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Question 2641Question →

An older adult client with a history of mild dementia is receiving care for severe dehydration secondary to gastroenteritis. The client is usually cooperative but suddenly becomes extremely restless and begins pulling at their intravenous tubing. The practical nurse (PN) obtains a heart rate of 114 beats/min and a blood pressure of 94/56 mm Hg. What is the priority action for the PN?

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Answer: Immediately report the altered mental status and vital sign changes to the registered nurse (RN).

Answer

The priority action is to immediately report the altered mental status and vital sign changes to the registered nurse (RN).
The client is demonstrating classic signs of early hypovolemic shock caused by dehydration: tachycardia, hypotension, and altered mental status (restlessness due to decreased cerebral perfusion). Recognizing these subtle but critical changes and immediately notifying the RN is the priority action within the PN scope of practice to facilitate life-saving interventions, such as an intravenous fluid bolus.

Step-by-Step Solution

1
Analyze the client's clinical presentation and recent history.
The client has a history of severe fluid loss (gastroenteritis) and is now showing acute restlessness, tachycardia (114 beats/min), and hypotension (94/56 mm Hg).
Understanding the complete clinical picture is the first step in recognizing physiological deterioration.
2
Differentiate between the client's baseline cognitive status and acute changes.
The acute restlessness and pulling at tubes represent a significant change from their baseline 'mild dementia' and cooperative nature.
Sudden mental status changes (delirium) often indicate an underlying physiological problem, such as poor cerebral perfusion or hypoxia.
3
Prioritize nursing actions based on the severity of the findings and the PN scope of practice.
The findings indicate impending hypovolemic shock, requiring immediate escalation of care to the RN for rapid medical intervention.
Under the PN scope of practice, acute hemodynamic instability is a life-threatening priority that must be immediately reported.

Key Concept

Early recognition of hypovolemic shock and acute delirium in older adults.
Estimated Time:1m 30s
Question 2642Question →

An adult client is transferred to the medical-surgical unit 4 hours after a subtotal thyroidectomy. The client reports mild neck discomfort and difficulty swallowing. To promote comfort, minimize tissue swelling, and reduce tension on the surgical site, which position is most appropriate for the nurse to assist the client into?

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Answer: Semi-Fowler's position with pillows supporting the head and neck in neutral alignment

Answer

Semi-Fowler's position with pillows supporting the head and neck in neutral alignment
Following a thyroidectomy, placing the client in a Semi-Fowler's position (head of the bed elevated 30 to 45 degrees) with the head and neck supported by pillows in a neutral position is the standard of care. The elevation minimizes tissue edema and swelling that could compromise the airway, while the neutral alignment prevents stretching or tension on the surgical incision, thereby reducing pain and the risk of wound separation.

Step-by-Step Solution

1
Analyze the client's postoperative status and the anatomical location of the surgery (subtotal thyroidectomy).
Recognize that the surgical site is in the anterior neck, making the airway highly vulnerable to compression from swelling.
Identifying the specific risks of the procedure (edema, airway compromise, and bleeding) is essential before selecting a comfort intervention.
2
Determine the optimal degree of bed elevation.
Select a Semi-Fowler's position (head of bed elevated 30 to 45 degrees).
Elevating the upper body uses gravity to promote venous return, which decreases tissue swelling and edema around the airway and incision.
3
Determine the optimal alignment for the cervical spine.
Ensure the head and neck are supported in a neutral alignment using pillows.
Maintaining a neutral position prevents neck flexion or hyperextension, both of which place dangerous tension on the fresh suture line and cause discomfort.

Key Concept

Postoperative Positioning for Neck Surgery
Estimated Time:1m 0s
Question 2643Question →

A practical nurse (PN) realizes they have just administered the wrong oral medication to a client. Arrange the following actions in the correct priority order the PN should perform them to ensure client safety.

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Answer

The correct sequence is: Assess the client, notify the provider, implement new orders, document in the chart, and complete the incident report.
In the event of a medication error, the nursing process dictates that assessment is always the first action to ensure client safety. Following assessment, the nurse must communicate the findings to the provider to receive further orders. Once the client is stabilized through new interventions, the nurse completes the legal documentation in the health record. The final step is the administrative task of filing an incident report.

Step-by-Step Solution

1
Assess the client's vital signs and physiological status.
The PN determines the client's baseline condition immediately following the error.
Client safety is the paramount concern. Assessment must always precede communication.
2
Notify the healthcare provider and the charge nurse.
The provider is made aware of the error and the client's current status.
The provider needs this information to determine if any counteractive measures are necessary.
3
Implement any new prescriptions or interventions ordered by the healthcare provider.
The client receives necessary monitoring or treatments.
Prompt execution of medical orders minimizes the potential harm from the medication error.
4
Document the medication administered and the client's response in the health record.
An accurate, legal record of the event is established in the client's chart.
Factual documentation of care provided is a legal nursing responsibility.
5
Complete an institutional incident or variance report.
The facility receives data for quality improvement and risk management.
Incident reports help facilities identify systemic issues, but they do not go in the client's chart and are the lowest clinical priority.

