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A practical nurse (PN) is caring for a 74-year-old client who has been receiving continuous nasogastric (NG) tube suctioning for the past 48 hours due to a small bowel obstruction. Which of the following assessment findings indicate a potential complication and should be reported immediately to the registered nurse (RN)? Select all that apply.

Select all that apply

Apical pulse of 112 beats/min with thready peripheral pulses

New onset of agitation and disorientation to time and place

Client reports of severe leg cramps and generalized muscle weakness

Hypoactive bowel sounds auscultated in all four abdominal quadrants

Urine output of 150 mL collected in the indwelling catheter over the past 4 hours

Capillary refill time of 2 seconds in the bilateral upper extremities

Show answer & explanation

Answer: Apical pulse of 112 beats/min with thready peripheral pulses; New onset of agitation and disorientation to time and place; Client reports of severe leg cramps and generalized muscle weakness

Answer

The abnormal findings that indicate potential complications and require immediate reporting are the apical pulse of 112 beats/min with thready pulses, the new onset of agitation and disorientation, and the reports of severe leg cramps with muscle weakness.

Continuous nasogastric suctioning rapidly depletes the body of fluids and electrolytes, particularly potassium. An apical pulse of 112 beats/min with thready pulses directly points to hypovolemia and impending shock. New-onset agitation and disorientation indicate diminished cerebral perfusion or a profound electrolyte disturbance, requiring emergent evaluation. Severe leg cramps and generalized muscle weakness are classic, immediate indicators of symptomatic hypokalemia. These acute physiological shifts must be reported to the RN for timely intervention.

Step-by-Step Solution

Analyze the client's current treatments and associated risks.

The client is undergoing continuous NG tube suctioning, which removes significant amounts of fluid, stomach acid, and electrolytes (especially potassium).

Identifying the therapy's physiological impact helps anticipate specific complications like fluid volume deficit, hypokalemia, and metabolic alkalosis.

Evaluate each assessment finding against normal limits and expected disease manifestations.

Tachycardia/thready pulses, acute confusion, and muscle cramping are abnormal and indicate deterioration. Hypoactive bowel sounds, 150 mL urine output over 4 hours, and a 2-second capillary refill are expected or normal findings.

Differentiating between expected findings of a bowel obstruction and acute signs of systemic instability is essential for safe prioritization.

Select the findings that reflect physiological instability.

The circulatory, neurological, and electrolyte-related abnormalities are identified as the priority complications to report.

Acute changes affecting ABCs (circulation/perfusion) and severe electrolyte shifts fall outside the PN scope of independent management and require RN intervention.

Key Concept

Recognizing systemic complications of fluid and electrolyte depletion

Question 262Question →

A licensed practical nurse (LPN) is assigned to a client who had a total hip arthroplasty the previous day. Upon entering the room, the LPN observes that the client is pale, restless, and diaphoretic. The electronic health record indicates a morning hemoglobin level of 7.9 g/dL, which is a significant decrease from the post-operative value of 10.8 g/dL. Current vital signs include a heart rate of 116 beats per minute and a blood pressure of 90/56 mm Hg. What is the most appropriate initial action for the LPN to take?

Increase the rate of the continuous intravenous fluid infusion to improve blood pressure.

Administer the client's scheduled oral analgesic to promote comfort and reduce restlessness.

Promptly notify the supervising registered nurse about the client's current status.

Record the vital signs and hemoglobin drop in the chart for the provider to review during rounds.

Show answer & explanation

Answer: Promptly notify the supervising registered nurse about the client's current status.

Answer

The most appropriate initial action is to promptly notify the supervising registered nurse about the client's current status.

The client is exhibiting classic signs of hypovolemic shock (tachycardia, hypotension, restlessness, diaphoresis) and internal bleeding (dropping hemoglobin) following major surgery. The LPN's priority action when identifying an unstable, deteriorating client is to immediately notify the supervising registered nurse or healthcare provider so that life-saving interventions can be initiated.

Step-by-Step Solution

Analyze the client's clinical presentation, vital signs, and laboratory data.

The client displays tachycardia, hypotension, restlessness, diaphoresis, and a dropping hemoglobin level.

Identifying these cues is essential to recognize early signs of hypovolemic shock caused by post-operative hemorrhage.

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

The most critical action is to immediately escalate these life-threatening findings.

The LPN must collaborate with the registered nurse or provider when a client becomes unstable, as managing shock requires advanced interventions.

