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2933 questions

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A nurse is caring for a 72-year-old client being treated for a complicated urinary tract infection. The client's partner states, "My spouse is usually very sharp, but today they are extremely drowsy and talking about things that do not make sense." Assessment reveals a temperature of 97.6°F (36.4°C), apical pulse of 109 bpm, respirations of 22 breaths/min, and blood pressure of 92/52 mm Hg. Based on these findings, which intervention is the priority?

Communicate the assessment findings to the supervising registered nurse immediately.

Assure the partner that acute confusion is an expected part of the aging process during hospitalization.

Document the vital signs in the client's chart and continue with routine rounding.

Administer the client's prescribed oral analgesic for flank pain to promote comfort.

Show answer & explanation

Answer: Communicate the assessment findings to the supervising registered nurse immediately.

Answer

Communicate the assessment findings to the supervising registered nurse immediately.

The client is exhibiting classic signs of early sepsis and impending septic shock, including altered mental status, tachycardia, and borderline hypotension. The priority action for the practical nurse is to immediately escalate these critical, life-threatening findings to the supervising registered nurse or provider for rapid medical intervention.

Step-by-Step Solution

Analyze the client's clinical presentation.

The client has a diagnosed infection and is now presenting with new-onset altered mental status, tachycardia (109 bpm), and hypotension (92/52 mm Hg).

Identifying acute changes from the baseline is essential to recognize impending complications.

Correlate the findings with potential physiological adaptations.

The combination of infection, altered mentation, and hemodynamic instability strongly suggests early sepsis and impending septic shock.

Sepsis causes systemic vasodilation, leading to dropped blood pressure, a compensatory increase in heart rate, and decreased cerebral perfusion causing confusion.

Determine the priority nursing action based on the PN scope of practice.

The PN must immediately escalate the critical findings to the RN or healthcare provider.

Medical emergencies require immediate collaborative intervention outside the independent scope of the practical nurse.

Key Concept

Recognition of Sepsis and Shock

Question 2702Question →

A practical nurse is assisting a client with the collection of a clean-catch midstream urine specimen for a culture and sensitivity test. Arrange the following steps in the correct chronological order to ensure an uncontaminated specimen is obtained.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: 1) Perform hand hygiene and don clean gloves; 2) Cleanse the perineal area from front to back; 3) Instruct the client to begin voiding into the toilet; 4) Place the sterile specimen container into the active urine stream.

The established sequence for a clean-catch urine collection minimizes the risk of specimen contamination. Hand hygiene and donning gloves form the foundational step of standard precautions. Cleansing the meatus front-to-back prevents the introduction of rectal flora to the urinary tract. Voiding the initial stream into the toilet effectively flushes the distal urethra of resident bacteria. Finally, catching the midstream urine ensures the sample genuinely reflects the microbiological status of the bladder.

Step-by-Step Solution

Identify the standard precautions required before the procedure.

Hand hygiene is performed and clean gloves are donned.

To protect the nurse from exposure to body fluids and prevent introducing environmental contaminants to the client's supplies.

Determine the correct anatomical cleansing technique.

The perineal area is cleansed with antiseptic wipes from front to back.

This specific motion removes flora from the urinary meatus while preventing the introduction of bacteria from the anal region.

Determine the correct timing for starting the collection.

The client is instructed to begin voiding into the toilet before the cup is introduced.

The initial stream of urine serves to mechanically flush out normal resident bacteria present in the distal urethra.

Determine the correct method to catch the sterile specimen.

The sterile cup is placed directly into the midstream flow.

The midstream portion most accurately reflects the status of the bladder and kidneys, ensuring the culture results are reliable.

Key Concept

The purpose of a clean-catch midstream urine collection is to obtain a sample that is free from external contamination. This is achieved by anatomically cleansing the meatus and flushing the urethra before capturing the midstream flow.

Question 2703Question →

A licensed practical nurse (LPN) is planning daily care activities for a client recovering from a left below-the-knee amputation performed 48 hours ago. Which basic comfort and mobility interventions are essential to include in the client's care? Select all that apply.

Select all that apply

Position the client prone for 20 to 30 minutes, three to four times a day.

Support the left residual limb on a pillow to elevate it while the client is supine.

Offer reassurance by telling the client they will walk normally with a prosthetic leg very soon.

Keep the left knee fully extended using an amputation board when the client sits in a chair.

Cleanse the residual limb gently with warm water and mild soap, ensuring complete drying.

Show answer & explanation

Answer: Position the client prone for 20 to 30 minutes, three to four times a day.; Keep the left knee fully extended using an amputation board when the client sits in a chair.; Cleanse the residual limb gently with warm water and mild soap, ensuring complete drying.

Answer

The correct interventions are positioning the client prone periodically, keeping the knee fully extended while sitting, and properly cleansing the residual limb with mild soap and water.

Appropriate basic care for a below-the-knee amputation after the first 24 hours focuses on contracture prevention and skin integrity. Assisting the client into a prone position multiple times a day helps stretch the hip flexors. Supporting the knee in full extension while sitting prevents knee flexion contractures. Washing the residual limb daily with mild soap and water maintains skin integrity and prevents infection without causing chemical irritation.

Step-by-Step Solution

Analyze the client's postoperative timeline and surgical site.

The client is 48 hours postoperative following a left below-the-knee amputation.

