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Question 2661Question →

During an afternoon shift on a long-term care unit, a resident who underwent a left-eye cataract removal earlier that morning asks for help getting comfortable in bed. Which positioning technique should the practical nurse use for this resident?

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Answer: Elevate the head of the bed to 30 degrees and position the resident on their right side.

Answer

The correct strategy is to elevate the head of the bed to 30 degrees and position the resident on their right side (the unoperated side).
Following cataract surgery, the primary goal of positioning is to prevent an increase in intraocular pressure (IOP) and to protect the surgical site from physical trauma. Elevating the head of the bed to at least 30 degrees (Semi-Fowler's position) promotes venous drainage from the head, which naturally reduces IOP. Furthermore, positioning the client on the unoperated (right) side prevents direct weight and pressure from being applied to the healing surgical (left) eye.

Step-by-Step Solution

1
Identify the surgical procedure and the affected side.
The client had a left-eye cataract removal.
Determining the operative side is essential to avoid placing pressure on the surgical site during rest.
2
Determine the primary physiological goal for positioning this client.
The goal is to prevent any increase in intraocular pressure (IOP) and protect the operative eye from injury.
Increased IOP can rupture the surgical incision, leading to vision loss and severe complications.
3
Select the position that meets these criteria while promoting comfort.
A Semi-Fowler's position on the non-operative (right) side or directly on the back is appropriate.
Elevating the head promotes venous drainage from the head, naturally lowering IOP, while avoiding the left side prevents accidental trauma to the healing eye.

Key Concept

Postoperative Positioning for Cataract Surgery
Question 2662Question →

A practical nurse (PN) is providing care for an older adult resident in a skilled nursing facility. The resident, who currently has a "Do Not Resuscitate" (DNR) order in their medical record, states, "I have changed my mind. If my heart stops, I want you to do everything possible to save me." In what 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 ask the resident to elaborate on their decision, then report the request to the charge nurse and provider, document the conversation in the medical record, confirm the provider has canceled the order, and finally change the resident's code status identifiers.
When a client requests a change to their advance directive, the practical nurse must first assess the client's understanding and intent. Because the practical nurse cannot independently alter medical orders, the request must be escalated to the registered nurse and provider. Documentation follows immediately to create a legal record of the client's verbal revocation. The practical nurse must then wait for the provider to officially cancel the order in the chart before physically changing the client's care plan and identification tools to reflect a 'Full Code'.

Step-by-Step Solution

1
Collect data by exploring the resident's request.
The practical nurse understands the resident's intent and ensures the request is voluntary.
Data collection is the necessary first step of the nursing process before taking any further action.
2
Notify the charge nurse and healthcare provider.
The individuals with the authority to legally alter the medical order are informed.
A practical nurse cannot independently cancel a legal advance directive such as a DNR order.
3
Document the interaction and notifications.
A formal legal record of the resident's wishes and the nurse's actions is established.
Timely documentation is required to protect client rights and maintain accurate medical records.
4
Verify the new medical prescription.
The practical nurse confirms the DNR order has been legally discontinued by the provider.
Nursing interventions regarding code status must be based on a valid, updated provider prescription.
5
Update the care plan and client identifiers.
The interdisciplinary team is made aware of the resident's new 'Full Code' status.
Updating physical identifiers and the care plan ensures that all staff will perform life-saving measures if a cardiac event occurs.

Key Concept

A competent client has the right to revoke an advance directive, such as a DNR order, at any time. The practical nurse's role is to gather information, escalate the request to the provider for a legal order change, document the event, and update care identifiers only after the new order is verified.
Question 2663Question →

A charge nurse is coordinating care on a general medical unit. Match each specific client care requirement with the most appropriate healthcare team member who should be assigned or consulted to complete the task.

Click a left item, then click its matching right item

Items

Developing an initial individualized care plan for a newly admitted client
Administering routine oral medications to a client with a stable, chronic condition
Helping a client with stable mobility limitations perform daily hygiene activities
Providing specialized recommendations for a complex, non-healing stage 4 pressure wound

Matches

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Answer

Developing the initial care plan is assigned to the Registered Nurse (RN). Administering routine oral medications is assigned to the Practical Nurse (PN). Assisting with hygiene is delegated to the Assistive Personnel (AP). Complex wound recommendations require a consultation with the Wound Care Nurse Specialist.
Safe and effective care requires assigning tasks based on the legal scope of practice and collaborating with specialists when client needs exceed standard care parameters. The RN must perform the initial planning; the PN safely handles stable medication administration; the AP manages routine ADLs; and complex clinical issues like stage 4 wounds require a specialist's advanced expertise.