Key Concept

Prioritization of Care Post-Medication Error
Question 2644Question →

A practical nurse is caring for a client who underwent a bowel resection 1212 hours ago. The client appears increasingly restless, reports an abdominal pain level of 88 on a 00 to 1010 scale, and requests a prescribed PRN dose of oral hydrocodone-acetaminophen. A routine dose of oral carvedilol is also due at this time. Current vital signs are blood pressure 86/5286/52 mmHg, apical heart rate 118118 beats/min, and respiratory rate 2222 breaths/min. Which of the following actions should the practical nurse take first?

Show answer & explanation

Answer: Withhold both medications and immediately notify the registered nurse.

Answer

The practical nurse should withhold both the hydrocodone-acetaminophen and the carvedilol, and immediately notify the registered nurse.
The client's presentation of low blood pressure, high heart rate, and restlessness 1212 hours post-surgery indicates potential hemorrhage or hypovolemic shock. Carvedilol (a beta-blocker) lowers blood pressure and heart rate, which would blunt the body's compensatory mechanisms. Hydrocodone-acetaminophen (an opioid analgesic) causes vasodilation, which would further decrease blood pressure. The safest and most appropriate action within the practical nurse scope of practice is to withhold both medications and immediately alert the registered nurse so that rapid interventions (such as fluid resuscitation or blood products) can be initiated.

Step-by-Step Solution

1
Analyze the client's vital signs and clinical presentation.
The client has hypotension (86/5286/52 mmHg), tachycardia (118118 beats/min), and restlessness, which are classic signs of hypovolemia or early shock following abdominal surgery.
Identifying physiological instability is the first essential step before administering any pharmacological therapies.
2
Evaluate the pharmacological effects of the prescribed medications on the client's current state.
Carvedilol decreases blood pressure and heart rate. Hydrocodone causes vasodilation and can further decrease blood pressure.
Medications must be held if their therapeutic or adverse effects will worsen the client's compromised circulatory status.
3
Determine the appropriate action within the practical nurse scope of practice.
The nurse must withhold the contraindicated medications and escalate the situation to the registered nurse.
Practical nurses must immediately report acute, life-threatening changes in a client's condition to the RN or provider for advanced assessment and orders.

Key Concept

Pre-administration Assessment and Safe Medication Administration in Unstable Clients
Question 2645Question →

A practical nurse (PN) in an outpatient oncology clinic encounters different situations involving the release or discussion of client information. Match each clinical scenario (left) with the appropriate nursing action or regulatory determination (right) to maintain confidentiality.

Click a left item, then click its matching right item

Items

An unidentified telephone caller asks for an update on a client who is listed in the facility's 'do not announce' or 'opt-out' directory.
A client's spouse approaches the nursing station and asks to read the client's electronic health record (EHR) while the client is receiving treatment.
Two assistive personnel are overheard discussing a client's specific medical diagnosis and treatment plan while riding in a crowded facility elevator.
An official from the local public health department requests data regarding a client recently diagnosed with active tuberculosis.

Matches

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Answer

Caller asking about opt-out client matches with informing them the facility cannot confirm or deny presence. Spouse asking for EHR matches with explaining the need for client permission. Elevator discussion matches with interrupting the conversation. Public health request matches with disclosing the information under mandatory exemptions.
Each clinical scenario requires applying specific HIPAA guidelines: protecting opt-out clients by denying their presence, requiring consent for family EHR access, stopping public clinical discussions, and complying with public health reporting mandates.

Step-by-Step Solution

1
Evaluate the caller requesting information on an opt-out client.
Match with informing the caller that the facility cannot confirm or deny presence.
Clients have the right to be unlisted, requiring staff to withhold any acknowledgment of their admission or presence.
2
Evaluate the spouse requesting to read the EHR.
Match with explaining that the client must provide explicit permission.
Spouses do not have implicit rights to access medical records without the competent client's explicit consent.
3
Evaluate the situation of staff discussing a client in the elevator.
Match with interrupting the conversation immediately.
Public areas are inappropriate for clinical discussions, and the PN must actively intervene to stop a confidentiality breach.
4
Evaluate the public health department requesting information on a tuberculosis case.
Match with disclosing the information.
Mandatory reporting of specific communicable diseases to public health entities is a legal exception to HIPAA privacy rules.

Key Concept

HIPAA privacy rules require explicit client consent for releasing health information, prohibit discussing client data in public spaces, and have specific exceptions for mandatory public health reporting.
Estimated Time:1m 30s
Question 2646Question →

A client with active pulmonary tuberculosis and a draining methicillin-resistant Staphylococcus aureus (MRSA) wound on the right calf requires transport to the radiology department for an urgent diagnostic scan. Which set of actions should the practical nurse (PN) implement to maintain appropriate infection control during this transport?

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Answer: Apply a standard surgical mask to the client, ensure the MRSA wound is covered with a clean dressing, and notify the radiology department of the isolation precautions.

