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2933 questions

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A practical nurse is assessing a client who is 3 days postoperative following an abdominal laparotomy. The client experiences a vigorous coughing fit and suddenly reports a sensation of something "giving way" in their abdomen. Upon inspection, the nurse observes that the surgical incision has separated and a loop of intestine is protruding. In which order should the nurse perform the following actions? Arrange the steps from first priority to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence prioritizes securing immediate help, reducing physical strain on the wound, protecting the exposed tissue, assessing hemodynamic stability, and preparing for definitive surgical repair.

Wound evisceration is a medical emergency requiring rapid, sequential actions to protect the exposed bowel and stabilize the client. The immediate priority is to get help without leaving the client. Next, mechanical tension on the abdomen must be reduced by flexing the client's knees and elevating the head slightly. After reducing tension, the exposed organs are covered with sterile, moist dressings to prevent necrosis. Once the tissue is protected, assessing vital signs for shock becomes the priority before ultimately preparing the client for emergency surgical repair.

Step-by-Step Solution

Secure help and escalate.

Additional personnel are mobilized to notify the provider and gather supplies.

The primary nurse must not leave the bedside of a client experiencing an acute evisceration.

Modify the client's position to low-Fowler's with flexed knees.

Intra-abdominal pressure is significantly reduced.

This prevents further loops of bowel from protruding through the separated incision.

Cover the viscera with sterile, saline-moistened dressings.

The exposed bowel is kept moist and protected from environmental contaminants.

Preserves tissue viability and prevents necrosis prior to surgical intervention.

Assess a full set of vital signs.

Baseline data during the emergency is established.

Allows for the early identification of hypovolemic shock resulting from fluid shifts and stress.

Initiate preoperative preparation protocols.

The client is ready for rapid transport.

Evisceration is a surgical emergency requiring immediate closure in the operating room.

Key Concept

Prioritization of care during wound evisceration

Question 2722Question →

A client who underwent a total hip arthroplasty 24 hours ago is found pulling at their intravenous tubing. The client, who was fully oriented during the morning assessment, is now highly restless and disoriented to place. The current heart rate is 112 beats per minute and the respiratory rate is 26 breaths per minute. What is the priority action for the practical nurse in this situation?

Inform family members that temporary confusion is an expected, normal finding in older adults after major surgery.

Contact the provider to obtain a prescription for an anti-anxiety medication to control the agitated behavior.

Obtain a pulse oximetry reading and immediately evaluate the client's respiratory status.

Log the mild tachycardia in the medical record and proceed with the standard scheduled checks.

Show answer & explanation

Answer: Obtain a pulse oximetry reading and immediately evaluate the client's respiratory status.

Answer

The priority action is to evaluate the client's respiratory status by obtaining a pulse oximetry reading and assessing the airway and breathing.

Sudden onset of restlessness, agitation, and confusion, particularly when accompanied by tachypnea and tachycardia, are classic early indicators of hypoxia. Because this client is 24 hours post-hip arthroplasty, they are at high risk for a pulmonary embolism or fat embolism. The nurse must prioritize the 'Airway and Breathing' components of the ABC framework by immediately evaluating the client's oxygenation status before considering other interventions.

Step-by-Step Solution

Analyze the clinical cues presented by the client.

The client exhibits sudden restlessness, disorientation, tachycardia, and tachypnea 24 hours post-surgery.

Identifying acute deviations from a client's baseline is the first step in clinical reasoning and recognizing complications.

Determine the most life-threatening potential cause for these new symptoms.

Sudden agitation and confusion, accompanied by increased heart and respiratory rates, are hallmark early signs of hypoxia (such as from a pulmonary embolism or fat embolism).

Prioritization requires addressing airway, breathing, and circulation (ABC) before considering secondary psychological or environmental concerns.

Select the intervention that directly addresses the highest priority need.

Assessing oxygenation status is the immediate priority to rule out or confirm a life-threatening respiratory compromise.

Nursing interventions must follow the ABC framework; assessing respiratory function takes precedence over administering sedatives or performing routine documentation.

Key Concept

Hypoxia Recognition and ABC Prioritization

Question 2723Question →

A practical nurse (PN) is assisting a client with ambulation in the hallway using a gait belt. The client suddenly reports feeling dizzy, their knees buckle, and they begin to fall. Arrange the following actions the PN should take in the correct chronological order to safely assist the client to the floor.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to establish a base of support, bring the client close, extend a leg for the client to slide down, lower them by bending the knees while protecting the head, and then call for help to assess for injuries.

When a client begins to fall during ambulation, the nurse's priority is to perform a controlled 'assisted fall' to minimize injury. The sequence must begin with the nurse establishing their own stability by taking a wide stance. Next, bringing the client close to the nurse's center of gravity provides control over the descending weight. Extending a leg creates a safe slide path, preventing a rapid drop. Bending at the knees ensures the nurse uses strong leg muscles rather than straining the back, while the nurse actively protects the client's head from impact. Finally, once safely on the floor, the client must remain stationary until a thorough assessment is completed to prevent exacerbating any potential injuries.

Step-by-Step Solution

Establish stability.

The nurse takes a wide stance with feet apart.

Creates a broad base of support to prevent the nurse from losing balance when taking on the client's weight.

Control the client's weight.

The client is pulled close to the nurse using the gait belt.

Aligns the client with the nurse's center of gravity, providing maximum control and reducing back strain.

Create a descent path.

The nurse extends one leg forward.