Step-by-Step Solution

1
Analyze the requirement to develop an initial care plan.
This requires comprehensive assessment and formulation of nursing diagnoses.
These skills fall strictly within the legal scope of practice of the Registered Nurse (RN).
2
Analyze the requirement to administer routine oral medications.
This is a standard procedure for a predictable, stable condition.
This task is safely and legally within the scope of practice of the Practical Nurse (PN).
3
Analyze the requirement to help a stable client with daily hygiene.
This is a basic, non-invasive, routine activity of daily living (ADL).
Standard, unchanging ADLs can be safely delegated to Assistive Personnel (AP).
4
Analyze the requirement for complex stage 4 wound recommendations.
This requires advanced tissue evaluation and expertise beyond standard nursing care.
This situation requires interprofessional collaboration and a direct referral to a Wound Care Nurse Specialist.

Key Concept

Scope of Practice, Delegation, and Interprofessional Collaboration
Estimated Time:1m 0s
Question 2664Question →

While monitoring an older adult client who had a bowel resection earlier today, the practical nurse (PN) reviews the most recent vital signs and clinical data. The client is at increased risk for hypovolemic shock due to surgical blood loss. Which assessment finding should the PN identify as the body's earliest physiological adaptation to fluid volume deficit?

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Answer: A resting heart rate that increases from 76 to 114 beats per minute

Answer

The correct answer is a resting heart rate that increases from 76 to 114 beats per minute.
As blood volume decreases, the body's earliest physiological adaptation is to stimulate the sympathetic nervous system. This causes an increase in the heart rate (tachycardia) in an attempt to maintain cardiac output and ensure adequate oxygen delivery to vital organs. Recognizing this early sign allows the nurse to intervene promptly before irreversible shock occurs.

Step-by-Step Solution

1
Identify the client's primary physiological risk.
The client had major surgery and is at risk for hypovolemic shock.
Surgical procedures often involve significant blood loss, which can lead to a decreased intravascular volume.
2
Recall the body's initial compensatory response to fluid volume deficit.
The body attempts to compensate for lost fluid volume by stimulating the sympathetic nervous system, increasing the heart rate.
This sympathetic nervous system response helps maintain cardiac output before the blood pressure begins to fall.
3
Evaluate the provided assessment findings to identify the early sign.
An increasing heart rate is an early compensatory sign, whereas a drastic drop in blood pressure is a late sign.
Selecting the early sign ensures timely recognition of shock before tissue damage occurs.

Key Concept

Early physiological adaptation to hypovolemia involves a compensatory increase in heart rate (tachycardia) to maintain cardiac output and tissue perfusion.
Estimated Time:45s
Question 2665Question →

A practical nurse is preparing to transfer a client who has right-sided hemiparesis from the bed to a wheelchair using a stand-and-pivot technique. In what order should the nurse perform the following actions to maintain proper ergonomics and client safety? Arrange the steps in the correct chronological sequence.

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Answer

The correct sequence begins with equipment setup on the strong side, followed by preparing the client, applying the safety device, using proper nurse body mechanics, and finally executing the pivot transfer.
Safe transfer protocols require a structured approach to minimize injury risk for both the client and the nurse. First, the environment must be prepared by placing the wheelchair on the client's strong (left) side and locking the wheels. Next, the client is brought to a sitting position and provided with non-skid footwear to prevent slipping. A gait belt is then applied to give the nurse a secure handling point. The nurse then adopts a wide base of support and braces the client's weak (right) leg to prevent buckling. Finally, the client pivots on their strong leg to safely lower themselves into the wheelchair.

Step-by-Step Solution

1
Position the wheelchair on the client's left side at a 45-degree angle and lock the wheels.
The equipment is safely secured on the client's strong side.
Preparing the destination environment is always the first priority to ensure safety before mobilizing the client.
2
Assist the client to sit on the edge of the bed and apply non-skid footwear.
The client is sitting securely with appropriate traction.
Dangling allows for cardiovascular adjustment, and non-skid footwear prevents slipping during the pivot.
3
Apply a transfer gait belt securely around the client's waist over their clothing.
The nurse has a safe handling mechanism to control the client's center of gravity.
Using a gait belt prevents joint injuries and skin shearing that can occur if lifting by the arms.
4
Face the client, maintain a wide base of support, and brace the client's right knee.
The nurse's body is ergonomically positioned, and the client's weak leg is stabilized.
A wide base lowers the nurse's center of gravity, and bracing the hemiparetic limb prevents it from buckling when bearing weight.
5
Instruct the client to push up from the bed, pivot on the left leg, and reach for the wheelchair armrest.
The client safely transitions from the bed to the wheelchair.
Utilizing the client's unaffected side maximizes their independence and reduces physical strain on the nurse.