Key Concept

Recognizing early signs of shock and escalating critical findings

Estimated Time:1m 0s

Question 263Question →

A client arrives at the medical unit with a suspected Neisseria meningitidis infection, presenting with a high fever and nuchal rigidity. Which infection control interventions should the practical nurse implement? Select all that apply.

Select all that apply

Assign the client to a single-patient private room.

Ensure the client wears a standard surgical mask during transport outside the room.

Don a fit-tested N95 respirator mask before entering the client's room.

Wear a clean isolation gown and gloves for all routine client interactions.

Instruct visitors to wear a standard surgical mask when in the client's room.

Maintain negative-pressure airflow in the client's room with the door tightly closed.

Show answer & explanation

Answer: Assign the client to a single-patient private room.; Ensure the client wears a standard surgical mask during transport outside the room.; Instruct visitors to wear a standard surgical mask when in the client's room.

Answer

The correct interventions are assigning the client to a single-patient private room, ensuring the client wears a surgical mask during transport, and instructing visitors to wear a surgical mask when inside the room.

Neisseria meningitidis is transmitted via large respiratory droplets. Appropriate droplet precautions include placing the client in a private room, ensuring the client wears a standard surgical mask when transport is necessary to contain secretions, and requiring anyone entering the room, including visitors, to wear a surgical mask to prevent inhalation of droplets.

Step-by-Step Solution

Identify the mode of transmission for the suspected pathogen.

Neisseria meningitidis causes meningococcal meningitis, which is transmitted through large respiratory droplets.

Determining the transmission route is necessary to select the correct isolation precautions.

Determine the required environmental and personal protective equipment (PPE) interventions.

Droplet precautions require placing the client in a private room and the use of a standard surgical mask for anyone entering the room.

Large respiratory droplets travel short distances (usually within 3 feet) and do not require airborne isolation or contact PPE unless splashing is expected.

Select the appropriate actions for client transport and visitors.

The client must wear a surgical mask for source control during transport, and all visitors must wear a surgical mask to prevent inhalation of droplets.

Source control and visitor protection are essential components of standard droplet precaution guidelines.

Key Concept

Droplet Precautions

Question 264Question →

A practical nurse (PN) is caring for a client who is receiving a continuous intravenous (IV) fluid infusion. The electronic infusion pump repeatedly sounds a high-priority "internal system malfunction" alarm. The PN verifies that the IV tubing is not kinked, the roller clamps are open, and the client's IV insertion site is patent. Which action is the most appropriate for the PN to take?

Turn off the pump, label it with a defective equipment tag, and remove it from the client care area.

Disconnect the pump and administer the hourly fluid requirement via an intravenous push.

Apply soft wrist restraints to the client to prevent accidental manipulation of the malfunctioning alarm panel.

Convert the infusion to a gravity setup and visually estimate the flow rate without calculating the exact drops per minute.

Show answer & explanation

Answer: Turn off the pump, label it with a defective equipment tag, and remove it from the client care area.

Answer

The most appropriate action is to turn off the pump, label it with a defective equipment tag, and remove it from the client care area.

When a piece of biomedical equipment, such as an IV pump, exhibits a continuous internal malfunction, it poses a direct safety risk to the client. The correct protocol for the safe use of equipment is to immediately stop using the device, remove it from the patient care environment, and clearly label it with a 'defective equipment' tag. It should then be sent to the facility's clinical engineering or maintenance department for repair. A replacement pump must be obtained to safely continue the client's prescribed therapy.

Step-by-Step Solution

Assess the source of the alarm by checking the IV tubing, clamps, and insertion site.

No physical issues with the tubing or client site are identified.

Basic troubleshooting is required to differentiate between a simple occlusion and a true mechanical failure.

Identify the 'internal system malfunction' message as a mechanical or electrical failure.

The device is deemed unsafe for continued patient care.

Internal errors cannot be fixed at the bedside and pose a risk of incorrect fluid delivery.

Remove the pump from service, tag it as defective, and obtain a replacement.

The defective equipment is isolated, and the client's infusion can be safely resumed with a working pump.

Standard equipment safety protocols require removing and labeling broken devices so they are not accidentally used by other staff members.

Key Concept

Biomedical Equipment Safety Protocols

Question 265Question →

An 8-year-old client weighing $39.6\text{ lb}$ is being treated for a severe respiratory infection in an outpatient clinic. The healthcare provider prescribes cefdinir oral suspension at $40\text{ mg/kg/day}$ to be administered in equally divided doses every $8\text{ hours}$ . The pharmacy dispenses a reconstituted suspension with a concentration of $250\text{ mg}/5\text{ mL}$ . How many milliliters will the nurse administer for a single dose?

