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Question 2621Question →

A practical nurse is preparing to place a regular bedpan for a client who is on strict bed rest and unable to lift their hips. After donning gloves and ensuring privacy, in what order should the nurse perform the following actions? Arrange the steps from first to last.

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Answer

The correct sequence is: raise the bed and lower the head, assist the client to roll onto their side, position the bedpan firmly against the buttocks, roll the client back onto the bedpan, and finally elevate the head of the bed.
When assisting a client who cannot lift their hips onto a bedpan, the nurse must first prioritize safety and ergonomics by flattening the bed and raising it to working height. The client is then rolled to the side so the bedpan can be pressed against the buttocks. The nurse holds the bedpan steady while rolling the client back onto it. Finally, raising the head of the bed restores a functional, gravity-assisted position for elimination.

Step-by-Step Solution

1
Raise the bed to a comfortable working height and lower the head of the bed flat.
The nurse's back is protected, and the client is in a safe, flat position for turning.
Maintaining proper ergonomics and reducing the physical effort required to turn the client.
2
Assist the client to roll onto their side facing away from the nurse.
The client's buttocks are exposed and accessible.
Since the client cannot lift their hips, the log-rolling or side-lying method must be used to place the device.
3
Position the bedpan firmly against the client's buttocks.
The bedpan is properly aligned with the client's anatomy.
Ensuring the bedpan is secure prevents spillage and skin shearing during the return roll.
4
Roll the client back onto the bedpan while holding it in place.
The client is now supine and centered over the bedpan.
Holding the device securely during the maneuver ensures it remains under the client's buttocks.
5
Elevate the head of the bed to a semi-Fowler's position.
The client is sitting in a somewhat upright position.
An upright position mimics the natural posture for defecation or urination, utilizing gravity and intra-abdominal pressure.

Key Concept

Procedural sequencing for basic elimination care
Estimated Time:1m 30s
Question 2622Question →

A client is receiving postoperative care on the medical-surgical unit following a lumbar laminectomy. The client reports mild discomfort from lying flat and requests assistance to turn onto their side. Which of the following techniques should the nurse implement to safely reposition this client?

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Answer: Obtain assistance from another staff member to logroll the client's entire body as a single unit, keeping a pillow placed between the client's legs.

Answer

The nurse must obtain assistance to logroll the client as a single unit with a pillow between the legs.
Following spinal surgery such as a lumbar laminectomy, the vertebral column must remain in straight anatomical alignment. Logrolling the client as a single unit prevents any twisting (torsion) or flexion of the spine. Placing a pillow between the legs ensures the hips remain parallel and the spine stays aligned during the lateral movement.

Step-by-Step Solution

1
Identify the surgical procedure and its specific mobility precautions.
The client had a lumbar laminectomy, which requires maintaining strict, neutral spinal alignment.
Postoperative spinal care mandates the prevention of any twisting, flexion, or hyperextension to protect the surgical site and spinal cord.
2
Evaluate the proposed positioning techniques against the required precautions.
Logrolling is the only technique that moves the head, shoulders, and hips simultaneously.
Techniques that involve pulling on rails, elevating the head, or turning the upper and lower body at different times create dangerous torsion (twisting) on the spine.
3
Select the safest execution method for the required technique.
Using extra staff to logroll and placing a pillow between the legs prevents adduction of the upper leg, keeping the spine straight during the turn.
Proper body mechanics and sufficient staff are fundamental elements of basic care and comfort that prevent injury to both the client and the nurse.

Key Concept

Basic care positioning for a postoperative spinal surgery client requires logrolling to prevent spinal flexion and torsion.
Question 2623Question →

A practical nurse (PN) has completed wound care for a client on contact and droplet precautions. Arrange the following steps for removing personal protective equipment (PPE) in the correct chronological order to minimize the risk of self-contamination.

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Answer

The correct sequence for doffing PPE is to first remove the gloves, followed by the face shield, then the gown, then the mask, and finally perform hand hygiene.
The Centers for Disease Control and Prevention (CDC) guidelines dictate that PPE should be removed in a specific order that minimizes the risk of cross-contamination. Gloves are the most contaminated and are removed first. The face shield is removed next by handling only the clean headbands. The gown is then removed and rolled inside out to contain pathogens. The mask is removed last because it protects the respiratory tract from potential exposure during the removal of the other items. Finally, hand hygiene is universally required to remove any residual pathogens.