Key Concept

Safe Patient Transfer and Ergonomics
Question 2666Question →

An oncoming practical nurse (PN) is receiving the morning shift report on a pulmonary medicine floor. The nursing supervisor has distributed several tasks to the PN. Which of the following activities should the PN accept as appropriate and within their legal scope of practice? Select all that apply.

Select all that apply

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Answer: Providing routine tracheostomy care and suctioning for a stable client who has a long-term tracheostomy; Administering scheduled oral levofloxacin to a client recovering from community-acquired pneumonia; Collecting a morning sputum specimen for culture and sensitivity testing from a client with suspected bacterial bronchitis

Answer

The practical nurse should accept providing routine tracheostomy care for a stable client, administering scheduled oral antibiotics, and collecting a sputum specimen.
The practical nurse (PN) scope of practice encompasses caring for stable clients with predictable health outcomes, administering routine oral medications, performing standard procedures on established airways (like chronic tracheostomy care), and collecting specimens. Therefore, providing tracheostomy care for a stable client, administering oral levofloxacin, and collecting a sputum specimen are all appropriate tasks for the PN to accept.

Step-by-Step Solution

1
Evaluate each assigned task against the legal scope of practice for a practical nurse (PN).
Identify tasks involving stable clients, basic procedural care, and standard medication administration.
The PN scope of practice focuses on clients with predictable outcomes and relies on established nursing protocols.
2
Identify tasks that require complex assessment, IV push medications, or provider responsibilities.
Determine that pushing IV medications during an acute exacerbation and detailing procedural complications are outside the PN scope.
IV push medications for unstable clients require RN-level comprehensive assessment. Explaining procedural risks is strictly the provider's duty.
3
Assess tasks for ethical and legal compliance regarding client privacy.
Recognize that sharing medical information with a neighbor violates healthcare privacy laws.
Nurses must strictly maintain client confidentiality and share information only with authorized individuals.

Key Concept

Delegation and Practical Nurse (PN) Scope of Practice
Question 2667Question →

A client who recently received intravenous antineoplastic medications accidentally drops a urinal, spilling contaminated urine on the floor. Arrange the following actions in the priority order the practical nurse should perform them to safely manage the biohazardous spill.

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Answer

The correct sequence prioritizes nurse safety, spill containment, decontamination, safe disposal, and final hand hygiene.
Safe management of a cytotoxic spill requires a strict chronological approach. First, the nurse must protect themselves by donning appropriate PPE (gown and double gloves). Second, the spill must be immediately contained using absorbent pads to prevent spreading. Third, the area is cleaned with an approved detergent to eliminate residue. Fourth, all contaminated materials are isolated in a designated chemotherapy waste receptacle. Finally, PPE is removed and hand hygiene is performed to ensure no trace hazardous materials remain on the nurse.

Step-by-Step Solution

1
Don appropriate personal protective equipment (gown and double gloves).
The nurse is protected from direct contact with cytotoxic fluids.
Antineoplastic agents are hazardous and require protective barriers before any intervention.
2
Cover the spill with absorbent pads.
The fluid is contained and prevented from spreading.
Immediate containment minimizes the surface area of contamination and prevents aerosolization.
3
Clean the surface with an approved detergent.
Chemical residues are neutralized and removed from the floor.
Thorough decontamination is required to ensure the environment is safe for clients and staff.
4
Dispose of materials in a chemotherapy waste receptacle.
Hazardous waste is isolated in a leak-proof, highly visible container.
Proper disposal prevents secondary exposure to environmental services and other healthcare workers.
5
Remove PPE and wash hands with soap and water.
The nurse is free of any trace contaminants.
Hand hygiene mechanically removes any microscopic chemical traces that might have penetrated the gloves.

Key Concept

Management of Hazardous Medication Spills (Antineoplastic Precautions)
Question 2668Question →

After completing morning care for a client placed in a negative-pressure isolation room due to a primary varicella-zoster infection, a practical nurse (PN) prepares to leave the room. The PN is currently wearing disposable gloves, a protective gown, and an N95 respirator. Place the following steps for removing personal protective equipment (PPE) and exiting the area in the correct chronological order.

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Answer

The correct sequence for doffing PPE in airborne precautions is: remove gloves, remove gown, exit the isolation room, remove the N95 respirator, and perform hand hygiene.
The Centers for Disease Control and Prevention (CDC) strictly mandates that PPE be removed in a specific sequence to prevent self-contamination. The most contaminated items (gloves) are removed first, followed by the gown. Because the client has an airborne illness (primary varicella-zoster), the N95 respirator must remain on until the nurse has exited the negative-pressure room and closed the door. Finally, hand hygiene is always the last step to ensure any accidentally transferred pathogens are eliminated.