(Record the answer to the nearest tenth. Do not include units in the answer.)

Show answer & explanation

Answer: 4.8

Answer

4.8

The correct calculation requires sequential conversion: establishing the weight in kg, determining the 24-hour milligram total, dividing by the number of daily administrations (every 8 hours = 3 doses), and utilizing dimensional analysis with the dispensed concentration to find the liquid volume per dose.

Step-by-Step Solution

Convert the client's weight from pounds to kilograms.

18\text{ kg}

The medication dosage is prescribed in mg/kg, requiring the weight to be in metric units (

39.6\text{ lb} \div 2.2 = 18\text{ kg}

Calculate the total daily medication requirement.

720\text{ mg/day}

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

18\text{ kg} \times 40\text{ mg/kg/day} = 720\text{ mg/day}

Calculate the amount of medication required for a single dose.

240\text{ mg/dose}

The medication is given every 8 hours, which equals 3 doses per 24-hour period. Divide the daily total by 3 (

720\text{ mg} \div 3 = 240\text{ mg/dose}

Calculate the volume in milliliters to administer for one dose.

4.8\text{ mL}

Use the formula (Desired / Have) * Volume.

(240\text{ mg} \div 250\text{ mg}) \times 5\text{ mL} = 0.96 \times 5\text{ mL} = 4.8\text{ mL}

Key Concept

Weight-based pediatric dosage calculation and liquid medication volume conversion.

Estimated Time:2m 0s

Question 266Question →

A practical nurse is assigned to care for a client who underwent a lumbar laminectomy 24 hours ago. The client has become increasingly restless, is exhibiting new-onset mild confusion, and requires a bed bath with a complete linen change. Which of the following actions should the practical nurse take? Select all that apply.

Select all that apply

Use the logrolling technique with the assistance of at least one other staff member to turn the client.

Document the client's confusion as an expected, normal finding related to the aging process.

Elevate the head of the bed to 45 degrees and place a rolled towel under the client's knees.

Place a pillow between the client's legs to maintain proper spinal alignment during the turn.

Provide the prescribed as-needed analgesic medication approximately 30 minutes before beginning the hygiene care.

Apply soft wrist restraints immediately to prevent the confused client from touching the surgical dressing.

Show answer & explanation

Answer: Use the logrolling technique with the assistance of at least one other staff member to turn the client.; Place a pillow between the client's legs to maintain proper spinal alignment during the turn.; Provide the prescribed as-needed analgesic medication approximately 30 minutes before beginning the hygiene care.

Answer

The practical nurse should use the logrolling technique with assistance, place a pillow between the client's legs for alignment, and administer prescribed pain medication 30 minutes prior to the bed bath.

Following a lumbar laminectomy, the client's spine must be kept in neutral alignment to prevent injury to the surgical site. This requires the logrolling technique with multiple staff members and the use of a pillow between the legs to prevent twisting of the spine. Furthermore, administering prescribed analgesia before a demanding physical activity like a linen change promotes optimal comfort and reduces pain during movement.

Step-by-Step Solution

Analyze the client's surgical procedure and strict postoperative positioning requirements.

The client had a lumbar laminectomy, meaning the lumbar spine must be kept perfectly straight (neutral alignment) to prevent surgical site damage.

Understanding physical limitations dictates safe mobility and positioning techniques, ruling out bending the spine or head elevation.

Evaluate the need for comfort and proactive pain management.

The client requires a linen change which involves movement. Administering an analgesic 30 minutes prior ensures the medication peaks during the physical turning.

Proactive pain management is a key component of basic care and significantly improves client tolerance of necessary hygiene tasks.

Assess the correct response to the client's new-onset confusion and restlessness.

Sudden confusion requires investigation for underlying physiological causes (like hypoxia) and the implementation of least-restrictive safety measures, rather than immediate restraint application or dismissing it as normal aging.

Promoting safety while maintaining client rights prevents complications and the unnecessary, unsafe use of restraints.

Key Concept

Basic care, safe positioning, and comfort measures for a postoperative spinal surgery client.

Question 267Question →

During morning rounds, the practical nurse (PN) evaluates a client recovering from a severe lower respiratory tract infection. The PN monitors the client for potential respiratory compromise. Which of the following clinical manifestations should the PN recognize as early indicators of hypoxia? Select all that apply.