Step-by-Step Solution

1
Identify and remove the most contaminated item.
Gloves are removed first.
Gloves have direct contact with the client and contaminated environmental surfaces.
2
Protect the mucous membranes of the eyes.
The face shield or goggles are removed second.
This prevents splashes or transfer to the eyes while the gown is subsequently being manipulated.
3
Remove the bulk of the remaining contaminated equipment.
The gown is removed third by pulling it away and rolling it inside out.
Rolling the gown traps contaminants inside, protecting the nurse's bare arms and uniform.
4
Remove respiratory protection.
The mask is removed fourth.
The mask is kept on until all other contaminated PPE is safely discarded to protect the airway from potential airborne particles during doffing.
5
Eliminate any residual pathogens.
Hand hygiene is performed last.
This ensures any cross-contamination that occurred during the removal process is completely washed away.

Key Concept

Standard Sequence for Removing (Doffing) Personal Protective Equipment
Question 2624Question →

A practical nurse (PN) is gathering personal protective equipment (PPE) before entering the isolation room of a newly admitted client. For which client must the PN don an N95 respirator, an isolation gown, and clean gloves prior to entry?

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Answer: An immunocompromised client diagnosed with disseminated herpes zoster.

Answer

The client with disseminated herpes zoster requires both an N95 respirator (airborne precautions) and an isolation gown with gloves (contact precautions).
Disseminated herpes zoster (caused by the varicella-zoster virus) is highly contagious and can be transmitted through both airborne viral particles and direct contact with lesion exudate. Therefore, healthcare workers must implement both airborne precautions (requiring a fit-tested N95 respirator) and contact precautions (requiring an isolation gown and gloves) prior to entering the client's room.

Step-by-Step Solution

1
Analyze the PPE specified in the stem to determine the required transmission-based precautions.
An N95 respirator is used for airborne precautions. An isolation gown and clean gloves are used for contact precautions. The question is asking which client requires BOTH airborne and contact precautions.
Identifying the corresponding isolation categories is the first step in matching the PPE to the correct pathogen.
2
Evaluate the isolation requirements for each client option.
Disseminated herpes zoster requires airborne and contact precautions. Pulmonary tuberculosis requires airborne precautions only. RSV requires contact and droplet precautions. Localized covered herpes zoster requires standard precautions.
Different pathogens and clinical presentations dictate specific combinations of infection control measures.
3
Select the client whose requirements perfectly match the combination of an N95 respirator, gown, and gloves for room entry.
The immunocompromised client with disseminated herpes zoster is the only client requiring this exact PPE combination.
Applying the exact mandated precautions prevents nosocomial transmission of highly contagious viruses.

Key Concept

Disseminated herpes zoster (varicella-zoster virus) requires the concurrent use of both airborne and contact precautions until lesions are dry and crusted.
Question 2625Question →

During a scheduled safety check, the practical nurse finds a client with a history of chronic obstructive pulmonary disease (COPD) and mild dementia attempting to pull off their oxygen nasal cannula. The client appears highly restless and agitated. Current vital signs indicate a heart rate of 112 beats/min, respirations of 28 breaths/min, and an oxygen saturation of 85% on 2 L/min. What is the priority action for the practical nurse to take?

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Answer: Elevate the head of the client's bed and immediately verify that the oxygen system is functioning properly.

Answer

The priority action is to elevate the head of the bed and ensure the oxygen delivery equipment is working correctly.
Restlessness, tachycardia, and tachypnea are early signs of hypoxia. The priority is to address the client's airway and breathing (ABCs). Elevating the head of the bed promotes maximum lung expansion, and checking the oxygen equipment ensures the client is actually receiving the prescribed oxygen. These are immediate, independent nursing actions that directly treat the underlying problem.

Step-by-Step Solution

1
Analyze the clinical cues from the scenario.
The client is exhibiting restlessness, agitation, tachypnea (28 breaths/min), tachycardia (112 beats/min), and hypoxia (SpO2 85%).
Recognizing early signs of hypoxia is essential for safe and effective client care.
2
Prioritize interventions using the ABC (Airway, Breathing, Circulation) framework.
Airway and breathing are the immediate priorities over secondary concerns like behavioral symptoms or pain.
Hypoxia is a life-threatening condition that requires prompt physiological intervention.
3
Select the most appropriate, independent nursing action within the practical nurse's scope of practice.
Positioning the client in a high-Fowler's position and verifying the oxygen flow directly supports breathing and oxygenation.
These actions are rapid, within the practical nurse scope, and directly address the physiological cause of the client's distress.

Key Concept

Early Signs of Hypoxia and ABC Prioritization
Estimated Time:1m 0s
Question 2626Question →

A client is receiving intravenous (IV) fluid therapy for severe dehydration caused by acute gastroenteritis. The practical nurse is collaborating with a registered nurse (RN) to manage the client's care. Which actions by the practical nurse demonstrate the correct application of risk reduction principles? Select all that apply.