Answer

The practical nurse should apply a standard surgical mask to the client, ensure the MRSA wound is securely covered with a clean dressing, and notify the receiving department of the required precautions.
During the transport of a client on combined airborne and contact precautions, the primary infection control strategy is source control. Applying a standard surgical mask to the client effectively traps exhaled mycobacteria, preventing airborne environmental contamination. Covering the draining MRSA wound with a clean, dry dressing prevents the shedding of infectious bacteria onto transport equipment or hospital surfaces. Finally, notifying the receiving department in advance is a mandatory safety standard so they can prepare appropriate personal protective equipment and arrange for immediate environmental decontamination following the procedure.

Step-by-Step Solution

1
Identify the transmission-based precautions required for the client's current diagnoses.
The client requires Airborne Precautions for active pulmonary tuberculosis and Contact Precautions for the draining MRSA wound.
Accurate identification of isolation requirements dictates the necessary source control measures during transport.
2
Determine the appropriate source control interventions required before the client leaves the negative-pressure room.
The client must wear a standard surgical mask to contain respiratory droplets, and the draining wound must be covered with a clean, dry dressing to contain the MRSA.
During transport, the primary goal is source control—containing the pathogens at the source to prevent environmental contamination and exposure to others.
3
Establish communication with the receiving department.
The radiology department is notified of the client's Airborne and Contact precaution status prior to transport.
Advance notification allows the receiving department to prepare appropriate PPE, clear the waiting area if necessary, and arrange for immediate post-procedure environmental cleaning.

Key Concept

Infection Control during Client Transport
Estimated Time:1m 30s
Question 2647Question →

While performing midnight rounds, the nurse finds a client who was previously calm now highly agitated. The client is persistently pulling at their intravenous (IV) catheter and attempting to climb out of bed. Which intervention should the nurse implement first to maintain client safety?

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Answer: Apply a long-sleeved gown to conceal the intravenous site and offer the client a soft washcloth to fold.

Answer

The nurse should implement least restrictive alternatives first, such as concealing the intravenous line with a long-sleeved gown and providing a diversionary activity like folding a washcloth.
The correct action prioritizes client safety while strictly adhering to the principle of using the least restrictive environment. By hiding the IV line with clothing and providing a tactile distraction, the nurse addresses the unsafe behavior safely and effectively without resorting to restraints.

Step-by-Step Solution

1
Assess the immediate risk to the client's safety and medical devices.
The client is identified as being at high risk for falls and accidental removal of their intravenous catheter due to sudden agitation.
Identifying specific safety hazards dictates the urgency and type of interventions needed.
2
Determine the least restrictive intervention that can mitigate the identified risks.
Concealment of the medical device and diversionary strategies are selected as the initial approach.
Nursing standards and client rights require that all less restrictive alternatives be exhausted before considering physical or chemical restraints.
3
Implement the non-pharmacological interventions.
The nurse covers the intravenous site with a long-sleeved gown and provides a safe, familiar object for the client to manipulate.
Out of sight often means out of mind for confused clients, and keeping their hands busy with a safe task prevents picking at medical lines.

Key Concept

Restraint Alternatives and Hazard Mitigation
Question 2648Question →

A practical nurse (PN) is reviewing morning laboratory results for a client receiving a continuous intravenous heparin infusion. The client also began oral warfarin therapy 4848 hours ago. The client's baseline platelet count on admission was 250,000/mm3250,000/\text{mm}^3. The current laboratory results are as follows:

Laboratory TestCurrent ResultReference/Control
International Normalized Ratio (INR)1.41.42.02.0 - 3.03.0 (Target)
Activated partial thromboplastin time (aPTT)6868 seconds3030 seconds (Control)
Platelet count82,000/mm382,000/\text{mm}^3150,000150,000 - 400,000/mm3400,000/\text{mm}^3

The PN is preparing to administer the scheduled morning dose of oral warfarin. Based on these findings, which of the following is the priority action by the PN?

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Answer: Withhold the scheduled warfarin and immediately notify the registered nurse (RN) of the platelet count.

Answer

Withhold the scheduled warfarin and immediately notify the registered nurse (RN) of the platelet count.
The correct action is to withhold the warfarin and notify the RN immediately. The significant drop in platelets (greater than 50%50\% from baseline) indicates a high probability of Heparin-Induced Thrombocytopenia (HIT), a paradoxical, life-threatening clotting disorder caused by heparin exposure. In acute HIT, administering oral warfarin is strictly contraindicated because it rapidly depletes Protein C, drastically increasing the risk of microvascular thrombosis and venous limb gangrene. The practical nurse must prioritize client safety by withholding the medication and escalating this critical laboratory finding so the healthcare team can halt the heparin infusion and initiate a non-heparin anticoagulant.