Select all that apply

Unexplained restlessness and agitation

Heart rate elevating to 118 beats per minute

New-onset confusion and altered mental status

Bluish tinge to the lips and oral mucosa

Respirations slowing to 10 breaths per minute

Show answer & explanation

Answer: Unexplained restlessness and agitation; Heart rate elevating to 118 beats per minute; New-onset confusion and altered mental status

Answer

The early indicators of hypoxia include unexplained restlessness and agitation, an elevated heart rate, and new-onset confusion.

The correct responses represent the body's initial compensatory mechanisms when deprived of adequate oxygen. The sympathetic nervous system responds to early hypoxia by increasing the heart rate (tachycardia) to deliver blood more rapidly. Additionally, because the brain demands a constant high supply of oxygen, early deficits manifest as neurological changes, such as unexplained restlessness, anxiety, and new-onset confusion.

Step-by-Step Solution

Analyze the clinical scenario and the specific question being asked.

The goal is to differentiate between early compensatory signs of hypoxia and late decompensation signs.

Early recognition of hypoxia allows for prompt intervention before respiratory failure occurs.

Evaluate the neurological assessment options.

Restlessness, agitation, and new-onset confusion are identified as correct early signs.

The cerebral cortex is extremely sensitive to oxygen deprivation, making neurological changes some of the earliest observable signs of hypoxia.

Evaluate the cardiovascular and respiratory vital sign options.

An elevated heart rate (tachycardia) is identified as correct, while a slow respiratory rate and a bluish tinge to the mucosa are identified as incorrect.

Tachycardia is an early compensatory mechanism to circulate more oxygen. Cyanosis and bradycardia/hypoventilation occur late in the process when the body can no longer compensate.

Key Concept

Early versus Late Signs of Hypoxia

Estimated Time:1m 0s

Question 268Question →

A client with heart failure is prescribed a scheduled dose of oral furosemide. During the morning data collection, the practical nurse notes that the client's serum potassium level is $2.9\text{ mEq/L}$ . The client's vital signs include a heart rate of $108\text{ beats/min}$ and a blood pressure of $96/58\text{ mmHg}$ . Which action is the priority for the nurse?

Withhold the furosemide and immediately report the findings to the supervising registered nurse.

Administer the furosemide because mild tachycardia and slight hypotension are expected in heart failure.

Document the potassium level in the chart and proceed with the scheduled medication administration.

Prepare to administer a dose of potassium chloride via intravenous push to quickly correct the deficit.

Show answer & explanation

Answer: Withhold the furosemide and immediately report the findings to the supervising registered nurse.

Answer

The priority action is to withhold the scheduled furosemide and immediately report the vital signs and laboratory results to the registered nurse.

The correct action is to withhold the furosemide and notify the registered nurse. The client's potassium level of 2.9 mEq/L indicates severe hypokalemia. Since furosemide is a potassium-depleting loop diuretic, administering the dose would worsen the hypokalemia, placing the client at high risk for lethal cardiac dysrhythmias. Furthermore, the client's borderline vital signs (tachycardia and hypotension) suggest clinical deterioration that must be escalated.

Step-by-Step Solution

Analyze the laboratory results.

The serum potassium level is 2.9 mEq/L, which indicates critical hypokalemia (normal range: 3.5 to 5.0 mEq/L).

Identifying abnormal laboratory values is essential before administering medications that affect those values.

Evaluate the medication's mechanism of action.

Furosemide is a potassium-wasting loop diuretic. Administering it will further lower the client's potassium level.

Understanding drug classifications helps predict adverse effects and prevents medication errors.

Determine the appropriate nursing intervention based on scope of practice.

The nurse must withhold the medication to prevent harm and notify the registered nurse or provider.

Practical nurses must escalate critical findings and withhold medications when administration poses a direct safety risk.

Key Concept

Pre-administration safety checks and recognizing critical laboratory values associated with pharmacological therapies.

Question 269Question →

During a morning shift at a long-term care facility, a nursing team is preparing to move an obese resident from a supine position in bed to a stationary bedside recliner. The resident requires a mechanical full-body sling lift for the transfer. Which actions by the nursing staff demonstrate adherence to safe equipment use and proper ergonomics? Select all that apply.

Select all that apply

Adjusting the mattress elevation to the waist level of the shortest caregiver when rolling the resident to place the sling.

Fastening the resident's hands to the suspension straps using cloth limb holders to prevent reaching out.

Expanding the wheelbase chassis of the lifting device to its maximum width prior to hoisting the resident.