Select all that apply

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Answer: Alerting the RN that the client's heart rate has gradually increased from 84 to 110 beats per minute over the last two hours.; Informing the healthcare provider that the practical nurse cannot administer a prescribed intravenous push (IVP) antiemetic medication.; Stopping the IV fluid infusion and elevating the head of the bed when the client reports new-onset dyspnea and a tight chest.

Answer

The correct actions involve recognizing and escalating borderline vital signs (tachycardia), staying within the legal scope of practice by refusing to administer IV push medications, and intervening appropriately for early signs of fluid overload (dyspnea).
Risk reduction requires the practical nurse to identify early signs of complications (such as tachycardia indicating hypovolemia or dyspnea indicating fluid overload) and intervene immediately. Furthermore, client safety is maintained by strictly adhering to the legal scope of practice, which prohibits practical nurses from administering IV push medications.

Step-by-Step Solution

1
Analyze the client's clinical context and the role of the practical nurse.
The client is receiving IV fluids, placing them at risk for fluid shifts. The practical nurse must monitor for complications, escalate critical findings, and stay strictly within their defined scope of practice.
Understanding the clinical risks dictates the appropriate and safe nursing actions.
2
Evaluate each option against established risk reduction principles and the practical nurse scope of practice.
Tachycardia, out-of-scope IV push medication orders, and fluid overload require immediate, specific actions. Delaying the reporting of hypokalemia, skipping barcode scans, and performing initial assessments violate safety standards.
Risk reduction requires strict adherence to safety protocols, rapid escalation of critical data, and knowing practice limitations.

Key Concept

Reduction of Risk Potential in Practical Nursing involves strict adherence to the scope of practice, diligent medication safety practices, and the prompt escalation of critical laboratory values and subtle changes in client condition.
Question 2627Question →

A practical nurse (PN) enters the room of a client on a pulmonary unit to administer a prescribed pre-procedure sedative. The client, who is scheduled for a bronchoscopy in one hour, states, "I have decided not to go through with this test today." In which order should the PN perform the following actions? Arrange the actions from first to last.

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Answer

The correct sequence is to first withhold the medication, then clarify the client's concerns, followed by notifying the healthcare provider, and finally documenting the event.
In any situation where a client revokes consent, the absolute first priority is to stop the procedure or any preparatory actions (such as administering sedatives). Next, the nurse should assess the situation by asking the client to clarify their feelings. Third, the nurse must communicate the refusal to the healthcare provider, who is responsible for discussing the medical implications with the client. Finally, the nurse must document the entire event objectively in the medical record.

Step-by-Step Solution

1
Withhold the pre-procedure sedative medication.
Client safety and autonomy are immediately protected.
When a client revokes consent, all procedure-related interventions must stop immediately to prevent battery and respect their legal rights.
2
Ask the client to elaborate on their decision.
The PN gathers relevant data regarding the refusal.
Understanding the client's fears or concerns helps inform the healthcare team, though the PN must remain within scope and not attempt to explain medical risks themselves.
3
Notify the healthcare provider.
The provider is alerted to intervene.
It is exclusively the provider's scope of practice to explain the medical consequences of refusing the procedure and to formally accept the revoked consent.
4
Document the event in the medical record.
A formal legal record is established.
Accurate, objective documentation of the client's refusal, the time, and the notification of the provider protects both the client and the healthcare facility.

Key Concept

Clients have the right to revoke informed consent at any time; the PN must prioritize withholding interventions and notifying the provider who is responsible for explaining the risks of refusal.
Estimated Time:1m 30s
Question 2628Question →

Upon concluding a dressing change for a pediatric client diagnosed with respiratory syncytial virus (RSV), the nurse steps toward the doorway to exit the isolation room. The nurse is wearing a gown, gloves, a surgical mask, and a face shield. Arrange the following actions in the correct chronological sequence for safely removing this personal protective equipment (PPE) according to standard infection control protocols.

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Answer

The correct sequence is: 1) Remove gloves, 2) Remove face shield, 3) Remove gown, 4) Remove mask, 5) Perform hand hygiene.
According to the Centers for Disease Control and Prevention (CDC) guidelines, the standard sequence for removing personal protective equipment is designed to minimize the risk of self-contamination. The most contaminated items, the gloves, are removed first. Eye protection is removed next by handling only the clean headband. The gown is then unfastened and rolled inward. The mask is removed last (prior to hand hygiene) because it protects the airway during the doffing of the other items. Finally, hand hygiene is universally mandated as the concluding step to ensure safety.

