charge nurse immediately regarding the client's decision.

Answer

Notify the operating surgeon and the charge nurse immediately regarding the client's decision.

Clients retain the legal and ethical right to withdraw informed consent at any time prior to the initiation of a procedure, regardless of having previously signed a consent form. When a client revokes consent, the immediate priority for the practical nurse is to communicate this critical information to the healthcare provider and the charge nurse so that surgical preparations are halted and the provider can appropriately discuss the decision with the client.

Step-by-Step Solution

Recognize that a client has the absolute right to revoke informed consent at any point before a procedure begins.

The PN identifies that the client's statement constitutes a legal withdrawal of consent.

Informed consent is an ongoing, voluntary process, not simply the act of signing a physical document.

Determine the boundaries of the PN scope of practice in this specific scenario.

The PN acknowledges that discussing the medical risks of refusal or altering procedure orders is the provider's responsibility.

The PN's legal role is to advocate for the client and communicate critical changes in status to the healthcare team.

Prioritize the immediate next step to ensure client safety and honor their legal rights.

The PN selects the action to immediately escalate the client's decision to the operating surgeon and charge nurse.

The surgical team must be alerted immediately to halt preoperative preparations and allow the provider to speak directly with the client.

Key Concept

A client has the right to revoke informed consent at any time, and the practical nurse's priority is to immediately notify the healthcare provider of this change without attempting to educate on medical risks.

Estimated Time:1m 0s

Question 2620Question →

A practical nurse (PN) on a medical-surgical unit encounters several different situations involving requests for client information. Match each clinical scenario with the appropriate nursing determination regarding confidentiality and disclosure.

Click a left item, then click its matching right item

Show answer & explanation

Answer

Health department request maps to permissible for public health; neighbor inquiry maps to impermissible without consent; physical therapist request maps to permissible for care coordination; UAP inquiry maps to impermissible because standard precautions apply universally.

Each scenario is evaluated against HIPAA guidelines and the practical nursing scope of practice. Disclosures to direct care team members and public health authorities are legally permissible. Conversely, disclosures to unauthorized visitors or staff without a direct need-to-know violate client confidentiality.

Step-by-Step Solution

Analyze the request from the health department for the client with tuberculosis.

Matches with permissible disclosure required for public health reporting.

Tuberculosis is a reportable disease, and public health laws mandate disclosure to appropriate agencies, overriding general HIPAA restrictions.

Evaluate the neighbor's request for information about the client's stroke recovery.

Matches with impermissible disclosure requiring explicit client consent.

Nurses cannot disclose any health information to visitors, friends, or neighbors without explicit permission from the client or their designated proxy.

Assess the physical therapist's need to check the pain medication schedule.

Matches with permissible disclosure under the need-to-know basis for care coordination.

Healthcare team members directly involved in the client's care are permitted access to the medical record to coordinate and safely provide treatment.

Determine the validity of the UAP's request regarding the client's bloodborne disease status for transport.

Matches with impermissible disclosure because standard precautions apply regardless of the diagnosis.

The transporter does not require the specific diagnosis to perform their duty. Standard precautions are required for all clients to prevent transmission of bloodborne pathogens.

Key Concept

Under HIPAA, client information may only be disclosed on a 'need-to-know' basis for treatment, payment, or healthcare operations, or when legally mandated (e.g., public health reporting).

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