Discussing the resident's specific weight and mobility limitations with visitors in the hallway to explain a delay in care.

Instructing the resident to fold both arms across their torso while the fabric hammock is actively raised.

Positioning the resident near the front edge of the recliner seat cushion to facilitate an easier standing transfer later in the day.

Show answer & explanation

Answer: Adjusting the mattress elevation to the waist level of the shortest caregiver when rolling the resident to place the sling.; Expanding the wheelbase chassis of the lifting device to its maximum width prior to hoisting the resident.; Instructing the resident to fold both arms across their torso while the fabric hammock is actively raised.

Answer

The correct actions are adjusting the bed height to the waist level of the shortest caregiver, expanding the wheelbase of the mechanical lift to its maximum width, and instructing the resident to fold their arms across their torso during the lift.

Correct ergonomics dictate that the working surface (the bed) should be adjusted to the waist level of the shortest caregiver to prevent lumbar strain when rolling the resident. When operating a mechanical full-body lift, expanding the base legs to their widest position is required to provide maximum stability and prevent the heavy device from tipping. Additionally, instructing the resident to cross their arms over their torso ensures their center of gravity remains balanced and prevents their limbs from inadvertently striking the metal equipment frame during the transfer.

Step-by-Step Solution

Evaluate the ergonomic requirements for the caregivers during the preparatory phase of the transfer.

The bed must be raised to the waist height of the shortest caregiver to minimize back strain when rolling the resident to position the sling.

Proper body mechanics require working at a comfortable height to prevent musculoskeletal injuries.

Analyze the equipment safety protocols for operating a mechanical full-body sling lift.

The base legs (wheelbase) of the lift must be opened to their widest position before the resident is lifted off the mattress.

A wider base provides a larger polygon of support, maximizing stability and preventing the heavy equipment from tipping over.

Determine the safest physical position for the resident while suspended in the lift.

The resident's arms should be crossed over their chest.

This centralizes the resident's center of gravity and protects their extremities from getting caught in the lift's metal components.

Identify and eliminate actions that violate safety, positioning, or ethical standards.

Discard the options involving tying the hands, placing the resident at the edge of the chair, or discussing private health information in public.

These represent improper restraint use, unsafe positioning leading to fall risks, and HIPAA/confidentiality breaches, respectively.

Key Concept

Safe Operation of Mechanical Lifts and Ergonomic Principles

Question 270Question →

A registered nurse (RN) delegates the care of a 6-month-old infant diagnosed with pertussis (whooping cough) to a practical nurse (PN). Which action by the PN demonstrates safe adherence to transmission-based precautions and scope of practice?

Donning a standard surgical mask immediately before entering the infant's private room to administer prescribed oral medications.

Accepting the delegation to formulate and document the initial nursing care plan regarding the infant's respiratory isolation requirements.

Lowering the surgical mask to rest around the neck while speaking to the parents, then repositioning it securely over the nose and mouth.

Removing the surgical mask first before taking off the gloves that were used to dispose of the infant's soiled tissues.

Show answer & explanation

Answer: Donning a standard surgical mask immediately before entering the infant's private room to administer prescribed oral medications.

Answer

The correct action is to don a standard surgical mask immediately before entering the infant's private room to administer prescribed oral medications.

Pertussis requires droplet precautions, meaning a standard surgical mask must be worn when entering the client's room. Administering oral medications is a routine task that falls safely within the scope of practice for a practical nurse (PN).

Step-by-Step Solution

Identify the transmission-based precautions required for pertussis (whooping cough).

Pertussis is transmitted via large respiratory droplets, requiring droplet precautions.

Knowing the correct precaution determines the necessary personal protective equipment (PPE), which includes a standard surgical mask.

Evaluate the clinical tasks assigned to the PN for scope of practice appropriateness.

Administering oral medications is within the PN scope of practice, whereas formulating an initial care plan is restricted to the RN.

The PN must recognize and decline tasks that require RN-level assessment or planning to ensure safe client care.

Assess the correct usage and doffing sequence of PPE in the remaining options.

Wearing a mask around the neck or removing a mask with contaminated gloves are both critical safety violations.

Improper handling of PPE leads to self-contamination and the spread of infectious pathogens.

Key Concept

Droplet Precautions and PN Scope of Practice

Question 271Question →

A practical nurse (PN) is assisting a client with evening hygiene and preparing them for sleep. The client had a cataract extraction on the left eye earlier in the day. Which action by the PN is the most appropriate to promote comfort and prevent complications during rest?