Provides a physical surface for the client to safely slide down rather than free-falling.

Lower the client to the floor.

The nurse bends at the knees and protects the client's head.

Uses strong leg muscles (proper body mechanics) and prevents traumatic head injury upon contact with the floor.

Manage post-fall care.

The client is instructed to stay still while the nurse calls for assistance.

Moving a client immediately after a fall can worsen undetected fractures or internal injuries.

Key Concept

Safe Management of an Active Client Fall (Assisted Fall Technique)

Question 2724Question →

A client with progressive dementia resides in a subacute rehabilitation facility and is scheduled for the surgical placement of a percutaneous endoscopic gastrostomy (PEG) tube. The healthcare provider discussed the procedure with the client's legally designated healthcare proxy the previous day. The proxy arrives at the facility to sign the consent form. As the practical nurse (PN) presents the document, the proxy asks, "I know the doctor explained it yesterday, but could you quickly remind me of the alternative options if we decline the feeding tube?" Which action should the PN take?

Review the healthcare provider's progress notes with the proxy to clarify the alternative treatments.

Explain the available alternative methods for providing artificial nutrition before witnessing the signature.

Withhold the consent form and contact the healthcare provider to address the proxy's questions.

Request that the registered nurse (RN) explain the alternative treatment options to the proxy.

Show answer & explanation

Answer: Withhold the consent form and contact the healthcare provider to address the proxy's questions.

Answer

Withhold the consent form and contact the healthcare provider to address the proxy's questions.

The practical nurse's legal role in informed consent is to witness the signature, confirm the client or proxy is competent, and verify that consent is voluntary. Explaining the procedure, its risks, benefits, and any alternative treatments is solely the responsibility of the healthcare provider. Because the proxy expressed a need for clarification regarding alternatives, the nurse must withhold the consent form and notify the provider to answer these questions before the signature is obtained.

Step-by-Step Solution

Identify the practical nurse's legal role in the informed consent process.

The nurse's role is strictly to act as a witness to the signature, verify the person signing is competent, and ensure consent is given voluntarily.

This establishes the legal boundaries of the nursing scope of practice.

Evaluate the healthcare proxy's statement.

The proxy is asking for clarification regarding alternative medical options to the PEG tube.

Determining the nature of the proxy's question indicates whether valid informed consent has been achieved.

Determine the appropriate intervention based on scope of practice.

Because explaining risks, benefits, and alternatives is exclusively the healthcare provider's responsibility, the nurse must halt the consent process and notify the provider.

Answering medical questions about alternatives falls outside the nursing scope of practice, and valid consent cannot be obtained until the provider directly answers the proxy's questions.

Key Concept

The practical nurse's role in informed consent is limited to witnessing the signature and verifying voluntary agreement; any questions about the procedure, risks, or alternatives must be directed to the healthcare provider.

Question 2725Question →

A practical nurse (PN) has finished providing morning care and changing the bed linens for a client diagnosed with both *Rubella* and *Norovirus*. As the PN prepares to leave the isolation room, which sequence of actions is correct?

Remove the gloves and gown inside the client's room, exit the room, remove the surgical mask, and immediately wash hands with soap and water.

Remove the gloves and gown inside the room, perform hand hygiene with an alcohol-based hand rub, exit the room, and remove the surgical mask.

Remove the gown, gloves, and N95 respirator inside the room, then perform hand hygiene using an alcohol-based hand sanitizer.

Exit the room wearing all personal protective equipment, remove the surgical mask, gown, and gloves in the hallway, and wash hands with soap and water.

Show answer & explanation

Answer: Remove the gloves and gown inside the client's room, exit the room, remove the surgical mask, and immediately wash hands with soap and water.

Answer

The correct sequence is to remove the gloves and gown inside the client's room, exit the room, remove the surgical mask, and then immediately wash hands with soap and water.

The client requires Contact Precautions for *Norovirus* and Droplet Precautions for *Rubella*. To prevent cross-contamination, contact personal protective equipment (gown and gloves) must be removed inside the patient's room. Droplet protective equipment (the surgical mask) should be removed after exiting the room. Because *Norovirus* is an enteric pathogen that is resistant to alcohol-based hand rubs, hand hygiene must be performed using soap and water rather than sanitizer.

Step-by-Step Solution

Identify the transmission-based precautions required for the specific pathogens.

*Norovirus* requires Contact Precautions with enhanced enteric hand hygiene. *Rubella* requires Droplet Precautions.

Pathogen-specific protocols dictate the type of personal protective equipment (PPE) worn and the exact method of hand hygiene required.

Determine the correct location for removing Contact Precaution PPE (gown and gloves).

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

Removing contaminated contact PPE outside the room spreads pathogens to the clean hallway environment.

Determine the correct location for removing Droplet Precaution PPE (surgical mask).

The surgical mask must be removed after exiting the client's room and closing the door.

Removing the mask inside the room exposes the nurse's respiratory tract to airborne droplets still suspended in the patient's immediate environment.

Select the appropriate hand hygiene method based on the pathogens present.

Hands must be washed with soap and water.

Alcohol-based hand rubs lack efficacy against non-enveloped enteric viruses like *Norovirus*. Mechanical friction with soap and water is required to physically remove the viral particles from the skin.