Step-by-Step Solution

1
Analyze the INR result.
An INR of 1.41.4 is expected after 4848 hours of warfarin therapy, as it typically takes 33 to 55 days to reach the therapeutic range of 2.02.0 to 3.03.0.
Understanding the expected timeline for oral anticoagulants prevents inappropriate dosage adjustments.
2
Analyze the aPTT result.
An aPTT of 6868 seconds is within the normal therapeutic range for a continuous heparin infusion (typically 1.51.5 to 2.52.5 times the control value).
Verifying that the heparin infusion is therapeutic rules out overt toxicity as the primary issue.
3
Analyze the platelet count trend.
The platelet count has dropped from 250,000/mm3250,000/\text{mm}^3 to 82,000/mm382,000/\text{mm}^3, representing a decrease of more than 50%50\%.
A severe drop in platelets during heparin therapy is the hallmark sign of Heparin-Induced Thrombocytopenia (HIT).
4
Determine the safest clinical action based on the LPN scope of practice.
The PN must withhold the warfarin and immediately escalate the critical findings to the RN.
HIT is a life-threatening complication. Warfarin is contraindicated in acute HIT due to the high risk of venous limb gangrene, and the heparin infusion must be halted by the RN.

Key Concept

Heparin-Induced Thrombocytopenia (HIT) and Anticoagulant Safety

Alternative Method

While calculating the exact percentage drop in platelets is helpful, simply recognizing that the platelet count has plummeted from a normal baseline to well below the normal range during heparin therapy is sufficient to flag the finding as a critical adverse reaction requiring immediate escalation.
Estimated Time:2m 0s
Question 2649Question →

A practical nurse is preparing to administer a mixed dose of short-acting (Regular) and intermediate-acting (NPH) insulin to a client with type 2 diabetes mellitus. Place the following steps for drawing up the insulins in the correct chronological order.

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Answer

The correct sequence is to roll the intermediate-acting insulin, inject air into the intermediate-acting insulin, inject air into the short-acting insulin, withdraw the short-acting insulin, and finally withdraw the intermediate-acting insulin.
When mixing insulins, the standard safety protocol is 'clear before cloudy' (short-acting before intermediate-acting). This prevents the intermediate-acting insulin from contaminating the short-acting vial. The sequence ensures proper mixing of the suspension (rolling), equalization of pressure in both vials (injecting air into cloudy, then clear), and safe withdrawal (drawing clear, then cloudy).

Step-by-Step Solution

1
Roll the vial of intermediate-acting insulin between the palms of the hands.
The suspension is mixed evenly.
NPH insulin is a suspension that settles. Rolling mixes it without creating bubbles that could lead to inaccurate dosing.
2
Inject a volume of air equal to the prescribed dose into the intermediate-acting insulin vial.
Pressure is equalized in the NPH vial.
Injecting air prevents a vacuum, making it easier to withdraw the medication later. Doing this first prevents contamination of the needle with clear insulin.
3
Inject a volume of air equal to the prescribed dose into the short-acting insulin vial.
Pressure is equalized in the Regular insulin vial.
Injecting air prepares the vial for withdrawal. Since the needle is already in this vial, the nurse can immediately proceed to the next step.
4
Invert the vial and withdraw the prescribed dose of short-acting insulin.
The clear insulin is drawn into the syringe first.
Drawing clear (short-acting) insulin before cloudy (intermediate-acting) insulin prevents the longer-acting insulin from contaminating the short-acting insulin vial.
5
Insert the syringe into the intermediate-acting insulin vial and withdraw the prescribed dose.
The total mixed dose is now in the syringe.
The cloudy insulin is drawn last to complete the mixture safely.

Key Concept

Safe administration and preparation of mixed insulins (Clear before Cloudy)
Question 2650Question →

A client with a history of vascular dementia is hospitalized for severe dehydration and is receiving continuous intravenous (IV) fluids. During evening rounds, the practical nurse observes the client aggressively pulling at the IV tubing, stating, "I need to untie this rope." Which action should the nurse take first to prevent injury and protect the intravenous access?

Show answer & explanation

Answer: Conceal the intravenous insertion site and tubing by loosely applying a stockinette over the client's arm.

Answer

Conceal the intravenous insertion site and tubing by loosely applying a stockinette over the client's arm.
The standard of care mandates utilizing the least restrictive intervention first. For clients with dementia, 'out of sight, out of mind' is a highly effective strategy. Concealing the intravenous site with a long sleeve or stockinette removes the visual trigger and protects the line without restricting the client's mobility, preserving their dignity and avoiding the severe physical and psychological hazards associated with physical restraints.

Step-by-Step Solution

1
Identify the immediate safety risk.
The client is actively pulling at a necessary medical device, creating a high risk for hemorrhage, infection, or loss of intravenous access.
Recognizing the immediate threat to client safety dictates the urgency of the intervention.
2
Evaluate the client's cognitive status and behavioral triggers.
The client has dementia and is misinterpreting the medical tubing as a rope, demonstrating a lack of capacity to understand the treatment's necessity.
Understanding the cause of the behavior helps select an intervention that addresses the symptom (visual trigger) without escalating agitation.
3
Apply the hierarchy of least restrictive interventions.
Visual concealment is selected as the priority action over physical restraints or holds.
The standard of care mandates that the least restrictive, non-invasive measures must be attempted and proven ineffective before considering physical restraints.