The postoperative timeline dictates whether certain positioning strategies (like elevation) are therapeutic or contraindicated.

Evaluate the risk of complications associated with this specific amputation.

The primary physical risks are hip and knee flexion contractures, skin breakdown, and infection. The primary psychological risk involves grief over limb loss.

Basic care and comfort must proactively address these specific risks to promote successful rehabilitation.

Determine the correct positioning and hygiene interventions.

Prone positioning and knee extension prevent contractures, while daily washing with mild soap prevents skin breakdown. Pillows for elevation and false reassurance must be avoided.

These actions perfectly align with the evidence-based physical and emotional needs of the healing stump.

Key Concept

Postoperative amputation positioning and basic stump care focus on preventing hip and knee flexion contractures while maintaining skin integrity.

Question 2704Question →

A practical nurse (PN) is reviewing the morning laboratory results and medication administration record for a client being treated for a deep vein thrombosis (DVT). The client has been receiving a continuous intravenous heparin infusion and was recently started on oral warfarin. The morning laboratory results reveal an International Normalized Ratio (INR) of $4.2$ and a platelet count of $145,000/\text{mm}^3$ . The provider has prescribed a scheduled dose of oral warfarin $5$ mg and a new, one-time prescription for oral phytonadione $2.5$ mg. The pharmacy has dispensed the phytonadione as a $5$ mg/mL oral liquid.

Based on these findings, what is the priority sequence of actions for the practical nurse to take?

Withhold the scheduled oral warfarin, notify the registered nurse of the laboratory results, and measure

2.0

mL of the phytonadione oral liquid to address the elevated INR.

Independently discontinue the warfarin prescription in the medical record due to the toxic INR level, and administer the phytonadione via the intravenous (IV) route to ensure rapid reversal of anticoagulation.

Withhold the scheduled oral warfarin, notify the registered nurse of the critical INR result, and prepare to administer

0.5

mL of the oral phytonadione after checking two distinct client identifiers.

Measure

0.5

mL of the phytonadione oral liquid, scan the medication barcode on the bottle at the bedside, and immediately administer the dose because the supratherapeutic INR requires emergent intervention.

Show answer & explanation

Answer: Withhold the scheduled oral warfarin, notify the registered nurse of the critical INR result, and prepare to administer $0.5$ mL of the oral phytonadione after checking two distinct client identifiers.

Answer

The most appropriate sequence is to withhold the scheduled oral warfarin, notify the registered nurse of the critical INR result, and prepare to administer

0.5

mL of the oral phytonadione after checking two distinct client identifiers.

An INR of

4.2

is supratherapeutic (the normal therapeutic range for DVT is typically

2.0

3.0

), placing the client at a high risk for hemorrhage. The PN must prioritize client safety by withholding the scheduled warfarin (an oral anticoagulant) and promptly notifying the RN or provider of the critical laboratory result. Phytonadione (vitamin K) is the standard antidote utilized for warfarin toxicity. The prescribed dose is

2.5

mg, and the available concentration is

5

mg/mL. The correct volume to administer is calculated as: (

2.5

mg /

5

mg/mL) *

1

mL =

0.5

mL. Finally, the PN must rigidly adhere to medication safety protocols by verifying two distinct client identifiers prior to administration, even in urgent clinical scenarios.

Step-by-Step Solution

Evaluate the laboratory results against standard therapeutic ranges for the client's condition.

The INR of

4.2

is identified as supratherapeutic (above the target of

2.0

3.0

for DVT), indicating a high risk of hemorrhage.

Recognizing critical laboratory values is a fundamental nursing responsibility prior to administering any anticoagulant therapy.

Determine the appropriate intervention regarding the scheduled medications.

The scheduled dose of warfarin must be withheld immediately.

Administering additional warfarin to a client with a supratherapeutic INR would dangerously prolong clotting time and precipitate bleeding.

Calculate the correct dosage of the prescribed antidote (phytonadione).

The required volume to administer is calculated to be

0.5

mL.

Using the standard formula (Desired / Have) * Volume: (

2.5

mg /

5

mg) *

1

mL =

0.5

mL of the phytonadione oral liquid.

Identify the proper procedure for safe medication administration and interprofessional communication.

The PN must notify the RN of the critical lab value and verify two distinct client identifiers before administration.

Delegation guidelines require escalating critical findings to the RN, and safety standards universally mandate dual identifier verification, regardless of clinical urgency.

Key Concept

Pharmacological Therapies - Safe Medication Administration and PN Scope of Practice

Alternative Method

Instead of the standard Desired/Have formula, the ratio and proportion method can be utilized for the calculation:

5

mg /

1

mL =

2.5

mg /

X

mL. Cross-multiplying yields

5X = 2.5

, which mathematically simplifies to

X = 0.5

mL.

Estimated Time:2m 0s

Question 2705Question →

A practical nurse (PN) is participating in the admission care of a client who has just arrived at the medical-surgical unit with confirmed influenza A and a methicillin-resistant Staphylococcus aureus (MRSA) wound infection on the right heel. Which of the following actions are appropriate for the PN to take? Select all that apply.

Select all that apply

Place a standard surgical mask on the client if transport to another department is necessary.

Remove the disposable gown and gloves inside the client's room before stepping into the hallway.

Ensure that reusable medical equipment, such as a stethoscope, is dedicated solely to this client.