Key Concept

Combined Contact and Droplet Precaution Doffing Sequence

Question 2726Question →

A client is recovering on a medical-surgical unit following an ischemic stroke that resulted in severe dysphagia. The client is currently receiving continuous enteral nutrition via a nasogastric (NG) tube. A family member urgently calls the practical nurse into the room, reporting that the client is suddenly highly agitated, coughing forcefully, and attempting to pull out the feeding tube. The family member insists the nurse do something immediately to protect the tube. Which action should the nurse take first to prevent client injury?

Turn off the enteral feeding pump and immediately evaluate the client's respiratory effort.

Obtain a prescription to apply bilateral soft wrist restraints to prevent accidental tube dislodgement.

Administer a prescribed as-needed intravenous push sedative to rapidly control the client's agitation.

Apply additional securement tape to the nasogastric tube while attempting to verbally de-escalate the client.

Show answer & explanation

Answer: Turn off the enteral feeding pump and immediately evaluate the client's respiratory effort.

Answer

Turn off the enteral feeding pump and immediately evaluate the client's respiratory effort.

Sudden agitation and forceful coughing in a client receiving continuous enteral feeding are classic signs of pulmonary aspiration, which is a critical airway and breathing emergency. Stopping the infusion immediately prevents further aspiration injury, prioritizing physiological ABCs (Airway, Breathing, Circulation) over behavioral management or equipment protection.

Step-by-Step Solution

Analyze the client's clinical presentation and the immediate environment.

The client is experiencing sudden agitation and forceful coughing while receiving continuous enteral feeding.

Identifying acute, abnormal changes in the client's condition is the first step in clinical decision-making.

Identify the primary safety and injury risk based on the symptoms.

The combination of dysphagia, continuous feeding, and forceful coughing indicates a high probability of pulmonary aspiration.

Aspiration is a critical airway emergency that can lead to severe injury, respiratory failure, or death.

Determine the priority intervention based on the ABCs (Airway, Breathing, Circulation).

Stopping the infusion directly mitigates the source of the aspiration risk, protecting the airway.

Airway protection and breathing take physiological precedence over protecting equipment or managing behavioral symptoms.

Key Concept

Prioritization of Airway and Aspiration Prevention

Question 2727Question →

A practical nurse (PN) receives a list of delegated tasks from the charge nurse on a general medical unit. Which of the following tasks should the PN accept as appropriate for their legal scope of practice?

Administering scheduled enteral feedings and reinforcing dietary education for a client with a stable gastrostomy tube.

Completing the comprehensive admission assessment and formulating the initial care plan for a client transferred from the emergency department.

Explaining the surgical risks and alternative treatment options to a client before asking them to sign an operative consent form.

Providing a detailed clinical update regarding a client's condition to visiting family members in the unit waiting room.

Show answer & explanation

Answer: Administering scheduled enteral feedings and reinforcing dietary education for a client with a stable gastrostomy tube.

Answer

The correct assignment is administering scheduled enteral feedings and reinforcing dietary education for a client with a stable gastrostomy tube.

The practical nurse (PN) scope of practice includes performing established, routine procedures on stable clients, such as administering enteral feedings. Additionally, while the registered nurse (RN) is responsible for initial client education, the PN is authorized to reinforce that previously taught information.

Step-by-Step Solution

Analyze the scope of practice for a practical nurse (PN) regarding client care tasks.

The PN is authorized to perform routine, predictable tasks on stable clients and reinforce client education.

Safe delegation requires assigning tasks that align with the legal boundaries of nursing practice.

Evaluate the remaining options for scope of practice violations, legal boundaries, or safety concerns.

Comprehensive assessments, explaining surgical risks, and discussing client information in public areas are outside the PN's scope or violate ethical standards.

Identifying out-of-scope or unsafe actions prevents client harm and legal or ethical violations.

Key Concept

Practical Nurse Scope of Practice and Safe Delegation

Question 2728Question →

A practical nurse (PN) is caring for a client with hepatic encephalopathy who is disoriented and restless. Upon entering the room, the PN notices that the client's electronic enteral feeding pump has a cracked outer casing and is leaking liquid formula down the power cord onto the floor. The client is actively pulling at the device's tubing. Which action should the PN take first?

Perform a focused neurological assessment to determine the cause of the client's restlessness.

Unplug the feeding pump from the wall outlet, remove it from the client's reach, and tag it as out of service.

Apply bilateral soft wrist restraints to prevent the client from tampering with the electrical cord.

Delegate an unlicensed assistive personnel (UAP) to disconnect the broken pump and clean the spilled formula.

Show answer & explanation

Answer: Unplug the feeding pump from the wall outlet, remove it from the client's reach, and tag it as out of service.

Answer

Unplug the feeding pump from the wall outlet, remove it from the client's reach, and tag it as out of service.

When a piece of electrical equipment is visibly damaged, leaking fluid, or malfunctioning, it presents an immediate risk for electrocution or fire. The nurse must first ensure safety by disconnecting the power source, removing the item from the client's reach, and properly tagging it so that it is not used again until serviced by biomedical engineering.

Step-by-Step Solution

Identify the immediate threat to the client's safety.

Recognize that a cracked, leaking electrical device poses a high risk of electrocution, fire, and physical injury.

Environmental hazards must be addressed instantly to prevent harm.

Implement the safest immediate intervention.

Disconnect the device from its power source and remove it from the client's environment.

Removing power eliminates the electrical hazard, and removing the device prevents the disoriented client from further interaction.

Follow facility safety protocols for broken equipment.

Apply an out-of-service tag to the device and notify biomedical engineering.

This ensures the defective equipment is not inadvertently used by other staff members.

Key Concept

Management of defective biomedical equipment and prioritization of environmental safety.