Step-by-Step Solution

1
Identify the type of isolation precautions required for the client's condition.
Primary varicella-zoster (chickenpox) requires Airborne and Contact Precautions.
Understanding the required precautions dictates the specific PPE worn and the strict sequence for safe removal.
2
Determine the order of removal for PPE inside the isolation room.
Gloves are removed first, followed by the gown.
The most contaminated items are removed first. Gloves harbor the highest concentration of pathogens. The gown is removed next, rolling it inside out.
3
Identify the location for respirator removal.
The nurse must exit the negative-pressure room and close the door before removing the N95 respirator.
Removing the respirator inside the room would expose the nurse's respiratory tract to airborne droplet nuclei (varicella virus).
4
Determine the safe method for removing the respirator.
The bottom strap is removed first, followed by the top strap.
This technique prevents the contaminated front of the respirator from flipping forward and touching the nurse's face.
5
Determine the final step of the doffing sequence.
Hand hygiene is performed immediately after removing the respirator.
Hand hygiene removes any transient flora or pathogens that may have contacted the hands during the PPE removal process.

Key Concept

Standard sequence for PPE removal (doffing) in Airborne and Contact Precautions
Question 2669Question →

An immunocompromised client is receiving care in an airborne infection isolation room (AIIR) for localized herpes zoster. The client suddenly activates the call light and reports severe, acute shortness of breath. The practical nurse (PN) arrives at the threshold of the client's room. Which action should the PN take first?

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Answer: Put on an N95 respirator, isolation gown, and clean gloves prior to crossing the room threshold to assess the client.

Answer

Put on an N95 respirator, isolation gown, and clean gloves prior to crossing the room threshold to assess the client.
An immunocompromised client with localized herpes zoster requires strict airborne and contact precautions. Even in an acute respiratory emergency, healthcare personnel must prioritize putting on the correct personal protective equipment (PPE)—including an N95 respirator, gown, and gloves—before entering the room. Bypassing infection control protocols exposes the nurse and other clients to highly contagious pathogens. The practical nurse is responsible for initiating emergency assessment and cannot delegate the care of an unstable client to unlicensed assistive personnel or delay care by waiting for a registered nurse.

Step-by-Step Solution

1
Analyze the client's diagnosis and required infection control measures.
An immunocompromised client with localized herpes zoster requires both airborne and contact precautions, mandating the use of an N95 respirator, gown, and gloves.
Immunocompromised clients shed the virus more heavily, increasing transmission risk and necessitating heightened precautions compared to localized shingles in healthy adults.
2
Evaluate the clinical priority against facility safety standards.
The client is experiencing a respiratory emergency requiring immediate attention, but the nurse cannot enter the room without proper protective equipment.
Personal safety and infection control protocols must be strictly maintained even during life-threatening emergencies to prevent cross-contamination and healthcare worker exposure.
3
Determine the appropriate scope of practice for the practical nurse in this scenario.
The PN must personally don the correct PPE and initiate the emergency assessment.
The PN cannot delegate the assessment of an unstable client to a UAP, nor can the PN abandon airway prioritization by passively waiting in the hallway for an RN.

Key Concept

Maintaining Standard and Transmission-Based Precautions During Clinical Emergencies
Question 2670Question →

While preparing morning medications, a practical nurse (PN) is approached by the adult child of a client. The client is currently alert and oriented in their room. The child asks, "Can you tell me what my mother's kidney function test results were this morning? I am very worried about her condition." Which response by the PN is the most appropriate?

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Answer: I must obtain your mother's permission before I can share her medical information with you.

Answer

The nurse must inform the family member that the client's direct permission is required before sharing any medical information.
Alert and oriented clients have the legal right to decide who can receive updates about their medical condition. The practical nurse must directly ask the client for permission before disclosing any protected health information, including laboratory results, to family members.

Step-by-Step Solution

1
Assess the client's current cognitive status and ability to make healthcare decisions.
The client is documented as being alert and oriented.
Competent clients retain the legal right to control the disclosure of their own protected health information.
2
Evaluate the adult child's request for the laboratory results.
The request asks for specific, protected health information (kidney function tests).
Laboratory results are strictly confidential and cannot be shared with family members automatically, regardless of their relationship to the client.
3
Formulate a therapeutic response that protects client privacy while maintaining a professional demeanor.
The nurse informs the family member that permission from the client is required first.
This action upholds HIPAA regulations and respects the client's autonomy and privacy.