Key Concept

Restraint Alternatives and Injury Prevention
Question 2651Question →

A client is 6 hours postoperative following a partial colectomy. The client's indwelling urinary catheter has drained 20 mL over the past hour. Current vital signs reveal a heart rate of 112 beats/minute and a blood pressure of 102/64 mm Hg. A recently resulted hemoglobin level is 7.6 g/dL (76 g/L). The client also reports incisional pain rated 6 on a 0-to-10 scale. Which action is the priority for the practical nurse?

Show answer & explanation

Answer: Notify the registered nurse immediately regarding the combination of clinical and laboratory findings.

Answer

The priority action is to immediately notify the registered nurse about the combination of oliguria, tachycardia, hypotension, and critically low hemoglobin.
The client is exhibiting classic signs of hypovolemic shock due to postoperative hemorrhage, indicated by tachycardia, borderline hypotension, oliguria (less than 30 mL/hr), and a critically low hemoglobin level. The practical nurse must immediately escalate these findings to the registered nurse so that rapid medical interventions, such as intravenous fluid resuscitation or a blood transfusion, can be initiated.

Step-by-Step Solution

1
Analyze the client's vital signs and urine output.
The heart rate is elevated (112 beats/minute), blood pressure is borderline low (102/64 mm Hg), and urine output is critically low (20 mL/hr).
To identify early signs of impaired systemic perfusion.
2
Evaluate the laboratory results.
The hemoglobin is critically low at 7.6 g/dL (76 g/L).
To correlate the vital signs with a potential underlying cause, such as acute hemorrhage.
3
Synthesize the findings and determine the clinical priority.
The combination of findings strongly indicates hypovolemic shock, which is a life-threatening emergency that supersedes the client's pain.
To establish whether the situation requires immediate escalation over routine interventions.
4
Select the appropriate nursing action based on scope of practice.
Notify the registered nurse immediately.
Because the client is unstable and requires complex interventions (like fluid resuscitation or blood products) that are beyond the practical nurse's independent scope of practice.

Key Concept

Recognizing and Escalating Early Signs of Postoperative Hypovolemic Shock
Question 2652Question →

While assisting a client with a history of seizure disorders during their morning meal, the individual suddenly loses consciousness and begins exhibiting rhythmic, jerking muscle movements while seated in their chair. Arrange the following nursing interventions in the correct order of priority.

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Answer

The correct sequence is: Guide the client safely to the floor, place a pad beneath their head, turn them onto their side, loosen restrictive clothing, and finally note the time of onset and characteristics of the seizure.
In any acute medical emergency, nursing priorities dictate that immediate physical safety and airway protection come first. For a seizing client seated in a chair, the most imminent threat is a fall, requiring the nurse to first lower them to the floor. Once on the floor, the head is vulnerable to trauma from clonic jerking and must be padded. With gross physical safety secured, the priority shifts to airway management by rolling the client onto their side to prevent aspiration, followed by loosening restrictive clothing to optimize breathing. Only after these life-safety measures are established should the nurse focus on observing and timing the seizure.

Step-by-Step Solution

1
Ensure immediate physical safety from falls.
The client is guided from the chair to the floor.
The client has lost consciousness and is at severe risk for a traumatic fall from the chair.
2
Protect the head from traumatic injury.
A soft pad or blanket is placed beneath the head.
Tonic-clonic movements on a hard floor can cause severe head trauma if the head is not adequately cushioned.
3
Protect the airway from aspiration.
The client is turned onto their side.
The lateral position allows saliva and emesis to drain from the mouth, maintaining a patent airway during the event.
4
Remove mechanical restrictions to breathing.
Restrictive clothing around the neck and chest is loosened.
Tight clothing can impede respiratory effort and venous return during the intense physiological stress of a seizure.
5
Monitor and record the event details.
The time of onset and seizure characteristics are noted.
Accurate timing and observation are necessary for post-seizure medical management, but this must follow immediate safety interventions.

Key Concept

Acute Seizure Management and Safety Prioritization
Question 2653Question →

A practical nurse is preparing to measure the gastric residual volume for a client who is receiving continuous enteral tube feedings. In what order should the nurse perform the following actions to reduce the risk of aspiration and other clinical complications? Arrange the steps in the correct sequence from first to last.

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Answer

The correct sequence for checking gastric residual volume is: elevate the head of the bed, perform hand hygiene and don gloves, attach the syringe, aspirate and measure the contents, and finally reinstill the contents.
Evaluating gastric residual volume is a critical risk reduction intervention to prevent aspiration in clients receiving enteral feedings. The correct, safe sequence prioritizes airway protection first (elevating the head of the bed), followed by infection control (hand hygiene and gloves). Once safety parameters are set, the nurse attaches the syringe, withdraws the fluid to measure it, and finally reinstills the fluid to prevent dangerous electrolyte and fluid shifts.