Question 2729Question →

A 78-year-old client is on the surgical unit recovering from a femur repair performed this morning. The client is continuously restless and repeatedly asks the practical nurse about their current location. The latest vital signs show a heart rate of 114 beats per minute and a blood pressure of 94/56 mm Hg. Which action should the nurse take first?

Notify the registered nurse immediately regarding the assessment findings.

Reorient the client to the hospital room and provide a calming environment.

Offer the client a dose of prescribed analgesic to alleviate the restlessness.

Document the vital signs as an expected response following a major procedure.

Show answer & explanation

Answer: Notify the registered nurse immediately regarding the assessment findings.

Answer

The correct action is to notify the registered nurse immediately regarding the assessment findings.

The client is demonstrating early indicators of hypovolemic shock, including tachycardia, hypotension, and altered mental status (restlessness and confusion) due to decreased cerebral blood flow. Because this is an acute, unstable change in physiological status, the priority action within the practical nursing scope of practice is to immediately notify the registered nurse so that advanced assessment and resuscitative measures can begin.

Step-by-Step Solution

Analyze the clinical cues provided in the scenario.

The client has tachycardia (114 bpm), hypotension (94/56 mm Hg), restlessness, and new-onset confusion.

Identifying abnormal data is the first step in clinical judgment and recognizing physiological decompensation.

Relate the abnormal cues to potential postoperative complications.

These findings collectively indicate decreased cardiac output and poor tissue perfusion, which are early signs of hypovolemic shock or hemorrhage.

Postoperative clients, especially older adults having major orthopedic surgery, are at high risk for fluid volume deficit and bleeding.

Determine the priority action within the practical nurse scope of practice.

Escalate the unstable findings to the registered nurse.

Acute physiological deterioration requires immediate RN assessment and potential medical intervention to prevent severe harm.

Key Concept

Early Recognition of Hypovolemic Shock

Question 2730Question →

A medical-surgical unit is at maximum capacity, requiring some clients on transmission-based precautions to be cohorted in semi-private rooms. When reviewing the bed assignment board, which client pairing should the practical nurse (PN) recognize as a safe and appropriate cohorting strategy?

A client with a vancomycin-resistant Enterococcus (VRE) infected surgical wound sharing a room with a client who has a VRE urinary tract infection.

A client with Clostridioides difficile colitis sharing a room with a client experiencing severe diarrhea caused by a rotavirus infection.

A client with active pulmonary tuberculosis sharing a room with a client requiring airborne precautions for rubeola (measles).

A client with chemotherapy-induced neutropenia sharing a room with a client recovering from viral pneumonia.

Show answer & explanation

Answer: A client with a vancomycin-resistant Enterococcus (VRE) infected surgical wound sharing a room with a client who has a VRE urinary tract infection.

Answer

The safe and appropriate cohorting strategy is to pair the client with the VRE infected wound with the client who has a VRE urinary tract infection.

Cohorting is the practice of grouping clients with the same specific active infection. Because both clients in this pairing are infected with vancomycin-resistant Enterococcus (VRE), they can safely share a room without the risk of cross-infecting each other with a new, different pathogen. Both require contact precautions, and standard infection control measures must still be maintained between the clients.

Step-by-Step Solution

Identify the core principles of cohorting clients with infectious diseases in a shared room.

Clients should ideally be placed in private rooms. If unavailable, they may share a room only if they are confirmed to be infected with the exact same microorganism.

This prevents cross-contamination and the introduction of new, harmful pathogens to already vulnerable clients.

Evaluate each pairing to determine if the pathogens match or if a vulnerable client is placed at risk.

Only the pairing with VRE involves the exact same pathogen. The C. diff/rotavirus pairing and the TB/measles pairing involve different pathogens. The neutropenia/pneumonia pairing places an immunocompromised client in danger.

Matching the isolation category or symptom profile is insufficient; the specific causative organism must be identical for safe cohorting.

Key Concept

Cohorting in Infection Control

Estimated Time:1m 15s

Question 2731Question →

A practical nurse (PN) is caring for a client with chronic bronchitis who is receiving scheduled oral theophylline. The client was also started on oral ciprofloxacin $48\text{ hours}$ ago for a respiratory infection. The client now reports feeling unusually restless and nauseous. Current vital signs are blood pressure $138/82\text{ mm Hg}$ , heart rate $118\text{ bpm}$ , and respiratory rate $20\text{ breaths/min}$ . The morning serum theophylline level is reported as $23\text{ mcg/mL}$ . Based on these findings, which of the following is the most appropriate action for the PN to take?

Withhold the scheduled theophylline dose and immediately notify the registered nurse (RN) of the clinical findings.

Administer the scheduled theophylline dose with a full meal and document the laboratory results in the electronic health record.

Instruct the client in deep breathing and relaxation techniques to independently manage the acute restlessness.

Prepare to administer an intravenous (IV) push antiarrhythmic medication to rapidly stabilize the client's elevated heart rate.

Show answer & explanation

Answer: Withhold the scheduled theophylline dose and immediately notify the registered nurse (RN) of the clinical findings.

Answer

The most appropriate action is to withhold the scheduled theophylline dose and immediately notify the registered nurse (RN) of the clinical findings.

The correct action demonstrates an understanding of theophylline's narrow therapeutic index (

10-20\text{ mcg/mL}

) and the interaction with ciprofloxacin, which inhibits its metabolism. The client's level of

23\text{ mcg/mL}

, combined with symptoms of restlessness, nausea, and tachycardia, clearly indicates toxicity. To prevent life-threatening complications like seizures and ventricular arrhythmias, the PN must withhold the dose and promptly escalate the findings to the RN.