Step-by-Step Solution

1
Remove gloves
The most contaminated PPE is safely discarded
Gloves harbor the highest concentration of pathogens and removing them first prevents cross-contamination to the face or hair.
2
Remove face shield
Eye protection is safely removed without touching the contaminated front
Handling only the clean back headband protects the newly ungloved hands from splash contaminants.
3
Remove gown
The gown is folded inward and discarded
Removing the gown after the face shield prevents contamination of the uniform and ensures the mask remains in place during potential aerosolization.
4
Remove mask
The respiratory and droplet barrier is removed
The mask must remain on until all other potentially contaminated PPE is removed to protect the mucous membranes of the nose and mouth.
5
Perform hand hygiene
Hands are completely cleansed of residual pathogens
Hand hygiene is strictly required as the absolute final step before exiting the area or moving to the next client.

Key Concept

Standard and Transmission-Based Precautions: PPE Doffing Sequence
Estimated Time:1m 0s
Question 2629Question →

A client is receiving care for a severe systemic infection. A colleague who is currently off duty, but who cared for this client during the previous shift, calls the nursing station to ask if the client's morning laboratory results have improved. Which is the appropriate response by the practical nurse receiving the call?

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Answer: State that client information cannot be shared because the caller is not currently assigned to the client.

Answer

The practical nurse should state that client information cannot be shared because the caller is not currently assigned to the client.
The correct response upholds client confidentiality. Protected health information (PHI) should only be accessed by or shared with healthcare personnel who have a current clinical 'need to know'. Even though the caller previously cared for the client, being off duty means they are no longer actively involved in the client's care and therefore are not authorized to receive updates.

Step-by-Step Solution

1
Identify the caller's current relationship to the client's care.
The caller is an off-duty nurse and is not actively assigned to the client's care for the current shift.
Determining current assignment status is required to establish if there is a 'need to know' for clinical updates.
2
Apply the principle of 'need to know' under confidentiality and HIPAA guidelines.
Since the caller is off duty, they do not have a legitimate clinical need to access the client's protected health information at this time.
Healthcare workers may only access or receive client information if it is strictly necessary to perform their current job duties.
3
Select the response that protects the client's privacy.
The nurse must politely refuse to share the laboratory results.
Declining the request prevents an unauthorized disclosure of protected health information.

Key Concept

Confidentiality and the 'Need to Know' Principle
Estimated Time:1m 0s
Question 2630Question →

A healthcare provider prescribes knee-high anti-embolism stockings for a client who is currently sitting in a bedside chair. Arrange the following steps for applying the stockings in the correct chronological order.

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Answer

The practical nurse must first assist the client to a supine position for 15 to 30 minutes, measure the leg for correct sizing, turn the stocking inside out to the heel, apply the foot portion, and finally pull the remaining fabric smoothly up the calf.
Applying anti-embolism stockings requires specific preparation to be effective and safe. Because the client has been sitting in a chair, their legs have been in a dependent position, allowing venous blood to pool. The nurse must first assist the client to a supine position for 15 to 30 minutes to promote venous return and resolve dependent edema. Once the legs are rested, accurate measurements of the calf and leg length ensure the correct size is chosen, preventing a tourniquet effect from stockings that are too tight. After obtaining the right size, turning the stocking inside out to the heel allows the nurse to smoothly apply the foot portion first. Finally, pulling the remainder of the stocking up the calf ensures a wrinkle-free fit that effectively supports venous return.

Step-by-Step Solution

1
Assist the client to lie supine in bed for 15 to 30 minutes.
Dependent edema is reduced and venous return is maximized.
Applying stockings while the client has been in a dependent position can trap pooled venous blood in the lower extremities.
2
Measure the client's calf circumference and leg length.
The correct stocking size is identified.
Stockings that are too tight can restrict arterial blood flow, while those that are too loose fail to promote venous return.
3
Turn the stocking inside out down to the heel pocket.
The foot section is exposed and ready for application.
This technique allows the nurse to apply the stocking over the foot easily without bunching the stiff compression fabric.
4
Slide the foot portion of the stocking evenly over the client's toes and heel.
The stocking is secured over the foot with the heel patch correctly aligned.
Proper alignment over the heel prevents skin breakdown and ensures the compression gradient starts correctly at the ankle.
5
Pull the remaining fabric smoothly up the leg to just below the knee.
The stocking fits snugly and evenly across the calf.
Wrinkles or rolled-down bands can act as a tourniquet, completely occluding circulation and increasing the risk of deep vein thrombosis.