Step-by-Step Solution

1
Elevate the head of the client's bed to at least 30 degrees.
The client is placed in a semi-Fowler's or higher position.
This utilizes gravity to keep gastric contents in the stomach, directly reducing the risk of aspiration when the tube is accessed.
2
Perform hand hygiene and put on clean gloves.
The nurse's hands are sanitized and protected.
Standard infection control practices must be established before touching the client's lines or equipment.
3
Attach a large-volume syringe to the port of the feeding tube.
The syringe is secured to the enteral access point.
A closed system must be created with the syringe to safely draw out the fluid without leakage.
4
Pull back on the syringe plunger gently to withdraw and measure the fluid.
Gastric contents are pulled into the syringe barrel and quantified.
Measuring the volume identifies whether the client is digesting the feeding properly or is at risk for regurgitation due to delayed emptying.
5
Reinstill the aspirated gastric contents back into the client's stomach.
The fluid is safely returned to the gastrointestinal tract.
Gastric aspirate contains essential electrolytes and digestive enzymes; discarding it can rapidly lead to metabolic alkalosis and fluid deficits.

Key Concept

Enteral Tube Feeding Safety and Complication Prevention
Estimated Time:1m 0s
Question 2654Question →

An adult client is recovering on the surgical unit 3 hours after a septoplasty and turbinate reduction. During a routine assessment, the practical nurse observes that the client is swallowing frequently. The client's heart rate has increased to 118 beats per minute from a preoperative baseline of 76 beats per minute, and the blood pressure is 102/64 mmHg. Which action should the practical nurse take first?

Show answer & explanation

Answer: Immediately notify the registered nurse (RN) regarding the signs of potential bleeding.

Answer

Immediately notify the registered nurse (RN) regarding the signs of potential bleeding.
The client's frequent swallowing, combined with an increasing heart rate and a decreasing blood pressure, strongly indicates active postoperative bleeding (hemorrhage) following nasal surgery. The priority action for the practical nurse is to immediately notify the registered nurse or healthcare provider so that the client can be assessed for airway compromise and shock, and emergency interventions can be initiated.

Step-by-Step Solution

1
Analyze the client's postoperative clinical presentation.
The client exhibits frequent swallowing, new-onset tachycardia, and borderline hypotension.
Identifying abnormal assessment findings is the first step in recognizing postoperative complications.
2
Correlate the findings with the specific surgical procedure.
After nasal surgery (septoplasty), frequent swallowing indicates blood draining down the back of the throat, while the vital signs suggest early hypovolemic shock.
Connecting symptoms to the procedure context reveals an active hemorrhage.
3
Determine the priority nursing action based on the LPN scope of practice.
The situation requires immediate escalation to the RN or healthcare provider for emergency intervention.
Active hemorrhage and early shock are life-threatening complications that exceed the scope of independent LPN management.

Key Concept

Early Recognition of Postoperative Hemorrhage
Question 2655Question →

Before entering the isolation room of a client diagnosed with measles (rubeola) who also has a heavily draining leg wound, a nurse must apply full personal protective equipment (PPE) due to the combination of precautions required. Place the following steps for preparing and donning the required PPE in the correct sequential order.

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Answer

The correct sequence for donning full personal protective equipment is to first perform hand hygiene, then don the isolation gown, followed by the N95 respirator, then the face shield or goggles, and finally the clean gloves.
According to standard infection control guidelines provided by the Centers for Disease Control and Prevention (CDC), the sequence for donning full personal protective equipment is strict to minimize contamination risk. The nurse must begin with hand hygiene to ensure clean hands. The gown is put on first to cover the torso and arms. Next, the mask or N95 respirator is applied to protect the respiratory tract and establish a face seal, followed by goggles or a face shield for eye protection. Finally, gloves are donned last and pulled directly over the gown cuffs to establish a continuous, unbroken barrier against infectious agents.

Step-by-Step Solution

1
Perform hand hygiene using an alcohol-based hand sanitizer or soap and water.
Hands are clean and ready to handle uncontaminated PPE.
Hand hygiene is the foundational step to prevent the transfer of pathogens to the clean equipment being donned.
2
Fasten the isolation gown securely at the neck and waist.
The torso, arms, and uniform are covered and protected.
The gown is the first article of PPE donned to provide the largest surface area of protection before applying facial gear.
3
Apply an N95 respirator and perform a user seal check.
The respiratory tract is protected with a secure seal against airborne pathogens.
The respirator is applied prior to eye protection to ensure a tight, unimpeded seal against the face.
4
Position the face shield or goggles over the eyes.
The mucous membranes of the eyes are protected from exudate or respiratory secretions.
Eye protection is placed over the respirator straps to guard against potential splashes or sprays of infectious material.
5
Don clean gloves, extending them over the cuffs of the gown.
A continuous protective barrier is created over the hands and wrists.
Gloves must be donned last so they can cover and overlap the gown cuffs, preventing any exposure of the wrists during client care.

Key Concept

Standard donning sequence for personal protective equipment (PPE)
Question 2656Question →

A licensed practical nurse (LPN) is providing care for a 52-year-old client admitted with an acute upper gastrointestinal hemorrhage. The client is receiving continuous intravenous (IV) fluids and is on bed rest. Which of the following actions by the LPN are essential to minimize the client's risk of further complications? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Notify the registered nurse promptly if the client's resting heart rate steadily increases from 82 to 110 beats per minute.; Verify the client's identity using two distinct identifiers prior to administering any prescribed oral medications.; Assist the client into a side-lying position immediately if they begin to experience active hematemesis.