Key Concept

Client Confidentiality and HIPAA Regulations
Question 2671Question →

Upon entering the room of a client who underwent a bowel resection earlier in the shift, the practical nurse observes that the client is unusually restless and continuously picking at the bedsheets. The client's heart rate is 118 beats/min and blood pressure is 102/64 mm Hg, which represents a change from preoperative readings of 82 beats/min and 138/78 mm Hg. The client repeatedly states, 'I feel so thirsty.' Which action should the practical nurse take first?

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Answer: Check the abdominal dressing and any surgical drains for excessive bleeding.

Answer

The correct action is to check the abdominal dressing and any surgical drains for excessive bleeding.
The client is demonstrating early signs of hypovolemic shock, including an increased heart rate, borderline hypotension, restlessness, and severe thirst. In the postoperative period, these symptoms strongly suggest internal or external hemorrhage. The practical nurse must prioritize Circulation (ABCs) and immediately assess the surgical site and drains for bleeding to gather essential data for the registered nurse and healthcare provider.

Step-by-Step Solution

1
Analyze the client's clinical presentation and vital signs.
The client shows a significantly increased heart rate, decreased blood pressure, restlessness, and severe thirst compared to baseline.
Identifying acute changes from baseline is the first step in recognizing clinical deterioration.
2
Correlate the symptoms with potential postoperative complications.
The combination of tachycardia, borderline hypotension, altered mental status (restlessness), and thirst strongly indicates early hypovolemic shock.
Understanding the physiological meaning behind symptom clusters allows the nurse to anticipate the underlying problem.
3
Determine the priority nursing intervention.
The most appropriate action is to immediately inspect the surgical site for active bleeding before notifying the registered nurse.
Gathering focused data related to the suspected hemorrhage is essential for safe and effective collaborative care.

Key Concept

Recognition of Early Shock and Hemorrhage
Estimated Time:1m 0s
Question 2672Question →

A practical nurse observes an unlicensed assistive personnel (UAP) independently operating a motorized sit-to-stand lift to transfer a client with generalized weakness from the bed to a chair. Which action is the priority for the practical nurse?

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Answer: Intervene to halt the transfer and act as the required second staff member for the equipment

Answer

The practical nurse must immediately intervene and assist, as the safe operation of motorized patient lifts requires a minimum of two staff members.
Manufacturer guidelines and facility safety protocols mandate that motorized patient lifts (including sit-to-stand devices and full-body sling lifts) must be operated by at least two trained caregivers. Attempting a mechanical transfer single-handedly drastically increases the risk of the equipment tipping, the client falling, and the staff member sustaining an ergonomic injury. The nurse's immediate priority is client safety, which requires halting the unsafe action and providing the needed assistance.

Step-by-Step Solution

1
Identify the safety hazard in the scenario
A UAP is operating a mechanical sit-to-stand lift without the assistance of a second caregiver.
Recognizing unsafe equipment operation is the first step in preventing client injury.
2
Determine the standard protocol for mechanical lift transfers
Manufacturer guidelines and healthcare facility policies universally require at least two trained staff members to operate motorized lifts safely.
One person is needed to manage the lift controls and stabilize the machinery, while the other guides and protects the client.
3
Select the immediate priority action
The nurse must step in to stop the unsafe procedure and provide the necessary physical assistance to complete the transfer safely.
Immediate intervention is required to mitigate the acute risk of a fall or equipment tipping.

Key Concept

Ergonomics and Safe Use of Equipment
Question 2673Question →

A practical nurse (PN) is administering an intramuscular (IM) injection of iron dextran, a medication known to cause severe skin irritation and staining, to an adult client. The PN will utilize the Z-track method. Arrange the following steps of this procedure in the correct chronological order.

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Answer

The correct chronological order is: Prepare the site and don gloves; pull the skin laterally; insert the needle and inject slowly; wait 10 seconds; withdraw the needle and release the skin; and finally, apply light pressure without massaging.
The Z-track method requires strict adherence to a specific chronological sequence to prevent medication leakage. The site must first be prepared. Then, tissue displacement occurs to misalign the layers. The injection is given, followed by a mandatory 10-second wait to allow dispersion. Crucially, the needle withdrawal and tissue release must happen simultaneously to break the track. Finally, gentle pressure is applied, but the site must never be massaged to avoid pushing the medication out of the muscle.