Step-by-Step Solution

Identify the normal therapeutic range for theophylline.

The therapeutic range is

10-20\text{ mcg/mL}

Knowledge of narrow therapeutic index drugs is required to interpret the morning laboratory results.

Analyze the client's current laboratory value and clinical symptoms.

The level of

23\text{ mcg/mL}

is toxic. The restlessness, nausea, and tachycardia are early clinical manifestations of this toxicity.

Connecting the objective data (lab value) with subjective/objective clinical signs (nausea, high heart rate, restlessness) confirms a systemic toxic reaction rather than simple anxiety or disease progression.

Identify the pharmacological cause of the toxicity.

Ciprofloxacin inhibits the CYP450 enzymatic pathway, decreasing theophylline clearance and causing serum levels to rise.

Recognizing drug-drug interactions is critical for preventing adverse events when new medications are added to a client's regimen.

Determine the safest action within the PN scope of practice.

The PN must safely withhold the offending agent and immediately report the life-threatening risk to the RN.

The PN is responsible for basic data collection, holding unsafe medications, and reporting abnormal/critical findings to the supervising RN for advanced intervention.

Key Concept

Theophylline toxicity, drug-drug interactions (CYP450 inhibitors), and PN scope of practice regarding critical laboratory value escalation.

Question 2732Question →

While conducting evening rounds on a medical-surgical unit, a practical nurse evaluates a client who is 12 hours post-thyroidectomy. The client states, 'My lips and fingers feel like they are vibrating.' The nurse observes a respiratory rate of 22 breaths/min, a heart rate of 108 beats/min, and a blood pressure of 102/64 mm Hg. The most recent serum calcium level is reported as 7.2 mg/dL (1.80 mmol/L). Which action should the practical nurse take immediately?

Report the clinical symptoms, vital signs, and laboratory results to the supervising registered nurse.

Document the findings in the electronic health record and recheck the calcium level during the morning draw.

Administer a prescribed intravenous push dose of calcium gluconate to correct the electrolyte deficit.

Offer a prescribed oral analgesic and continue to monitor the mild tachycardia and hypotension.

Show answer & explanation

Answer: Report the clinical symptoms, vital signs, and laboratory results to the supervising registered nurse.

Answer

Report the clinical symptoms, vital signs, and laboratory results to the supervising registered nurse.

The client is exhibiting characteristic signs of acute hypocalcemia (circumoral and extremity paresthesia) following a thyroidectomy. This condition can rapidly progress to life-threatening laryngospasm, seizures, or cardiac arrhythmias. The practical nurse must immediately escalate these critical assessment findings, borderline vital signs, and abnormal laboratory values to the registered nurse for prompt collaborative intervention.

Step-by-Step Solution

Analyze the client's reported symptoms and laboratory data.

The client reports tingling in the lips and fingers (paresthesia), and has a serum calcium level of 7.2 mg/dL, indicating acute and severe hypocalcemia.

Thyroidectomy carries a high risk of inadvertent parathyroid gland removal or damage, which abruptly disrupts calcium regulation.

Evaluate the current vital signs for additional signs of physiological instability.

The heart rate of 108 beats/min and blood pressure of 102/64 mm Hg are borderline vital signs indicating potential compensatory mechanisms.

Severe hypocalcemia severely impairs cardiac contractility, and postoperative bleeding into the neck is a concurrent risk requiring vigilant monitoring.

Determine the appropriate, safe nursing intervention within the practical nurse scope of practice.

The immediate and safest action is to escalate the findings to the supervising registered nurse.

The practical nurse must recognize impending life-threatening complications (such as tetany or laryngospasm) and coordinate care, as correcting severe hypocalcemia requires RN or provider-level interventions.

Key Concept

Recognizing and escalating signs of acute postoperative hypocalcemia and borderline vital signs.

Question 2733Question →

A pediatric client weighing $44\text{ lb}$ ( $20\text{ kg}$ ) has a new prescription for phenytoin oral suspension at $5\text{ mg/kg/day}$ divided into two equal doses. The unit's medication supply contains phenytoin at a concentration of $125\text{ mg}/5\text{ mL}$ . When retrieving and delivering this medication, which action by the practical nurse (PN) represents safe pharmacological practice?

Draw up

2.0\text{ mL}

into an oral syringe and confirm the client's identity using their name and date of birth.

Measure

4.0\text{ mL}

of the suspension to provide the client's entire daily dosage requirement in one administration.

Check the medication label against the MAR three times and use the client's bed number for identification to prevent sleep interruption.

Ask an unlicensed assistive personnel (UAP) to independently recalculate the medication dosage prior to entering the client's room.

Show answer & explanation

Answer: Draw up $2.0\text{ mL}$ into an oral syringe and confirm the client's identity using their name and date of birth.

Answer

The correct action is to draw up 2.0 mL of the medication and verify the client using their name and date of birth.

Administering

2.0\text{ mL}

of phenytoin correctly delivers the required

50\text{ mg}

individual dose. Furthermore, verifying the client using two acceptable identifiers (such as name and date of birth) complies with fundamental medication safety rights and scope of practice.

Step-by-Step Solution

Calculate the total daily dose of phenytoin based on the client's weight.

20\text{ kg} \times 5\text{ mg/kg/day} = 100\text{ mg/day}

The prescription is weight-based, so the total daily requirement must be established first.