Remove the standard surgical mask before doffing the contaminated isolation gown and gloves.

Apply disposable gloves before donning the isolation gown and standard surgical mask.

Perform the initial comprehensive nursing assessment to document the baseline condition of the MRSA wound.

Show answer & explanation

Answer: Place a standard surgical mask on the client if transport to another department is necessary.; Remove the disposable gown and gloves inside the client's room before stepping into the hallway.; Ensure that reusable medical equipment, such as a stethoscope, is dedicated solely to this client.

Answer

The appropriate actions are placing a surgical mask on the client during transport, removing the gown and gloves inside the room, and dedicating reusable medical equipment to the client.

The client requires both Droplet Precautions for influenza A and Contact Precautions for the MRSA infection. Dedicating reusable equipment and doffing the gown and gloves inside the room are standard Contact Precaution measures necessary to prevent environmental contamination. Placing a surgical mask on the client during transport acts as essential source control for Droplet Precautions.

Step-by-Step Solution

Identify the required transmission-based precautions based on the client's diagnoses.

Influenza A requires Droplet Precautions, and the MRSA wound infection requires Contact Precautions.

Pathogen transmission routes dictate the specific isolation categories necessary to protect staff and other clients.

Determine the appropriate clinical actions and environmental controls for the combined precautions.

Appropriate actions include dedicating reusable equipment (Contact), removing gown/gloves before leaving the room (Contact), and placing a mask on the client during necessary transport (Droplet).

These combined measures act as source control for respiratory droplets and prevent direct transmission of infectious organisms from the client's immediate environment.

Evaluate the distractors against established PPE sequencing rules and the PN scope of practice.

The incorrect options violate the CDC sequence for donning and doffing PPE, and inappropriately assign an initial comprehensive assessment to the PN.

Improper PPE sequencing increases cross-contamination risks, and an RN must establish the initial baseline assessment.

Key Concept

Standard and Transmission-Based Precautions

Question 2706Question →

A client diagnosed with schizophrenia is scheduled to receive a morning dose of oral clozapine. Upon reviewing the electronic health record, the practical nurse notes that the client's most recent absolute neutrophil count (ANC) is $800/\text{mm}^3$ . Which action should the nurse take first?

Withhold the dose of clozapine and immediately notify the registered nurse.

Administer the medication as prescribed and document the laboratory results in the client's chart.

Independently cancel the medication order in the electronic health record to prevent future administration.

Ask the client to state their name and administer the medication, bypassing barcode scanning to ensure prompt delivery.

Show answer & explanation

Answer: Withhold the dose of clozapine and immediately notify the registered nurse.

Answer

Withhold the dose of clozapine and immediately notify the registered nurse.

Clozapine carries a black box warning for severe neutropenia and agranulocytosis. An absolute neutrophil count (ANC) of

800/\text{mm}^3

is dangerously low. The practical nurse is legally and ethically responsible for reviewing relevant laboratory data prior to administration, withholding the medication if a critical abnormality is found, and promptly notifying the supervising registered nurse or provider.

Step-by-Step Solution

Identify the medication and its associated physiological risks.

Clozapine is an atypical antipsychotic known to cause agranulocytosis, which severely lowers the white blood cell and neutrophil counts.

Understanding the specific adverse effects of a medication is crucial for determining which client assessments and laboratory values require monitoring before administration.

Evaluate the client's current laboratory data against normal reference ranges.

The client's absolute neutrophil count (ANC) is

800/\text{mm}^3

, which is significantly below the normal range (typically

1,500

8,000/\text{mm}^3

Safe medication administration requires ensuring that the client's physiological status can safely tolerate the drug without life-threatening complications.

Determine the appropriate nursing intervention within the practical nurse (PN) scope of practice.

The PN must withhold the scheduled dose and immediately escalate the critical laboratory finding to the registered nurse or healthcare provider.

Administering the medication could lead to fatal infection due to severe immunosuppression, and independently altering orders exceeds the PN's legal scope of practice.

Key Concept

Monitoring adverse effects of medications and escalating critical laboratory values within the practical nurse scope of practice.

Question 2707Question →

An older adult client with acute confusion is restless and repeatedly attempts to get out of bed without assistance, creating a high risk for falls. In what order should the practical nurse (PN) implement the following safety interventions, from least restrictive to most restrictive?

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence from least to most restrictive is to first address physiological triggers, then relocate the client for better visualization, next activate a bed-exit alarm, and finally apply physical restraints as a last resort.

When managing a client at high risk for falls due to confusion, the nurse must follow the principle of using the least restrictive intervention first. The sequence begins with assessing and treating underlying physiological causes. If agitation persists, environmental modifications like moving the client closer to the nursing station are implemented. Next, technological safety devices such as bed alarms are utilized. Finally, if all non-restrictive alternatives have failed and the client's safety is in immediate jeopardy, physical restraints may be applied with a healthcare provider's prescription.

Step-by-Step Solution

Identify and address underlying physiological triggers, such as a full bladder or untreated pain.

Basic physical causes of agitation are resolved.

Addressing foundational physiological needs is the least restrictive and most direct way to resolve confusion-related restlessness.

Relocate the client to a room directly across from the nursing station for frequent visual monitoring.

The environment is modified for increased safety.

Environmental surveillance is a non-invasive safety measure that does not physically restrict the client.