Step-by-Step Solution

1
Select site and apply standard precautions.
The ventrogluteal site is prepared, minimizing the risk of infection.
Hand hygiene, gloving, and site identification are universal prerequisites for any parenteral administration.
2
Displace the skin and tissue laterally by 1 to 1.5 inches.
The skin and subcutaneous layers are shifted out of their normal alignment with the underlying muscle.
This is the foundational step of the Z-track method, preparing the offset track that will seal the medication.
3
Insert the needle at a 90-degree angle and inject slowly.
The medication is delivered deep into the ventrogluteal muscle.
A 90-degree angle ensures intramuscular delivery, and a slow injection rate minimizes pain and tissue trauma.
4
Wait 10 seconds before removing the needle.
The medication disperses into the muscle belly.
Allowing time for dispersion reduces the risk of the medication tracking back up the needle pathway upon withdrawal.
5
Withdraw the needle and simultaneously release the displaced skin.
The tissue layers slide back into their original anatomical positions.
This breaks the needle track alignment (creating the 'Z' shape), physically sealing the irritating medication inside the muscle layer and preventing seepage.
6
Apply gentle pressure without massaging.
The site is secured without disrupting the trapped medication.
Massage is strictly contraindicated because it can force the medication out of the muscle and into the subcutaneous tissue, causing the severe irritation or staining that the Z-track method is designed to prevent.

Key Concept

The Z-track intramuscular injection method is utilized to administer highly irritating or staining medications, sealing the drug deep within the muscle tissue to protect superficial layers.
Estimated Time:2m 0s
Question 2674Question →

A practical nurse is providing basic care for a client who is two days postoperative following a right total hip arthroplasty (posterior approach). Which of the following care and positioning interventions should the nurse include in the client's daily routine? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Place an abduction wedge between the client's legs while resting in bed.; Provide a raised toilet seat for the client's bowel and bladder elimination needs.; Remind the client to avoid crossing their legs at the ankles or knees while sitting.

Answer

The correct interventions are placing an abduction wedge between the legs, providing a raised toilet seat, and reminding the client not to cross their legs.
Following a posterior approach total hip arthroplasty, the client is at high risk for joint dislocation if the hip is flexed beyond 90 degrees, adducted across the body's midline, or internally rotated. Using an abduction wedge prevents adduction. Providing a raised toilet seat keeps the hip flexion angle safe during elimination. Instructing the client not to cross their legs prevents both adduction and internal rotation. All of these interventions are essential basic care measures to ensure safety and comfort.

Step-by-Step Solution

1
Identify the surgical procedure and the associated anatomical risks.
The client had a total hip arthroplasty using a posterior approach.
Different surgical approaches have different postoperative precautions. The posterior approach requires strict avoidance of severe hip flexion, adduction, and internal rotation.
2
Evaluate each care intervention against posterior hip precautions.
Interventions preventing flexion greater than 90 degrees, adduction, and internal rotation are safe. Interventions causing these movements are contraindicated.
Adhering to strict positioning rules prevents dislocation of the newly placed prosthetic joint.
3
Select the options that promote safety and comfort without violating precautions.
Using an abduction wedge, using a raised toilet seat, and avoiding leg crossing are all necessary protective measures.
These actions integrate essential joint protection into routine daily basic care.

Key Concept

Postoperative Basic Care and Joint Precautions for Total Hip Arthroplasty
Question 2675Question →

While working in the emergency department, a practical nurse (PN) assists a healthcare provider who is preparing to insert a central venous catheter for an alert and oriented client. The provider hands the blank informed consent form to the PN and states, 'I need to grab the ultrasound machine. Have the client sign this now, and I will explain the procedure's risks while I am setting up the sterile field.' Which of the following is the most appropriate action for the PN to take?

Show answer & explanation

Answer: Inform the provider that the procedure must be fully explained to the client before the consent form can be signed.

Answer

The PN should inform the provider that the procedure must be fully explained to the client before the consent form can be signed.
Informed consent is a legal process that requires the healthcare provider performing the procedure to explain the risks, benefits, alternatives, and potential complications before the client signs the document. The role of the practical nurse (PN) is limited to advocating for the client, verifying they understand the provider's explanation, and witnessing the voluntary signature. Obtaining a signature before the provider explains the procedure renders the consent invalid. Therefore, the PN must intervene and ensure the provider fulfills their legal obligation before the form is signed.

Step-by-Step Solution

1
Evaluate the legal requirements for informed consent.
Recognize that true informed consent requires the provider to explain the procedure, risks, benefits, and alternatives prior to the client signing the form.
A signature obtained before this explanation is legally invalid, as the client is not yet informed.
2
Determine the PN's scope of practice regarding the consent process.
Identify that the PN's role is strictly limited to advocating for the client, ensuring comprehension, and witnessing the voluntary signature after the provider's explanation.
The PN cannot assume the provider's duty to explain the procedure or obtain the initial consent.
3
Select the safest and most legally sound action.
The PN must advocate for the client by politely reminding the provider to fulfill their responsibility before the client signs the document.
This ensures the client's legal rights are protected and adheres strictly to the PN's scope of practice.