Answer

The essential actions are to notify the registered nurse of the increasing heart rate, verify the client's identity with two identifiers before medication administration, and place the client in a side-lying position during active hematemesis.
In a client with an acute gastrointestinal hemorrhage, the primary risks are hypovolemic shock and airway compromise. An increasing heart rate is an early compensatory sign of hypovolemia that must be escalated immediately. Verifying patient identity with two identifiers is a fundamental standard to prevent medication errors. Positioning a client in a side-lying position during active vomiting (hematemesis) uses gravity to drain emesis and prevents aspiration, thus protecting the airway.

Step-by-Step Solution

1
Analyze the clinical scenario to identify the primary physiological risks for a client with an acute gastrointestinal hemorrhage.
The client is at high risk for hypovolemic shock due to blood loss and at risk for aspiration due to potential hematemesis.
Identifying the core physiological risks directs the prioritization of care and necessary risk reduction strategies.
2
Evaluate the assessment findings (heart rate and blood pressure) for early signs of hypovolemic shock.
An increasing heart rate (82 to 110 bpm) and a decreasing blood pressure (128/80 to 104/68 mm Hg) are compensatory mechanisms for blood loss and indicate impending shock.
Early recognition of subtle vital sign changes allows for prompt escalation and intervention before the client severely decompensates.
3
Assess the procedural and scope-of-practice actions for safety and legal compliance.
Verifying identity with two identifiers is a mandatory safety step. Administering IV push medications is outside the LPN scope of practice. Critical labs (hemoglobin 6.9 g/dL) require direct verbal reporting.
Adhering strictly to safety standards and the LPN scope of practice reduces the risk of iatrogenic injury and ensures appropriate care delivery.
4
Determine the correct physical positioning for a client experiencing active hematemesis.
The side-lying position is selected to allow emesis to drain from the mouth.
This position uses gravity to protect the airway and prevent aspiration of blood into the lungs.

Key Concept

Reduction of Risk Potential: Early Shock Recognition and Scope of Practice
Estimated Time:1m 30s
Question 2657Question →

A licensed practical nurse (LPN) is preparing to collect an aerobic wound culture from a client's purulent abdominal surgical incision. In what order should the LPN perform the following steps to ensure an accurate specimen? Arrange the actions in the correct chronological sequence.

Drag items to arrange them in the correct order

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Answer

The correct sequence is to remove the soiled dressing, cleanse the wound with sterile normal saline, rotate the swab over clean granulation tissue, place the swab into the culture tube, and apply a new sterile dressing.
To collect an accurate wound culture that directs appropriate antibiotic therapy, the nurse must first remove the old dressing. Crucially, the wound must then be cleansed with sterile normal saline. Culturing uncleansed purulent drainage often yields resident skin flora or dead organisms, leading to inaccurate results. After cleansing, a sterile swab is rotated over clean, viable granulation tissue. The swab is then immediately placed into the sterile transport tube to prevent contamination, and finally, a new sterile dressing is applied to protect the wound.

Step-by-Step Solution

1
Remove the soiled dressing and assess the appearance of the wound bed.
The wound is exposed and ready for evaluation.
The old dressing must be removed to access the site and determine where the culture should be taken.
2
Cleanse the wound bed with sterile normal saline.
Surface exudate, pus, and resident skin flora are washed away.
Culturing uncleansed surface pus yields inaccurate results; the goal is to identify the pathogen actively invading the tissue, not surface colonizers.
3
Rotate a sterile culture swab over an area of clean granulation tissue.
The pathogen causing the deep infection is collected.
Actively growing pathogens are concentrated in viable granulation tissue, providing the most accurate diagnostic specimen.
4
Place the swab securely into the sterile culture tube.
The specimen is secured in its transport medium.
Immediate placement prevents environmental contamination of the swab and protects the nurse from exposure.
5
Apply a new sterile dressing over the abdominal incision.
The wound is protected from the external environment.
Restoring the protective barrier is the final step after the procedure is complete.

Key Concept

Accurate wound culture collection requires cleansing the wound with sterile saline prior to swabbing to avoid capturing surface colonizers or old exudate.
Question 2658Question →

While preparing medications for a pediatric client weighing 37.4 lb37.4\text{ lb}, a practical nurse notes a new prescription for ibuprofen 8 mg/kg/dose8\text{ mg/kg/dose} every 66 hours as needed for fever. The medication is available as an oral suspension of 100 mg/5 mL100\text{ mg}/5\text{ mL}. How many mL\text{mL} should the nurse administer for one dose? (Record answer to the nearest tenth. Do not include units in answer.)

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Answer: 6.8

Answer

6.8
Administering 6.8 mL6.8\text{ mL} provides exactly the prescribed 136 mg136\text{ mg} dose, which is correct and safe for a 17 kg17\text{ kg} pediatric client receiving 8 mg/kg8\text{ mg/kg}.