Activate a bed-exit alarm system to alert nursing staff immediately upon movement.

Staff are notified if the client attempts to exit the bed.

Electronic monitoring is more intrusive than visual checks but is less restrictive than physical restraint.

Apply prescribed soft limb restraints as a final measure to prevent injury.

The client is physically prevented from leaving the bed.

Physical restraints are the most restrictive measure and are legally and ethically reserved as an absolute last resort.

Key Concept

Hierarchy of Least Restrictive Interventions for Fall Prevention

Question 2708Question →

An older adult client is seated in the procedure room awaiting a scheduled thoracentesis. When the practical nurse (PN) asks if the client is ready to sign the informed consent document, the client replies, "I will sign it, but I am still not entirely sure what happens if my lung gets punctured." Which action is the priority for the PN?

Explain the signs of a punctured lung and how the healthcare team would treat it.

Reassure the client that the provider performs this procedure frequently with minimal complications.

Stop the consent process and notify the healthcare provider to speak with the client.

Witness the client's signature and document the knowledge deficit in the medical record.

Show answer & explanation

Answer: Stop the consent process and notify the healthcare provider to speak with the client.

Answer

Stop the consent process and notify the healthcare provider to speak with the client.

Informed consent requires the client to fully understand the risks, benefits, and alternatives of a procedure. Because explaining these elements is strictly the responsibility of the healthcare provider, the practical nurse must advocate for the client by stopping the consent process and having the provider return to answer the client's questions.

Step-by-Step Solution

Assess the client's understanding of the procedure before witnessing the signature.

The client verbalizes a lack of understanding regarding potential procedural complications.

The PN must verify that the client has been fully informed by the provider and understands the risks.

Halt the consent process and notify the healthcare provider.

The provider returns to address the client's specific questions about lung puncture.

Explaining medical risks and complications is the sole responsibility of the provider, not the practical nurse.

Key Concept

The practical nurse's role in informed consent is limited to witnessing the signature and verifying voluntary agreement. If a client expresses a knowledge deficit, the PN must halt the process and notify the provider.

Question 2709Question →

A practical nurse (PN) is monitoring a client who had an uncomplicated vaginal delivery 3 hours ago. The client is resting in bed and states, "I feel suddenly very weak and a bit dizzy when I lift my head." The PN notes that the client has saturated one perineal pad over the last 45 minutes. The client's skin is cool and slightly clammy. Vital signs reveal a heart rate of 112 beats/min and a blood pressure of 98/60 mm Hg. Which of the following is the priority action for the PN?

Palpate the uterine fundus and immediately begin fundal massage if it feels soft or boggy.

Elevate the head of the bed to a high-Fowler's position to help alleviate the client's dizziness.

Reassure the client that these symptoms are expected and reassess the vital signs in 30 minutes.

Document the saturated pad as a normal clearance of lochia rubra during the early postpartum period.

Show answer & explanation

Answer: Palpate the uterine fundus and immediately begin fundal massage if it feels soft or boggy.

Answer

The priority action is to palpate the uterine fundus and immediately begin fundal massage if it feels soft or boggy.

The client's presentation of saturating a perineal pad in under an hour, combined with tachycardia, hypotension, dizziness, and clammy skin, points directly to postpartum hemorrhage and early hypovolemic shock. The most common cause of early postpartum hemorrhage is uterine atony (failure of the uterus to contract). The priority and most effective initial action for the practical nurse is to assess the uterine fundus. If it is soft or boggy, immediate fundal massage must be initiated to stimulate contraction and compress the bleeding vessels before further assistance is summoned.

Step-by-Step Solution

Analyze the clinical findings.

The client has saturated a pad in 45 minutes, has tachycardia (112 bpm), hypotension (98/60 mm Hg), clammy skin, and dizziness.

Recognizing the combination of excessive bleeding and abnormal vital signs identifies the complication as postpartum hemorrhage leading to hypovolemic shock.

Determine the priority nursing intervention.

The most common cause of early postpartum hemorrhage is uterine atony. The first action must address the immediate source of bleeding.

By prioritizing airway, breathing, and circulation (ABC), stopping the bleeding is the immediate necessity.

Select the correct PN action.

Palpating the fundus and massaging it if boggy is the appropriate direct intervention within the PN's scope of practice.

Fundal massage stimulates uterine contraction, which compresses bleeding vessels and reduces hemorrhage.

Key Concept

Postpartum Hemorrhage and Hypovolemic Shock Recognition

Question 2710Question →

A practical nurse (PN) is preparing to administer a scheduled dose of ampicillin intramuscularly (IM) to a pediatric client who weighs $52.8\text{ lb}$ . The healthcare provider's prescription reads: ampicillin $100\text{ mg/kg/day}$ IM divided in equal doses every 6 hours. The pharmacy dispenses a $1\text{ g}$ vial of ampicillin powder. The reconstitution instructions on the vial state: "Add $3.5\text{ mL}$ of sterile water for injection to yield a final volume of $4\text{ mL}$ with a concentration of $250\text{ mg/mL}$ ."

How many milliliters (mL) should the PN administer per dose?

Record your answer using one decimal place. Do not include units in your answer.