Key Concept

Proper application of anti-embolism stockings to promote venous return
Question 2631Question →

Upon receiving a client who just completed a percutaneous liver biopsy, the practical nurse must ensure the client is safely situated in bed. To effectively compress the biopsy site and prevent internal bleeding, which position is most appropriate?

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Answer: Right lateral position with a folded towel placed beneath the lower rib cage

Answer

The right lateral position with a folded towel placed beneath the lower rib cage.
The liver is a highly vascular organ located on the right side of the body. After a percutaneous liver biopsy, the client is at a high risk for hemorrhage. Positioning the client in a right lateral (side-lying) position with a towel or small pillow under the puncture site uses the client's own body weight to apply direct, continuous pressure to the liver capsule. This mechanical compression is a fundamental care measure essential to promote hemostasis and prevent internal bleeding.

Step-by-Step Solution

1
Identify the anatomical location of the liver and the procedural entry point.
The liver is located on the right side of the abdomen, and the biopsy is typically performed through the right lower rib cage.
Understanding the procedural site is required to determine where external pressure must be applied.
2
Determine the primary post-procedure complication associated with a liver biopsy.
Hemorrhage is the major risk because the liver is a highly vascular organ.
Identifying the primary complication guides the selection of the correct nursing intervention.
3
Select the basic care intervention that directly mitigates this risk.
Applying direct, continuous pressure to the puncture site promotes hemostasis and prevents internal bleeding.
Mechanical compression is necessary to allow blood vessels at the puncture site to clot.
4
Evaluate the given positions to find the one that provides the necessary compression.
The right lateral position uses the client's own body weight to compress the liver against the abdominal wall.
Only this position effectively targets the right side of the body where the biopsy occurred.

Key Concept

Post-procedure Client Positioning
Question 2632Question →

A healthcare team on a medical-surgical unit is dividing responsibilities for the upcoming shift. Connect each specific client care activity to the team member whose role and legal scope of practice best aligns with the duty.

Click a left item, then click its matching right item

Items

Establishing outpatient community resources and home care services for a client approaching discharge.
Completing the initial comprehensive admission assessment for a client presenting with an acute asthma exacerbation.
Administering a scheduled oral analgesic to a hemodynamically stable client recovering from an appendectomy.
Emptying a closed-wound drainage device and documenting the collected volume for a postoperative client.

Matches

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Answer

The Case Manager handles discharge resource coordination, the RN performs the initial comprehensive assessment, the LPN/VN administers the scheduled medication, and the UAP empties the drainage device.
Safe delegation requires understanding the legal scope of practice for each team member. The RN handles complex, unstable situations and initial assessments. The LPN/VN manages stable clients with predictable outcomes and administers routine medications. The UAP performs standard, repetitive tasks that do not require nursing judgment, such as emptying drains. Case managers facilitate interdisciplinary coordination and post-discharge needs.

Step-by-Step Solution

1
Analyze each clinical task to determine its complexity, stability, and required level of clinical judgment.
Identified the need for advanced assessment, routine medication, standard procedures, and multidisciplinary coordination.
Delegation and assignments must adhere to the legal boundaries defined by the Nurse Practice Act.
2
Match the task requiring the highest level of clinical judgment and initial care planning to the RN.
The initial comprehensive admission assessment is assigned to the RN.
The RN is responsible for initial baseline assessments and formulating the care plan.
3
Identify the task suitable for a licensed practical nurse.
Administering a scheduled oral analgesic to a stable client is assigned to the LPN/VN.
LPN/VNs care for stable clients and perform routine nursing tasks like oral medication administration.
4
Identify standard, unchanging tasks for delegation to assistive personnel.
Emptying the drainage device is assigned to the UAP.
UAPs handle routine hygiene, ambulation, and measuring standard intake and output.
5
Assign the system-level coordination task to the appropriate multidisciplinary team member.
Outpatient resource coordination is matched with the Case Manager.
Case managers specialize in continuum of care and community resource allocation.

Key Concept

Scope of practice and safe delegation principles
Estimated Time:1m 30s
Question 2633Question →

A practical nurse is caring for a client with heart failure who is resting supine in bed. The client suddenly becomes restless and reports severe difficulty breathing. In what sequence should the nurse perform the following actions? (Arrange the actions from first to last.)

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Answer

The correct sequence is: assist the client into a high-Fowler's position, obtain vital signs and oxygen saturation, administer supplemental oxygen as prescribed, and finally report the change in condition to the charge nurse.
In any acute respiratory distress scenario, anatomical positioning to open the airway and facilitate lung expansion is the absolute first priority (Airway/Breathing). After the airway is physically optimized, the nurse collects necessary data (vital signs and oxygen saturation) to guide further intervention, administers prescribed physical treatments (oxygen), and finally communicates the status change to the broader healthcare team.