Determine the amount required for a single dose.

100\text{ mg} \div 2\text{ doses} = 50\text{ mg/dose}

The prescription specifies that the daily dose is to be given in two equally divided doses.

Calculate the liquid volume needed to deliver the single dose using the supplied concentration (

125\text{ mg}/5\text{ mL}

50\text{ mg} \times (5\text{ mL} / 125\text{ mg}) = 2.0\text{ mL}

This converts the ordered milligram amount into a measurable milliliter volume.

Identify the standard safety requirements for medication administration.

Use two unique identifiers (e.g., name and date of birth).

Safe pharmacological practice prohibits using environmental markers like room or bed numbers to identify clients.

Key Concept

Pediatric Dosage Calculation and Safe Medication Administration

Question 2734Question →

A practical nurse is caring for a client who is 24 hours postoperative following a right total knee arthroplasty. The client reports leg swelling and asks the nurse to place a pillow directly under the right knee for comfort. Which action should the nurse take?

Elevate the right leg by placing a pillow under the lower calf and ankle, ensuring the knee remains fully extended.

Place a soft pillow directly under the right knee to alleviate the reported joint tension and promote comfort.

Ask the client why they feel they need a pillow placed under their surgical knee.

Maintain the right leg flat on the mattress without elevation to prevent the risk of joint dislocation.

Show answer & explanation

Answer: Elevate the right leg by placing a pillow under the lower calf and ankle, ensuring the knee remains fully extended.

Answer

Elevate the right leg by placing a pillow under the lower calf and ankle, ensuring the knee remains fully extended.

Following a total knee arthroplasty, the primary basic care goals are to reduce edema and prevent flexion contractures. Elevating the leg by placing pillows under the lower calf and ankle allows for venous return while keeping the new knee joint straight and fully extended.

Step-by-Step Solution

Analyze the client's request for comfort measures.

The client requested a pillow directly under the right knee for swelling and comfort.

Understanding the client's specific request helps the nurse determine if the intervention is safe and aligns with postoperative protocols.

Evaluate the safety of the requested position.

Placing a pillow directly under the knee is contraindicated post-total knee arthroplasty.

Knee flexion during the postoperative period can lead to flexion contractures, which severely limit future mobility and joint function.

Determine the appropriate alternative basic care intervention.

The nurse must elevate the leg to address the swelling while keeping the knee completely straight.

Supporting the lower calf and ankle elevates the extremity to promote venous return, safely managing the edema while maintaining the required knee extension.

Key Concept

Proper postoperative positioning for total knee arthroplasty emphasizes maintaining knee extension to prevent flexion contractures while appropriately managing edema.

Question 2735Question →

A practical nurse (PN) is answering telephones at the nursing station. A caller identifies himself as the brother of a client and asks for an update on the client's condition following a surgical procedure. The PN checks the electronic health record (EHR) and notes that the client has opted out of the facility directory and has no authorized individuals listed for information release. Which of the following is the priority nursing action?

Inform the caller that no information can be provided and do not confirm the client's presence.

Transfer the call directly to the client's room so the caller can speak with the client.

Ask the caller to provide the client's date of birth and home address to verify identity.

State that the client's surgical procedure was successful but withhold specific medical details.

Show answer & explanation

Answer: Inform the caller that no information can be provided and do not confirm the client's presence.

Answer

Inform the caller that no information can be provided and do not confirm the client's presence.

When a client has specifically opted out of the facility directory and has not designated any authorized individuals to receive information, the nurse is legally obligated to maintain complete confidentiality. The only appropriate response is to inform the caller that no information can be provided, while strictly avoiding confirming or denying the client's admission to the facility.

Step-by-Step Solution

Analyze the client's privacy preferences in the electronic health record (EHR).

The client has opted out of the facility directory and has no authorized individuals listed for information release.

Establishing the legal boundaries for sharing information based on the client's explicit wishes is the first step in protecting their privacy.

Evaluate the caller's request against the client's privacy preferences.

The caller is asking for a medical update, but is not authorized to receive any information or even a confirmation of the client's presence.

Healthcare workers must strictly adhere to HIPAA regulations and specific client directives regarding privacy, regardless of the caller's claimed relationship.

Determine the most appropriate nursing response.

The nurse must state that no information can be provided and must neither confirm nor deny that the client is at the facility.

This action fully protects the client's confidentiality and complies with their directory opt-out status.

Key Concept

Under HIPAA regulations, if a client opts out of the facility directory, healthcare personnel cannot acknowledge the client's presence in the facility, transfer calls to their room, or release any information to callers, regardless of their familial relationship.

Estimated Time:1m 0s

Question 2736Question →

A practical nurse (PN) is providing care for a client who is receiving a continuous enteral feeding via a nasogastric (NG) tube. The client suddenly develops a severe coughing spell, becomes tachypneic, and appears highly restless.

In what order should the PN perform the following actions? Arrange the actions in sequence from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

First, stop the enteral feeding pump. Second, place the client in a high-Fowler's or side-lying position. Third, auscultate lung sounds and measure oxygen saturation. Fourth, report the condition to the registered nurse (RN). Finally, document the event.