Show answer & explanation

Answer: 2.4

Answer

2.4

To solve this problem, first convert pounds to kilograms (

52.8\text{ lb} \div 2.2 = 24\text{ kg}

). Next, determine the total daily dose (

24\text{ kg} \times 100\text{ mg/kg} = 2400\text{ mg/day}

). Since the medication is given every 6 hours (4 times a day), divide the daily dose by 4 to find the single dose (

2400\text{ mg} \div 4 = 600\text{ mg/dose}

). Finally, use the final yield concentration (

250\text{ mg/mL}

) to find the volume:

600\text{ mg} \div 250\text{ mg/mL} = 2.4\text{ mL}

. The values of

1\text{ g}

3.5\text{ mL}

of sterile water, and

4\text{ mL}

total volume are extraneous information not used in the final equation.

Step-by-Step Solution

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

24\text{ kg}

The medication is prescribed based on milligrams per kilogram (

mg/kg

), so the weight must be in standard metric units (

52.8\text{ lb} \div 2.2\text{ lb/kg} = 24\text{ kg}

Calculate the total daily dose of the medication.

2400\text{ mg/day}

Multiply the client's weight in kg by the prescribed daily dosage parameter (

24\text{ kg} \times 100\text{ mg/kg/day} = 2400\text{ mg/day}

Determine the amount of medication required for a single dose.

600\text{ mg/dose}

The medication is ordered every 6 hours, which equals 4 doses in a 24-hour period. Divide the total daily dose by 4 (

2400\text{ mg} \div 4 = 600\text{ mg/dose}

Calculate the required volume to administer using the final reconstituted concentration.

2.4\text{ mL}

Divide the desired dose (

600\text{ mg}

) by the concentration on hand (

250\text{ mg/mL}

). The diluent amount (

3.5\text{ mL}

) and total vial volume (

4\text{ mL}

) are extraneous distractors (

600\text{ mg} \div 250\text{ mg/mL} = 2.4\text{ mL}

Key Concept

Advanced dosage calculation requiring weight conversion, daily-to-single dose division, and identification of correct reconstitution concentration while filtering extraneous data.

Estimated Time:3m 0s

Question 2711Question →

During the morning briefing on a specialized nephrology floor, client assignments are being determined for the nursing staff. Which of the following clients represents the most appropriate assignment for a practical nurse (PN)?

A client admitted two hours ago with acute pyelonephritis who requires an initial comprehensive physical assessment.

A client scheduled for a cystoscopy who is requesting further explanation about potential surgical complications before signing the consent form.

A client with chronic kidney disease who is receiving scheduled oral phosphate binders and requires a daily weight measurement.

A client with acute kidney injury who has a morning serum potassium level of 6.9 mEq/L and reports new onset palpitations.

Show answer & explanation

Answer: A client with chronic kidney disease who is receiving scheduled oral phosphate binders and requires a daily weight measurement.

Answer

The client with chronic kidney disease who is receiving scheduled oral phosphate binders and requires a daily weight measurement.

The correct answer identifies a stable client with a chronic condition requiring predictable, standard care. The administration of routine oral medications (such as phosphate binders) and the monitoring of daily weights are safely within the standard scope of practice for a practical nurse.

Step-by-Step Solution

Evaluate the stability and acuity of each client described in the options.

Three clients are unstable, require complex assessment, or need provider intervention. One client is stable with predictable, chronic needs.

The PN scope of practice is limited to caring for stable clients with expected outcomes.

Determine which specific nursing tasks are within the PN scope of practice.

Routine oral medication administration and daily weights are within the PN scope. Initial assessments, managing critical lab values, and explaining surgical risks are outside the PN scope.

Delegation and assignments must adhere to the legal and educational boundaries of the practical nurse's license.

Key Concept

Delegating and Assigning Client Care Based on Scope of Practice

Question 2712Question →

A practical nurse (PN) is reinforcing teaching with a client about how to use a metered-dose inhaler (MDI) without a spacer. In which order should the PN instruct the client to perform the following steps? Arrange the actions in the correct sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to shake the inhaler, exhale deeply, seal the lips around the mouthpiece, press the canister while inhaling slowly, and finally hold the breath for 10 seconds.

Correct administration of a metered-dose inhaler requires a precise sequence to ensure maximum drug delivery to the lungs. Shaking the inhaler prepares the dose. Exhaling deeply creates room for maximum inhalation. Sealing the lips around the mouthpiece prevents medication loss. Actuating the inhaler while taking a slow, deep breath ensures the drug reaches the lower airways. Finally, holding the breath allows the medication to settle onto the bronchial walls for optimal therapeutic effect.

Step-by-Step Solution

Shake the inhaler vigorously for 3 to 5 seconds.

The medication and propellant are thoroughly mixed.

Ensures the correct dose of medication is delivered when actuated.

Exhale deeply to empty the lungs completely.

The lungs are emptied of air.

Prepares the lungs to take in a deep breath and draw the medication as deeply as possible into the lower airways.

Place the mouthpiece into the mouth and form a tight seal with the lips.

A secure airway connection is established.

Prevents the medication from escaping from the corners of the mouth during administration.

Press down firmly on the canister while inhaling slowly and deeply.

The medication is released and drawn into the respiratory tract.

Simultaneous actuation and inhalation carry the aerosolized particles down into the bronchioles.

Hold the breath for at least 10 seconds before exhaling slowly.

The medication settles in the lower airways.

Allows time for the medication to deposit onto the walls of the airways rather than being immediately exhaled.