Step-by-Step Solution

1
Convert the client's weight from pounds to kilograms.
37.4 lb÷2.2 lb/kg=17 kg37.4\text{ lb} \div 2.2\text{ lb/kg} = 17\text{ kg}
The prescribed dosage is weight-based in kilograms, so the client's weight must be converted first.
2
Calculate the required medication dose in milligrams.
17 kg×8 mg/kg=136 mg17\text{ kg} \times 8\text{ mg/kg} = 136\text{ mg}
This determines the exact milligram amount of medication the client needs for one single dose.
3
Calculate the liquid volume to administer using the provided concentration.
(136 mg÷100 mg)×5 mL=6.8 mL(136\text{ mg} \div 100\text{ mg}) \times 5\text{ mL} = 6.8\text{ mL}
This converts the required milligram dose into a measurable liquid volume to be drawn up in a syringe.

Key Concept

Pediatric Weight-Based Dosage Calculation
Question 2659Question →

A practical nurse (PN) is caring for a client who is 1212 hours postoperative following an open abdominal procedure. The client is scheduled to receive their routine morning dose of oral lisinopril. The client states, "I feel unusually thirsty and a bit dizzy when I move." The PN obtains the following vital signs: heart rate 112112 beats/minute, blood pressure 96/5896/58 mm Hg, respiratory rate 2020 breaths/minute, and oxygen saturation 97%97\% on room air. Which action should the PN take regarding the scheduled medication?

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Answer: Withhold the scheduled dose of the medication and immediately report the client's vital signs and symptoms to the registered nurse (RN).

Answer

Withhold the scheduled dose of the medication and immediately report the client's vital signs and symptoms to the registered nurse (RN).
The client's presentation of tachycardia, hypotension, dizziness, and thirst 1212 hours postoperatively strongly suggests early hypovolemic shock, potentially from occult bleeding or fluid shifts. Lisinopril is an antihypertensive medication. Administering it in this context would further lower the blood pressure, risking severe hypoperfusion and cardiovascular collapse. The safest and most appropriate action within the practical nurse scope of practice is to withhold the dose and immediately notify the registered nurse so a comprehensive assessment and medical interventions can be initiated.

Step-by-Step Solution

1
Analyze the client's clinical presentation and vital signs.
The client exhibits tachycardia (112112 beats/minute), mild hypotension (96/5896/58 mm Hg), dizziness, and thirst.
These are early clinical indicators of hypovolemia or potential postoperative hemorrhage, which require immediate medical evaluation.
2
Evaluate the scheduled medication's mechanism of action.
Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor that is designed to lower blood pressure.
Administering an antihypertensive medication to a client with borderline hypotension and signs of impending shock could precipitate severe cardiovascular collapse.
3
Determine the appropriate practical nursing action based on scope of practice.
The PN must withhold the medication and escalate the findings.
The PN scope of practice requires reporting unstable or significantly abnormal findings to the supervising RN for further assessment and advanced intervention.

Key Concept

Safe Medication Administration: Withholding Antihypertensives in Potential Shock
Question 2660Question →

A practical nurse is providing basic care for an older adult client who is completely immobile, has a high risk for pressure injuries, and is receiving continuous enteral tube feeding. The nurse is preparing to reposition the client to promote comfort and skin integrity. Which action is the most appropriate for the nurse to perform?

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Answer: Turn the client to a 30-degree lateral position and maintain the head of the bed elevated at 30 degrees.

Answer

The most appropriate action is to turn the client to a 30-degree lateral position while maintaining the head of the bed elevated at 30 degrees.
Turning the client to a 30-degree lateral position effectively offloads the sacrum without placing excessive pressure on the greater trochanter. Simultaneously maintaining the head of the bed at 30 degrees prevents gastric reflux and aspiration of the continuous enteral feeding, while keeping it low enough to prevent the severe shearing forces associated with higher Fowler's positions.

Step-by-Step Solution

1
Analyze the client's clinical profile.
Identified dual risks: high risk for pressure injuries due to immobility, and high risk for aspiration due to continuous enteral feeding.
Understanding these competing risks is essential for determining a safe positioning strategy.
2
Evaluate positioning requirements for continuous enteral feeding.
Determined that the head of the bed must remain elevated to at least 30 degrees.
Gravity is required to prevent gastric reflux and subsequent pulmonary aspiration of the continuous feeding formula.
3
Evaluate positioning requirements for pressure injury prevention.
Determined that a 30-degree lateral tilt is optimal, and high-Fowler's must be avoided.
A 30-degree tilt offloads the sacrum without crushing the trochanter. Head elevation above 30 degrees causes the body to slide, resulting in excessive tissue shearing.
4
Select the intervention that safely addresses both clinical requirements.
The 30-degree lateral position combined with a 30-degree head of bed elevation is selected.
This precise combination protects the airway while simultaneously minimizing pressure and shear forces on vulnerable skin.

Key Concept

Safe positioning strategies for clients with simultaneous aspiration and pressure injury risks
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