Key Concept

Informed Consent and PN Scope of Practice
Question 2676Question →

Following a client's arrival at a skilled nursing facility from an acute care hospital, the nursing team convenes to distribute care responsibilities. Which action taken by the practical nurse (PN) indicates a correct application of scope of practice guidelines?

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Answer: Requesting that the registered nurse (RN) complete the initial comprehensive admission assessment prior to assuming ongoing care of the client

Answer

The correct action is requesting that the registered nurse (RN) complete the initial comprehensive admission assessment.
According to national nursing guidelines and the scope of practice, the registered nurse (RN) is responsible for performing the initial comprehensive assessment and developing the initial plan of care for a newly admitted client. The practical nurse (PN) collects data, performs focused assessments, and contributes to the ongoing plan of care, but must defer the initial comprehensive evaluation to the RN.

Step-by-Step Solution

1
Analyze the scope of practice regarding client assessments for practical nurses.
Initial, comprehensive assessments and the formulation of the initial care plan are strictly the responsibility of the registered nurse (RN).
The PN role involves focused data collection and contributing to ongoing assessments, rather than establishing baseline comprehensive evaluations.
2
Evaluate the remaining actions against delegation, legal, and ethical guidelines.
Explaining procedure risks is the provider's role; IV push medications are outside the PN scope; discussing cases in public areas violates confidentiality.
Safe practice requires adhering to defined scope boundaries, recognizing the limits of informed consent duties, and maintaining strict client privacy.

Key Concept

Scope of Practice and Safe Client Care Delegation
Question 2677Question →

During a daytime shift, a practical nurse (PN) is caring for a 78-year-old client who was admitted two days ago for pneumonia. The client suddenly becomes disoriented, continuously attempts to remove their intravenous (IV) catheter, and tries to climb over the bed rails. Which of the following actions should the PN take to promote a safe environment? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Keep the bed in the lowest position with the wheels locked.; Activate the bed exit alarm system to alert staff of movement.; Request to relocate the client to a room closer to the nursing station for closer observation.

Answer

The nurse should keep the bed in the lowest position, activate the bed exit alarm, and relocate the client closer to the nursing station.
To ensure client safety in the least restrictive manner, the nurse must implement measures that reduce the risk of falls and allow for rapid intervention. Keeping the bed in its lowest position minimizes fall impact, activating a bed exit alarm provides immediate notification of unsafe movement, and moving the client closer to the nursing station allows for frequent visual monitoring.

Step-by-Step Solution

1
Analyze the client's presentation and current risks.
The client is experiencing acute confusion, attempting to pull medical devices (IV catheter), and showing high fall risk behaviors (climbing over bed rails).
Identifying the specific safety threats is necessary to select appropriate interventions.
2
Evaluate interventions based on the principle of least restrictive environment and scope of practice.
Non-restrictive measures (bed position, alarms, relocation) must be prioritized over physical restraints. Delegation tasks must also remain within the PN scope of practice.
Standard nursing guidelines mandate exhausting less restrictive alternatives before utilizing restraints, and PNs must legally operate within their defined scope to prevent errors.
3
Select the correct actions from the provided options.
Keeping the bed low, using a bed exit alarm, and moving the client closer to the nursing station are safe, in-scope, and non-restrictive actions.
These actions directly mitigate the risk of injury while adhering to ethical and legal nursing standards.

Key Concept

Prioritizing least restrictive safety measures and adhering to the practical nurse (PN) scope of practice when managing acute delirium and fall risks.
Question 2678Question →

A practical nurse (PN) is assigned to a busy urgent care clinic and is reviewing the facility's policies regarding the protection of protected health information (PHI). Which of the following actions by the PN demonstrate compliance with confidentiality and information security guidelines? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Logging off the electronic health record system immediately before stepping away to assist a client.; Positioning the computer monitor in the triage area to prevent individuals in the waiting room from viewing the screen.; Providing a client's medical update to a telephone caller who successfully provides the client's designated privacy passcode.

Answer

The correct actions include logging off the electronic health record system before leaving a workstation, positioning computer monitors away from public view, and verifying a designated privacy passcode before providing telephone updates.
The correct actions actively prevent unauthorized individuals from viewing or hearing protected health information. Logging off systems immediately, angling screens away from the public, and strictly enforcing the use of privacy passcodes for telephone inquiries are essential, standard safeguards required by healthcare privacy regulations.