When a client receiving an enteral feeding exhibits signs of respiratory distress such as a severe coughing spell and tachypnea, pulmonary aspiration is the primary concern. According to the Airway, Breathing, Circulation (ABC) priority framework, the absolute first step is to remove the immediate threat to the airway by pausing the feeding pump. Next, the airway must be mechanically protected by positioning the client upright or on their side. After the airway is physically safeguarded, the PN collects targeted data (lung sounds, oxygen saturation) to assess the severity of the breathing compromise. This critical data is then rapidly communicated to the RN or provider for advanced medical interventions. Documentation is strictly performed last, once the client is safe and the broader care team is engaged.

Step-by-Step Solution

Stop the continuous enteral feeding pump.

The flow of enteral formula is halted immediately.

Continuing the feeding while the client is coughing and tachypneic heavily increases the risk of massive pulmonary aspiration.

Place the client in a high-Fowler's or side-lying position.

The client's airway is physically protected.

An upright or side-lying position utilizes gravity to keep residual gastric contents from traveling up the esophagus and allows for maximum lung expansion.

Auscultate lung sounds and measure the client's oxygen saturation.

Quantitative and qualitative respiratory data are obtained.

The PN must collect targeted data to evaluate the degree of physiological adaptation and respiratory compromise before calling for help.

Report the sudden change in condition to the registered nurse (RN).

The healthcare team is alerted to the adverse event.

The PN operates under the direction of an RN or provider and must communicate critical changes so advanced interventions can be prescribed.

Document the clinical event, vital signs, and nursing interventions.

A legal and clinical record of the emergency is created.

Documentation must reflect the exact sequence of events, but it is strictly performed after the client is safe and handoff is complete.

Key Concept

Prioritization of emergency interventions during suspected aspiration (Airway-Breathing-Circulation approach).

Question 2737Question →

A client receiving a continuous intravenous infusion of 0.9% sodium chloride for dehydration suddenly develops a bounding pulse, jugular venous distention, and a new onset of dyspnea. Auscultation reveals crackles in the bilateral lung bases. Which immediate action should the practical nurse take?

Initiate an intravenous push of a loop diuretic as prescribed.

Instruct the client to use an incentive spirometer to expand the lungs.

Halt the intravenous infusion and position the client upright.

Document the lung sounds and plan to reassess the client in 30 minutes.

Show answer & explanation

Answer: Halt the intravenous infusion and position the client upright.

Answer

The practical nurse should immediately halt the intravenous infusion and position the client upright to address the acute fluid volume overload.

The client is exhibiting classic signs of fluid volume overload, likely due to the continuous intravenous infusion. The priority is to address Airway, Breathing, and Circulation (ABCs). Stopping the infusion prevents further fluid accumulation, and positioning the client upright (e.g., high Fowler's position) decreases venous return and maximizes lung expansion, thereby improving oxygenation. These are critical, immediate actions that fall within the practical nurse's scope of practice before escalating the situation to the registered nurse.

Step-by-Step Solution

Analyze the clinical presentation.

The client has a bounding pulse, jugular venous distention, dyspnea, and lung crackles.

Identifying the pattern of symptoms is necessary to determine the underlying complication.

Identify the complication.

These symptoms indicate fluid volume overload (pulmonary edema) caused by the continuous intravenous infusion.

Connecting the intravenous therapy to the new symptoms establishes the cause of the acute respiratory distress.

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

The immediate priorities are to stop the source of the excess fluid (the infusion) and improve respiratory mechanics (upright positioning).

These actions directly address the ABCs (Airway, Breathing, Circulation) and prevent further deterioration while awaiting RN or provider intervention.

Key Concept

Prioritization and Scope of Practice in Fluid Volume Overload

Question 2738Question →

A practical nurse (PN) is reviewing morning laboratory data and assessing assigned clients. Which of the following clinical findings indicate a risk for potential complications and require immediate escalation to the registered nurse? (Select all that apply)

Select all that apply

A client who had abdominal surgery 4 hours ago with a resting heart rate of 112 beats/min and a blood pressure of 96/60 mm Hg.

A client receiving daily furosemide whose morning serum potassium level is 3.1 mEq/L (3.1 mmol/L).

A client who underwent a total knee arthroplasty 2 days ago reporting incisional pain rated as a 5 on a 0 to 10 numeric scale.

A client who had a thoracentesis 1 hour ago reporting sudden, sharp chest pain and new-onset tachypnea.

A client prescribed an oral beta-blocker whose resting heart rate is 66 beats/min and blood pressure is 114/72 mm Hg.

A client scheduled for a contrast-enhanced computed tomography (CT) scan whose morning serum creatinine level is 2.4 mg/dL (212 µmol/L).

Show answer & explanation

Answer: A client who had abdominal surgery 4 hours ago with a resting heart rate of 112 beats/min and a blood pressure of 96/60 mm Hg.; A client receiving daily furosemide whose morning serum potassium level is 3.1 mEq/L (3.1 mmol/L).; A client who had a thoracentesis 1 hour ago reporting sudden, sharp chest pain and new-onset tachypnea.; A client scheduled for a contrast-enhanced computed tomography (CT) scan whose morning serum creatinine level is 2.4 mg/dL (212 µmol/L).

Answer

The findings requiring immediate escalation include the postoperative client with tachycardia and borderline hypotension, the client with a potassium level of 3.1 mEq/L, the post-thoracentesis client with sudden chest pain, and the client scheduled for a contrast CT scan with an elevated creatinine level.