Step-by-Step Solution

1
Identify the immediate threat to the client's stability.
The client is experiencing sudden respiratory distress, making airway and breathing the absolute top priority.
According to the ABCs (Airway, Breathing, Circulation) framework, respiratory compromise must be addressed before other actions.
2
Select the quickest, most direct intervention to improve breathing.
Assisting the client to a high-Fowler's position is chosen as the first action.
Repositioning provides immediate relief for dyspnea by utilizing gravity to pull organs away from the diaphragm, requiring no equipment or orders to initiate.
3
Determine the next priority after optimizing the client's airway.
Obtaining vital signs and oxygen saturation is the second action.
Data collection is necessary to quantify the severity of the distress and guide further clinical decisions within the PN scope of practice.
4
Implement ordered therapies based on the newly collected data.
Administering prescribed supplemental oxygen is the third action.
Oxygen therapy directly treats the underlying hypoxia identified during the assessment phase.
5
Ensure the healthcare team is aware of the acute change.
Reporting to the charge nurse is the final action in this immediate sequence.
Once the client is stabilized and initial interventions are complete, the supervising nurse must be informed for further medical evaluation and potential modification of the care plan.

Key Concept

Prioritization of airway and breathing management during acute respiratory distress
Question 2634Question →

A practical nurse (PN) is caring for a client in an outpatient oncology clinic who is preparing for a scheduled bone marrow aspiration. The healthcare provider has discussed the procedure and left the informed consent form with the client. As the PN prepares to witness the signature, the client asks, "Will I be completely asleep during this test?" Which action should the PN take first?

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Answer: Withhold the client's signature and notify the healthcare provider to return to clarify the procedure details.

Answer

Withhold the client's signature and notify the healthcare provider to return to clarify the procedure details.
The correct action is to pause the consent process and notify the healthcare provider. For informed consent to be legally valid, the client must fully understand the procedure, including the anesthesia, risks, and benefits. Because the client asked a direct question regarding sedation, they do not have a complete understanding. It is strictly the healthcare provider's responsibility—not the PN's or RN's—to explain the medical procedure. Therefore, the PN must withhold witnessing the signature until the provider has returned to answer the client's questions.

Step-by-Step Solution

1
Evaluate the client's statement.
The client is asking a specific question about the sedation used during the bone marrow aspiration.
Determining what the client knows or does not know is required to verify if true informed consent has been given.
2
Determine the legal boundaries of the PN's scope of practice.
The PN's role is strictly limited to verifying that the client signed voluntarily and appears competent.
Answering specific questions about a procedure's risks, benefits, and anesthesia is the sole responsibility of the healthcare provider.
3
Select the safest, most legally appropriate action.
The PN must halt the consent process and notify the healthcare provider.
Because the client still has questions, they are not fully informed. The provider must return to address the client's concerns before the document can be legally signed.

Key Concept

The practical nurse's role in informed consent is limited to witnessing the signature and verifying voluntary agreement. If the client has any questions about the procedure itself, the nurse must notify the provider to explain.
Question 2635Question →

A practical nurse is preparing to transfer a client who has limited mobility from a bed to a stretcher using a lateral transfer board (slide board). The nurse has already explained the procedure to the client, gathered an assistant, and performed hand hygiene. Arrange the following steps in the correct order to safely complete the transfer.

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Answer

The correct sequence is to first level and lock the bed and stretcher, turn the client away, position the board under the draw sheet, roll the client supine onto the board, and finally slide them across.
A safe lateral transfer requires a systematic approach to prevent client injury and nurse strain. First, stabilizing and leveling the surfaces (bed and stretcher) is the fundamental safety priority. Next, the client must be turned away from the destination to expose the bed surface, allowing the transfer board to be placed safely under the draw sheet without shearing the skin. The client is then rolled back onto the board to secure their weight, followed by a coordinated slide using the draw sheet to move the client smoothly across the gap.

Step-by-Step Solution

1
Adjust bed and stretcher height and lock wheels.
Both surfaces are level, stable, and secure.
This is the primary safety measure to prevent the bed or stretcher from separating or moving during the transfer.
2
Turn the client away from the stretcher.
The client is in a lateral position.
This exposes the bed surface and allows the nurse to position the board without forcing it roughly under the client.
3
Position the transfer board under the draw sheet.
The board bridges the gap between the bed and stretcher.
Placing it under the draw sheet protects the client's skin from friction and utilizes the sheet for the pulling action.
4
Return the client to a supine position.
The client is centered securely on the transfer board.
This properly distributes the client's weight and prepares their body alignment for the slide.
5
Slide the client across the board.
The client is successfully transferred to the stretcher.
Coordinating the pull with an assistant ensures proper ergonomics for the staff and a smooth, safe transfer for the client.