Key Concept

Metered-Dose Inhaler (MDI) Administration Sequence

Question 2713Question →

A client with complete paraplegia needs to be transferred from the hospital bed to a bedside chair. The practical nurse and an assistive personnel (AP) are using a mechanical full-body sling lift for the procedure. Arrange the following steps in the correct chronological order to ensure a safe transfer.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first position the sling under the client, move the lift into position and widen its base, attach the sling to the hanger bar, raise the client clear of the bed, and finally steer the lift to lower the client into the chair.

The correct sequence follows the standard principles of ergonomics and equipment safety: prepare the client, prepare and stabilize the equipment, secure the connection, perform the lift safely, and complete the transfer. Widening the base of the lift before attaching the client is critical for preventing falls and maintaining a low center of gravity.

Step-by-Step Solution

Position the sling

The sling is centered under the client's body.

This must be done first before bringing the lift over the bed to provide clearance and safety.

Widen the lift base

The lift is stabilized.

Widening the base of support lowers the center of gravity and prevents the lift from tipping over during the transfer.

Attach the sling loops

The client is safely connected to the lifting mechanism.

The connections must be checked for security before any lifting force is applied.

Elevate the client

The client clears the mattress.

Keeping the client close to the bed surface reduces injury risk if the sling were to fail.

Transfer to chair

The client is safely seated.

The final step is completing the transfer to the destination.

Key Concept

Mechanical Lift Safety and Ergonomics

Question 2714Question →

A client arrives at the medical-surgical unit shortly after undergoing a right-sided modified radical mastectomy. The practical nurse is initiating immediate postoperative care. Which of the following interventions should the nurse include to promote safety, basic care, and comfort? Select all that apply.

Select all that apply

Elevate the client's right arm on a pillow to facilitate lymphatic drainage.

Place the client in a semi-Fowler's position to promote comfortable breathing.

Instruct the client to squeeze a soft washcloth or ball with the right hand.

Position the client on the right side to provide counter-pressure against the incision.

Change the client's soiled surgical gown before verifying airway patency.

Explain the client's surgical procedure to the roommate to foster a supportive environment.

Show answer & explanation

Answer: Elevate the client's right arm on a pillow to facilitate lymphatic drainage.; Place the client in a semi-Fowler's position to promote comfortable breathing.; Instruct the client to squeeze a soft washcloth or ball with the right hand.

Answer

The correct actions include elevating the right arm on a pillow, placing the client in a semi-Fowler's position, and instructing the client to perform hand-squeezing exercises.

Appropriate basic care following a mastectomy focuses on preventing lymphedema and respiratory complications. Elevating the affected arm uses gravity to encourage lymphatic fluid return. A semi-Fowler's position reduces tension on the surgical site and promotes full lung expansion. Early, gentle hand exercises enhance circulation and prevent muscle contractures without straining the surgical area.

Step-by-Step Solution

Analyze the client's surgical procedure and anatomical risks.

The client had a right-sided mastectomy, meaning the right chest wall, axilla, and right arm are at high risk for swelling (lymphedema), impaired circulation, and compromised healing.

Understanding the anatomical risks determines safe positioning and activity limits.

Evaluate the positioning and comfort options based on the surgical risks.

Elevating the affected arm and using a semi-Fowler's position are identified as safe and effective to promote drainage and breathing. Early hand exercises promote circulation. Conversely, lying on the operative side is contraindicated because it compresses the area.

Proper body alignment and early gentle movement prevent lymphedema and respiratory complications.

Apply prioritization and ethical frameworks to the remaining options.

Assessing airway patency (ABCs) must strictly precede hygiene care. Sharing medical details with a roommate violates confidentiality.

Clinical judgment requires prioritizing life-threatening risks first and maintaining strict adherence to privacy regulations.

Key Concept

Post-Mastectomy Basic Care and Positioning

Question 2715Question →

An LPN is preparing to administer morning medications to a client with heart failure. The client's morning laboratory results show a serum potassium level of 2.9 mEq/L (2.9 mmol/L). Which action should the nurse take first?

Administer the scheduled dose of the daily diuretic.

Assess the client's skin turgor and oral mucous membranes.

Report the potassium level to the charge nurse immediately.

Document the potassium level in the electronic health record.

Show answer & explanation

Answer: Report the potassium level to the charge nurse immediately.

Answer

The priority action is to immediately report the critical potassium level to the charge nurse or healthcare provider.

The normal serum potassium level is 3.5 to 5.0 mEq/L. A level of 2.9 mEq/L indicates severe hypokalemia, which places the client at high risk for life-threatening cardiac arrhythmias. Within the practical nursing scope of practice, recognizing a critical laboratory value requires immediate escalation to the registered nurse or healthcare provider to ensure timely intervention and optimal risk reduction.

Step-by-Step Solution

Identify the normal range for serum potassium.

The normal serum potassium reference range is 3.5 to 5.0 mEq/L.

To determine if the client's laboratory value is within safe clinical limits.

Analyze the client's laboratory result.

A level of 2.9 mEq/L is significantly below the normal range, indicating severe hypokalemia.

To recognize potential clinical risks, such as life-threatening cardiac arrhythmias.

Determine the priority nursing action based on the LPN scope of practice.

The LPN must prioritize client safety by immediately notifying the supervising RN.