The correct findings all represent acute safety risks that fall outside expected parameters. A heart rate of 112 beats/min with a blood pressure of 96/60 mm Hg in a postoperative client indicates early hypovolemic shock or hemorrhage. A potassium level of 3.1 mEq/L is critically low (normal 3.5-5.0 mEq/L) and risks life-threatening arrhythmias, especially with loop diuretic use. Sudden chest pain and tachypnea after a thoracentesis are classic signs of a pneumothorax. An elevated creatinine level (normal 0.6-1.2 mg/dL) indicates renal impairment, placing the client at high risk for acute kidney injury if intravenous contrast dye is administered.

Step-by-Step Solution

Analyze each client finding to differentiate between expected baseline outcomes and signs of physiological instability.

Identified that post-surgical pain and stable vital signs on a beta-blocker are expected, benign findings.

Prioritization requires distinguishing normal therapeutic responses from acute threats.

Evaluate the laboratory values against normal reference ranges.

Identified that a potassium level of 3.1 mEq/L is critically low and a creatinine level of 2.4 mg/dL is abnormally high.

Recognizing critical laboratory values prevents adverse events such as dysrhythmias and nephrotoxicity.

Assess the post-procedure findings for signs of life-threatening complications.

Recognized that tachycardia/hypotension post-abdominal surgery indicates shock, and sudden chest pain post-thoracentesis indicates a pneumothorax.

Early recognition of shock and organ compromise allows for rapid medical intervention and prevents mortality.

Key Concept

Reduction of Risk Potential: Early Recognition of Complications and Critical Labs

Question 2739Question →

A practical nurse is preparing to change a one-piece ostomy pouching system for a client with an established descending colostomy. In what order should the nurse perform the following actions? Arrange the steps in the correct sequence from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence for changing an ostomy pouch is: 1) Remove the used pouch and skin barrier, 2) Cleanse the stoma and peristomal skin with warm water and pat dry, 3) Measure the stoma, 4) Cut the opening on the new skin barrier 1/8 inch larger than the stoma, and 5) Apply the new skin barrier and pouch.

The correct sequence ensures patient comfort, skin protection, and appliance adherence. First, the old pouch must be gently removed to avoid skin trauma. Next, the area is cleansed with warm water (avoiding soaps that leave residue) and dried completely to prepare the skin. Once clean, the stoma is measured accurately, as sizes can fluctuate. The new wafer is then cut 1/8 inch larger than the measurement to prevent stomal constriction while protecting the peristomal skin. Finally, the new appliance is applied and sealed with gentle pressure.

Step-by-Step Solution

Remove the used pouch and skin barrier.

The old appliance is safely detached from the skin.

This allows access to the stoma and peristomal skin for assessment and cleaning. Gentle removal prevents skin tears.

Cleanse the stoma and peristomal skin with warm tap water and pat dry.

The skin is free of effluent and moisture.

Thorough cleaning prevents infection and skin breakdown. Avoiding soap prevents leaving a residue that impairs adhesion. Drying is critical for the new wafer to stick.

Measure the stoma using a measuring guide.

The exact current size of the stoma is determined.

Stomas can swell or shrink. An accurate measurement ensures the new barrier will fit correctly without exposing skin or strangulating the stoma.

Cut the opening on the new skin barrier 1/8 inch larger than the stoma.

A custom-sized opening is created in the barrier.

Leaving a 1/8-inch margin prevents the rigid edge of the wafer from rubbing against and cutting the stoma, while still protecting the peristomal skin from fecal contact.

Center the new barrier over the stoma and apply pressure.

The new pouching system is securely attached.

Proper alignment and pressure activate the adhesive and create a seal, preventing leaks.

Key Concept

Proper ostomy care requires a sequential approach focused on protecting peristomal skin integrity and ensuring a secure appliance seal.

Question 2740Question →

During a midday staffing huddle on an inpatient rehabilitation floor, the nursing supervisor is distributing upcoming client care activities. To maintain client safety and comply with scope of practice regulations, match each specific clinical intervention to the most appropriate healthcare team member.

Click a left item, then click its matching right item

Show answer & explanation

Answer

The comprehensive assessment matches to the RN. Medication administration and teaching reinforcement match to the LPN/VN. Basic transfers and intake recording match to the UAP. Explaining surgical risks matches to the Primary Healthcare Provider.

Delegation relies on the National Council of State Boards of Nursing (NCSBN) guidelines. The RN retains accountability for comprehensive assessments and the initial plan of care. The LPN/VN safely provides care to stable clients with predictable outcomes, including administering routine medications and reinforcing education. The UAP handles standard, unchanging routines. Finally, the primary healthcare provider holds the legal responsibility for explaining surgical risks and obtaining informed consent.

Step-by-Step Solution

Evaluate the task requiring comprehensive assessment and care planning.

Matched to the Registered Nurse (RN).

RNs hold the legal scope of practice for conducting initial comprehensive assessments and formulating nursing diagnoses.

Evaluate the task involving routine medication administration and reinforcement of teaching.

Matched to the Licensed Practical/Vocational Nurse (LPN/VN).

LPN/VNs are licensed to administer standard medications and reinforce RN-initiated education for stable clients with predictable outcomes.

Evaluate the task requiring basic assistance with activities of daily living and standard data recording.

Matched to the Unlicensed Assistive Personnel (UAP).

UAPs are trained to perform routine, standard, and unchanging procedures for hemodynamically stable clients.

Evaluate the task of explaining surgical risks and benefits for informed consent.

Matched to the Primary Healthcare Provider.

The provider performing the medical procedure is legally obligated to explain its risks, benefits, and alternatives.

Key Concept

Delegation and Scope of Practice Guidelines

Estimated Time:1m 30s

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