Key Concept

Safe client handling and mobility: lateral transfer techniques
Question 2636Question →

A practical nurse (PN) at an inpatient rehabilitation facility answers a telephone call. The caller identifies themselves as the manager of a local business and asks when their employee, who was recently involved in an accident, will be discharged so they can adjust the upcoming work schedule. The client's medical record does not list this manager as an authorized contact. Which of the following is the appropriate nursing action?

Show answer & explanation

Answer: Advise the caller that federal privacy laws prevent the staff from confirming or denying any person's presence at the facility.

Answer

Advise the caller that federal privacy laws prevent the staff from confirming or denying any person's presence at the facility.
The correct response protects the individual's privacy by adhering strictly to HIPAA guidelines. By refusing to confirm or deny the person's presence, the nurse prevents any unauthorized disclosure of Protected Health Information (PHI).

Step-by-Step Solution

1
Identify the caller's relationship to the client and their authorization status in the medical record.
The caller is the client's manager and is not listed as an authorized contact.
Health Insurance Portability and Accountability Act (HIPAA) regulations require explicit client authorization before releasing any Protected Health Information (PHI).
2
Determine what information constitutes Protected Health Information (PHI).
The client's presence at the facility and their discharge date are both considered PHI.
PHI includes any information that can identify a client and relates to their past, present, or future physical or mental health condition or provision of healthcare.
3
Select the response that best protects the client's privacy without validating unauthorized assumptions.
The nurse must neither confirm nor deny the client's presence at the facility.
Even acknowledging that a person is a client at the facility is a breach of confidentiality.

Key Concept

Under HIPAA, a nurse must not release any Protected Health Information (PHI)—including confirming or denying a client's admission status—to unauthorized individuals, regardless of their relationship to the client.
Question 2637Question →

A practical nurse (PN) is caring for a client who is 12 hours postoperative following a transsphenoidal hypophysectomy. The client reports a mild headache and increased thirst. The PN notes that the client has produced 900 mL of pale urine over the past 2 hours. Current vital signs are blood pressure 102/64 mmHg, heart rate 114 beats/min, and respiratory rate 18 breaths/min. Which of the following actions should the PN take FIRST?

Show answer & explanation

Answer: Immediately report the urine output and vital signs to the registered nurse.

Answer

The correct action is to immediately report the urine output and vital signs to the registered nurse.
The client is exhibiting classic signs of acute Diabetes Insipidus (DI), a common complication following pituitary surgery. The massive loss of dilute urine (900 mL in 2 hours) has led to a fluid volume deficit, evidenced by early signs of hypovolemic shock (heart rate of 114 beats/min and blood pressure of 102/64 mmHg). Immediate escalation to the registered nurse is the priority so that rapid intravenous fluid replacement and synthetic antidiuretic hormone (ADH) can be initiated.

Step-by-Step Solution

1
Analyze the client's surgical history.
The client had a transsphenoidal hypophysectomy.
This surgery involves the pituitary gland, placing the client at extremely high risk for developing Diabetes Insipidus (DI) due to a sudden decrease in antidiuretic hormone (ADH) production.
2
Evaluate the current clinical findings.
The client has massive polyuria (900 mL in 2 hours), tachycardia (114 beats/min), and a borderline low blood pressure (102/64 mmHg).
These findings collectively indicate acute fluid volume depletion and the early stages of hypovolemic shock.
3
Determine the priority nursing action.
The practical nurse must escalate the findings immediately to the registered nurse.
The client requires urgent medical intervention (intravenous fluid resuscitation and synthetic ADH) to prevent severe cardiovascular collapse. Independent actions will delay life-saving care.

Key Concept

Recognizing early signs of hypovolemic shock secondary to postoperative Diabetes Insipidus
Question 2638Question →

A practical nurse working in a rehabilitation facility is reviewing the morning laboratory results for a resident who takes daily oral warfarin for atrial fibrillation. The resident's International Normalized Ratio (INR) is reported as 5.5. Which action is the most appropriate for the nurse to take?

Show answer & explanation

Answer: Withhold any scheduled warfarin doses and notify the supervising registered nurse immediately.