Critical laboratory values represent an immediate physiological risk that requires escalation for timely medical intervention.

Key Concept

Recognition and Escalation of Critical Laboratory Values

Estimated Time:1m 0s

Question 2716Question →

A practical nurse (PN) is caring for a client admitted with a severe gastrointestinal bleed. The client is restless and reports abdominal cramping rated as 7 on a 0 to 10 scale. Data collection reveals a heart rate of 118 beats/min, a blood pressure of 88/56 mm Hg, and a hemoglobin level of 6.8 g/dL (68 g/L). Which of the following actions should the PN take first?

Notify the registered nurse (RN) immediately about the assessment findings.

Administer the prescribed as-needed (PRN) analgesic for the abdominal cramping.

Reassess the client's vital signs in one hour to monitor for further changes.

Document the hemoglobin level in the electronic health record for the provider to review later.

Show answer & explanation

Answer: Notify the registered nurse (RN) immediately about the assessment findings.

Answer

The correct action is to immediately notify the registered nurse (RN) about the assessment findings.

The correct answer involves notifying the RN immediately because the client's tachycardia, hypotension, restlessness, and critically low hemoglobin indicate active bleeding and hypovolemic shock. Within the PN scope of practice, escalating critical, life-threatening changes is the absolute top priority.

Step-by-Step Solution

Analyze the client's clinical presentation.

The client has a history of a gastrointestinal bleed, is restless, has a high heart rate (118 beats/min), low blood pressure (88/56 mm Hg), and a critically low hemoglobin level (6.8 g/dL).

Recognizing abnormal data is the first step in clinical judgment.

Identify the underlying complication.

The combination of these findings indicates active bleeding leading to hypovolemic shock.

Connecting the data points helps determine the severity of the situation.

Determine the priority nursing action within the PN scope of practice.

The priority is to immediately communicate these critical findings to the RN.

The client requires rapid intervention (such as blood transfusions or intravenous fluids) that the RN must coordinate with the provider.

Key Concept

Prioritization of care in hypovolemic shock

Estimated Time:1m 0s

Question 2717Question →

A practical nurse (PN) is preparing to irrigate the widespread skin lesions of an immunocompromised client diagnosed with disseminated herpes zoster. Which of the following describes the correct sequence and selection of personal protective equipment (PPE) the PN must don before entering the client's airborne infection isolation room (AIIR)?

Fasten a disposable gown, apply an N95 respirator and perform a user seal check, place a face shield over the face, and pull clean gloves over the cuffs of the gown.

Fasten a disposable gown, apply a standard surgical mask, place a face shield over the face, and pull clean gloves over the cuffs of the gown.

Apply an N95 respirator and perform a user seal check, fasten a disposable gown, place a face shield over the face, and pull clean gloves over the cuffs of the gown.

Fasten a disposable gown, pull clean gloves over the cuffs of the gown, apply an N95 respirator and perform a user seal check, and place a face shield over the face.

Show answer & explanation

Answer: Fasten a disposable gown, apply an N95 respirator and perform a user seal check, place a face shield over the face, and pull clean gloves over the cuffs of the gown.

Answer

The correct action is to first put on the gown, followed by the N95 respirator, then the face shield, and finally the gloves.

The scenario requires the integration of three critical infection control concepts. First, disseminated herpes zoster requires both Airborne and Contact precautions, necessitating an N95 respirator, a gown, and gloves. Second, the act of irrigating lesions introduces a splash risk, which means a face shield or goggles must be added under Standard Precautions. Finally, the Centers for Disease Control and Prevention (CDC) strictly outlines the donning sequence to ensure maximum protection and minimize contamination: the gown is put on first, followed by the respirator, then the face shield, and lastly the gloves, which must extend over the cuffs of the gown.

Step-by-Step Solution

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

Disseminated herpes zoster requires both Airborne and Contact precautions.

The virus can be transmitted through both aerosolized airborne particles and direct contact with the vesicular fluid.

Determine if additional PPE is needed based on the planned nursing procedure.

Irrigating lesions poses a risk for splashes or sprays of infectious fluid.

Standard precautions dictate that eye and face protection (like a face shield) must be added when splashes are anticipated.

Apply the required PPE in the standardized CDC sequence for donning.

The correct order is: Gown -> Mask/Respirator (N95) -> Goggles/Face Shield -> Gloves.

This specific sequence ensures all protective barriers are securely in place, with gloves applied last to cover the gown's cuffs and prevent cross-contamination during the donning process.

Key Concept

Selection and sequencing of Personal Protective Equipment (PPE) for complex isolation scenarios.

Question 2718Question →

A practical nurse (PN) is assisting a colleague with a complex wound dressing change. The colleague uses a personal smartphone to photograph the wound, stating, "The facility camera is missing, and the wound care specialist needs to see this immediately. I made sure the client's face is not in the picture." Which action should the PN take first?

Instruct the colleague to immediately delete the photograph from the personal smartphone.

Confirm that no identifying features or room numbers are visible in the background of the photograph.

Obtain verbal consent from the client to send the image to the wound care specialist.

Report the incident directly to the facility's privacy officer or charge nurse.

Show answer & explanation

Answer: Instruct the colleague to immediately delete the photograph from the personal smartphone.

Answer

The correct action is to instruct the colleague to immediately delete the photograph from the personal smartphone.