Step-by-Step Solution

1
Analyze the principle of the 'need-to-know' basis.
A nurse should only access electronic or paper records for clients they are actively assigned to care for.
Accessing records for individuals (such as neighbors or family members) without a direct care relationship violates healthcare privacy laws.
2
Evaluate physical and electronic data security requirements.
Printed reports must be shredded, and computer screens must be shielded from public view or locked when unattended.
These physical safeguards prevent unauthorized visual access and incidental disclosure of protected health information.
3
Assess verbal and telephone disclosure rules.
Information cannot be given to outside callers unless they provide the predetermined privacy passcode or have documented authorization.
This strict verification process ensures that only individuals expressly approved by the client receive medical updates.

Key Concept

Practical nurses must implement physical, electronic, and procedural safeguards to protect client health information from unauthorized access, viewing, or disclosure at all times.
Question 2679Question →

A practical nurse (PN) is collecting data on a client who had an ileostomy created three days ago. The client has had a high volume of liquid ostomy output over the past 12 hours. Which of the following clinical findings should the PN identify as early indicators of fluid volume deficit? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Heart rate of 118 beats/minute; Dry, sticky oral mucous membranes; Dark amber, concentrated urine

Answer

The correct indicators of fluid volume deficit are a heart rate of 118 beats/minute, dry, sticky oral mucous membranes, and dark amber, concentrated urine.
The correct options represent the body's direct physiological and compensatory responses to significant fluid loss. A heart rate of 118 beats/minute demonstrates the cardiovascular system's immediate attempt to maintain cardiac output. Dry mucous membranes reflect the systemic depletion of interstitial fluids. Dark, concentrated urine indicates that the kidneys are appropriately compensating by conserving water to prevent further volume loss.

Step-by-Step Solution

1
Analyze the client's clinical risk factors based on the scenario.
The client has a new ileostomy with a high volume of liquid output over 12 hours, placing them at significant risk for hypovolemia (fluid volume deficit).
Identifying the primary risk factor guides the assessment toward recognizing signs of dehydration and circulatory compromise.
2
Evaluate each assessment finding against the expected physiological manifestations of fluid volume deficit.
Tachycardia, dry mucous membranes, and concentrated urine align with fluid loss. Hypertension, normal capillary refill, and localized pain do not indicate systemic fluid depletion.
The body compensates for fluid loss by increasing the heart rate, conserving water via the renal system, and shunting blood away from the periphery, while overall mucosal hydration visibly decreases.

Key Concept

Identifying the clinical manifestations of fluid volume deficit (hypovolemia) to ensure timely intervention and prevent circulatory collapse.
Question 2680Question →

While completing afternoon rounds, a practical nurse evaluates a 72-year-old individual who underwent a right femoral-popliteal bypass graft earlier in the day. The client is displaying new-onset agitation. Current physiological parameters reveal a heart rate of 114 beats per minute, blood pressure of 102/54 mm Hg, and a respiratory rate of 22 breaths per minute. A review of the preoperative record indicates a baseline blood pressure of 146/84 mm Hg. The surgical dressing over the incision site remains clean, dry, and intact. Which clinical action should the practical nurse prioritize?

Show answer & explanation

Answer: Communicate the physiological parameters and clinical presentation to the registered nurse immediately.

Answer

Communicate the physiological parameters and clinical presentation to the registered nurse immediately.
The client is demonstrating early signs of hypovolemic shock (relative hypotension, tachycardia, and agitation) following a major vascular procedure. Because the surgical dressing is dry, internal bleeding at the graft site or retroperitoneal space is highly suspected. Recognizing these subtle signs and immediately escalating the data to the registered nurse is the most critical action to reduce the risk of severe complications and circulatory collapse.

Step-by-Step Solution

1
Analyze the client's postoperative vital signs and compare them to preoperative baselines.
The heart rate is elevated (114 bpm), and the blood pressure has dropped significantly from 146/84 mm Hg to 102/54 mm Hg.
Identifying relative hypotension and tachycardia is crucial for detecting early circulatory compromise.
2
Correlate the vital sign changes with the client's new-onset agitation and surgical history.
The combination of these findings suggests decreased cerebral perfusion and early hypovolemic shock, likely from internal bleeding at the graft site.
Agitation is a classic early sign of hypoxia and shock, particularly in older adults, even if the external surgical dressing is intact.
3
Determine the appropriate scope of practice and priority action.
The practical nurse must immediately report these critical physiological changes to the registered nurse.
Suspected hypovolemic shock requires immediate RN assessment and potential provider notification for fluid resuscitation or surgical re-evaluation.

Key Concept

Early Recognition of Postoperative Hypovolemic Shock
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