Answer

Withhold any scheduled warfarin doses and notify the supervising registered nurse immediately.
The therapeutic INR range for a client on warfarin therapy is generally 2.0 to 3.0. An INR of 5.5 is critically elevated and places the client at an immediate high risk for spontaneous bleeding. The nurse must withhold the medication to prevent further elevating the INR and notify the supervising nurse or healthcare provider immediately so that potential dosage adjustments or reversal orders can be managed.

Step-by-Step Solution

1
Analyze the provided laboratory value (INR of 5.5).
Recognize that the value is significantly above the standard therapeutic range for warfarin (typically 2.0 to 3.0).
Identifying abnormal laboratory data is essential for determining medication safety.
2
Identify the primary risk associated with the abnormal finding.
Determine that a supratherapeutic INR places the client at a high risk for spontaneous and severe hemorrhage.
Understanding the clinical implication of the lab value guides prioritization.
3
Select the safest nursing intervention within the practical nurse scope of practice.
Decide to withhold the medication and escalate the critical finding to the RN or healthcare provider.
Preventing harm by stopping the causative agent and communicating with the care team is the priority for risk reduction.

Key Concept

Critical Laboratory Escalation and Risk Mitigation
Question 2639Question →

A licensed practical nurse (LPN) is assisting a healthcare provider with a bedside thoracentesis for a client who has a pleural effusion. In what order should the LPN perform the following actions to reduce the client's risk of potential complications? (Arrange the steps from first to last.)

Drag items to arrange them in the correct order

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Answer

The correct sequence is: Verify identity and consent, position the client upright over a table, instruct the client to remain still, apply a sterile dressing, and finally auscultate breath sounds.
To reduce the risk of complications during a thoracentesis, the practical nurse must follow a logical sequence from pre-procedure preparation to post-procedure monitoring. First, safety protocols require verifying identity and informed consent. Next, optimal positioning is required to safely access the pleural space. Once positioned, instructing the client to remain still prevents accidental lung puncture during the procedure. Immediately after the procedure, a sterile dressing prevents air entry and infection. Finally, the nurse monitors respiratory status to detect complications such as a pneumothorax.

Step-by-Step Solution

1
Verify identity and informed consent.
The correct client is identified and legal permission is confirmed.
This is the primary safety check and must always precede any invasive procedure.
2
Position the client upright and leaning over an overbed table.
The client is in the optimal anatomical position.
This specific position expands the intercostal spaces, allowing safe access to the pleural fluid and reducing the risk of puncturing the lung.
3
Instruct the client to remain still and avoid coughing.
The client understands the critical need for immobility.
Sudden movements or coughing during needle insertion can cause a traumatic pneumothorax or liver/spleen puncture.
4
Apply a sterile dressing to the puncture site.
The puncture site is sealed immediately after needle removal.
This prompt action prevents ambient air from entering the pleural cavity (which could cause a pneumothorax) and reduces infection risk.
5
Auscultate breath sounds and monitor respiratory rate.
The client's post-procedure respiratory status is evaluated.
Continuous monitoring is necessary to detect early clinical signs of a pneumothorax, respiratory distress, or hypoxemia.

Key Concept

Prioritizing nursing actions before, during, and after an invasive procedure to minimize the risk of complications such as organ puncture or pneumothorax.
Question 2640Question →

A practical nurse (PN) is reviewing the shift assignment provided by the registered nurse (RN) on a medical-oncology unit. Which assigned client care activity should the PN decline and request be reassigned to the RN?

Show answer & explanation

Answer: Administering the initial dose of an intravenous (IV) push antiemetic to a client experiencing acute nausea.

Answer

The PN should decline administering the initial dose of an intravenous (IV) push antiemetic to a client experiencing acute nausea.
The correct answer identifies a task (administering IV push medication for an acute symptom) that requires the advanced assessment skills and clinical judgment of a registered nurse (RN). The PN has a legal and ethical obligation to refuse assignments that fall outside their defined scope of practice to maintain client safety.

Step-by-Step Solution

1
Analyze the PN scope of practice regarding medication administration and client acuity.
IV push medications and initial assessments of unstable clients (such as those with acute nausea) fall outside the standard PN scope.
These interventions require the advanced pharmacological knowledge and comprehensive assessment skills of an RN.
2
Evaluate the remaining options against the PN scope of practice.
Witnessing consents, reinforcing education, and routine data collection (emptying drains) are all within the PN scope.
These tasks involve stable clients, predictable outcomes, and do not require initial comprehensive assessment or care planning.

Key Concept

The practical nurse (PN) must recognize the boundaries of their legal scope of practice, which typically excludes administering IV push medications and performing initial assessments on unstable clients.
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