Using an unencrypted personal device to capture any client clinical data is a direct violation of HIPAA and facility policy, regardless of whether the face is visible. The nurse's first responsibility when witnessing an active breach is to intervene immediately to mitigate the risk. Having the colleague delete the photo prevents it from being sent over an unsecured network or synced to a personal cloud.

Step-by-Step Solution

Identify the primary issue in the scenario.

A colleague is using an unsecured personal device to capture protected health information (PHI).

Recognizing the nature of the confidentiality breach determines the necessary intervention.

Determine the priority of action based on nursing leadership and safety principles.

The immediate priority is to stop the ongoing violation to prevent further dissemination of the data.

If the photo remains on the phone, it risks being transmitted via unsecured networks or backed up to a personal cloud server.

Select the option that addresses the immediate threat.

Instructing the colleague to delete the photograph directly halts the breach.

Direct intervention is prioritized over delaying to report or attempting to validate an already prohibited action.

Key Concept

HIPAA Compliance and Mobile Device Security

Estimated Time:1m 0s

Question 2719Question →

An older adult client is resting in bed after undergoing an endoscopic swallowing evaluation earlier in the shift. The nursing care plan notes that the client is experiencing intermittent confusion and requires assistance with oral intake and comfort measures. Which actions should the practical nurse select to safely implement basic care? Select all that apply.

Select all that apply

Verify the client's ability to swallow safely prior to initiating the prescribed clear liquid diet.

Position the client flat in a supine position to promote rest and recovery from the endoscopy.

Explain to the family that intermittent confusion is a normal physiological response to aging.

Provide warm saline gargles or throat lozenges to soothe localized oropharyngeal irritation.

Apply soft limb restraints to prevent the disoriented client from dislodging the intravenous access device.

Utilize a soft-bristled toothbrush or moistened sponge swab to perform comprehensive oral hygiene.

Show answer & explanation

Answer: Verify the client's ability to swallow safely prior to initiating the prescribed clear liquid diet.; Provide warm saline gargles or throat lozenges to soothe localized oropharyngeal irritation.; Utilize a soft-bristled toothbrush or moistened sponge swab to perform comprehensive oral hygiene.

Answer

The correct actions include verifying the client's ability to swallow safely before offering fluids, providing warm saline gargles or lozenges for throat discomfort, and using gentle tools for oral hygiene.

The correct actions prioritize airway safety and patient comfort. Verifying the ability to swallow safely prevents aspiration when resuming oral intake after an endoscopy. Providing warm saline gargles or lozenges addresses the expected localized throat irritation caused by the endoscopic tube, promoting comfort. Utilizing a soft-bristled brush or moistened swab ensures oral hygiene is maintained while preventing mucosal trauma in a potentially irritated oropharynx.

Step-by-Step Solution

Analyze the client's current physiological status and risks associated with a recent endoscopic procedure.

Identified high risk for aspiration and localized throat irritation.

Understanding procedural impacts helps prioritize airway safety and basic comfort.

Evaluate the significance of the client's intermittent confusion.

Determined that acute confusion is abnormal and requires further assessment, rather than being dismissed or immediately managed with restraints.

Recognizing delirium or hypoxia prevents inappropriate interventions and delays in care.

Select interventions that safely promote comfort and basic hygiene.

Chose gentle oral care, safe feeding practices, and non-pharmacological soothing measures.

These actions strictly align with the practical nurse's scope of practice for basic care and comfort.

Key Concept

Basic Care and Comfort: Post-Procedural Safety and Hygiene

Question 2720Question →

A practical nurse is preparing to administer a large-volume tap water cleansing enema to an adult client experiencing constipation. In what order should the nurse perform the following actions? Arrange the steps in the correct chronological sequence from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first position the client appropriately, lubricate the tube, insert the tube into the rectum, elevate the container to begin the flow, and finally, monitor the client and adjust the flow if cramping occurs.

Administering a large-volume enema requires a systematic approach to ensure safety, effectiveness, and comfort. The nurse must first place the client in the left lateral Sims' position to align with the anatomy of the descending colon. Once positioned, the nurse lubricates the tube to prevent mucosal trauma. The tube is then gently inserted 3 to 4 inches, following the direction of the umbilicus. After safe placement, the nurse elevates the container 12 to 18 inches above the anus and unclamps it to initiate the flow. Throughout the procedure, the nurse monitors the client's tolerance, lowering the container or clamping the tube if cramping occurs to allow the colon to relax.

Step-by-Step Solution

Position the client in the left lateral Sims' position.

The client is anatomically aligned for the procedure.

The left lateral position allows the enema solution to flow downward by gravity into the sigmoid colon.

Lubricate the distal end of the rectal tube.

The tube is prepared for safe insertion.

Water-soluble lubricant prevents tissue damage and eases the tube's passage through the anal sphincters.

Insert the tube 3 to 4 inches toward the umbilicus.

The tube is securely positioned in the rectum.

This depth and angle follow the natural course of the bowel and prevent perforation.

Elevate the container and unclamp the tubing.

The solution begins to instill into the colon.

A height of 12 to 18 inches ensures adequate pressure without causing rapid distention of the bowel.

Lower the container if the client experiences cramping.

The instillation rate is reduced or paused.

Stopping the flow temporarily relieves colon spasms and promotes fluid retention.

Key Concept

Safe procedural sequencing for enema administration

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