Instruct the client to sleep on their back or right side while keeping the head of the bed elevated at 30 degrees.

Assist the client to lay on their left side with a supportive pillow to promote relaxation and uninterrupted sleep.

Administer the client's prescribed nighttime eye drops by verifying the room number to avoid waking the roommate.

Tell the client, 'Why are you anxious about sleeping? Everyone does fine after this routine procedure.'

Show answer & explanation

Answer: Instruct the client to sleep on their back or right side while keeping the head of the bed elevated at 30 degrees.

Answer

Instruct the client to sleep on their back or right side while keeping the head of the bed elevated at 30 degrees.

The correct answer describes the optimal positioning for a client following cataract surgery. Elevating the head of the bed to 30 degrees (semi-Fowler's position) uses gravity to help decrease intraocular pressure. Sleeping on the back or the unoperated side (the right side, in this case) ensures that no direct physical pressure is applied to the newly operated left eye, promoting both comfort and safe healing.

Step-by-Step Solution

Identify the client's surgical procedure and the affected side.

The client had a cataract extraction on the left eye.

Knowing the surgical site is essential to determine appropriate post-procedure positioning and basic care needs.

Determine the physiological goals during the postoperative period for this specific surgery.

The primary goals are to prevent an increase in intraocular pressure (IOP) and protect the eye from physical trauma.

Increased IOP can damage the delicate surgical incision and lead to severe complications like hemorrhage or vision loss.

Select the nursing intervention that aligns with these physiological goals while providing basic care and comfort for sleep.

Elevating the head of the bed to 30 degrees (semi-Fowler's position) and keeping the client off the operative (left) side achieves these goals.

Gravity helps drain fluid away from the eye to reduce IOP, and avoiding the operative side prevents direct pressure on the healing eye.

Key Concept

Postoperative Basic Care and Positioning for Eye Surgery

Question 272Question →

During the night shift on a medical-surgical unit, an 84-year-old client who was previously alert and cooperative suddenly becomes disoriented, wanders into the hallway, and attempts to open a restricted stairwell door. Which action is the priority for the practical nurse to take to prevent client injury?

Document the nighttime wandering as an expected age-related cognitive change.

Apply a soft belt restraint to keep the client safely in bed for the remainder of the night.

Instruct the unlicensed assistive personnel to administer an intravenous sedative medication.

Redirect the client to their room and immediately assess vital signs and oxygen saturation.

Show answer & explanation

Answer: Redirect the client to their room and immediately assess vital signs and oxygen saturation.

Answer

The priority action is to redirect the client to their room and immediately assess vital signs and oxygen saturation.

Sudden confusion and wandering in an older adult often signal a physiological disturbance such as hypoxia, infection, or a medication adverse effect. The priority is to secure the client's immediate safety by redirecting them, followed immediately by an assessment of vital signs to identify and treat the underlying cause of the acute delirium.

Step-by-Step Solution

Identify the sudden change in the client's mental status.

The acute onset of disorientation indicates potential delirium rather than baseline chronic dementia.

Recognizing acute delirium is critical because it often stems from reversible, life-threatening physiological stressors.

Prioritize immediate safety and physiological assessment over restraints.

The nurse safely redirects the client away from the hazard (stairwell) and begins a physiological workup.

Securing the client's immediate environment prevents physical harm, while checking vital signs identifies potential physiological causes like hypoxia or infection.

Key Concept

Prioritization of safety and physiological assessment in acute delirium

Question 273Question →

A practical nurse (PN) has finished providing wound care for a client on Contact and Airborne precautions for a methicillin-resistant Staphylococcus aureus (MRSA) infection and active tuberculosis. The PN is wearing an N95 respirator, a face shield, an isolation gown, and gloves. In what order should the PN safely remove the personal protective equipment (PPE)? Arrange the actions in the correct sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence for doffing PPE is to first remove the gloves, then the face shield, followed by the isolation gown. After these items are removed, the nurse must exit the room and close the door before finally removing the N95 respirator.

According to standardized CDC guidelines for doffing personal protective equipment (PPE), the most contaminated items must be removed first to prevent cross-contamination. Gloves are removed first, followed by the face shield or goggles (handled by the clean ear pieces or headbands). Next, the isolation gown is removed by unfastening the ties and rolling it inside out. When Airborne Precautions are in place, the nurse must then exit the isolation room and close the door before safely removing the N95 respirator in the hallway or anteroom.

Step-by-Step Solution

Identify and remove the most contaminated piece of equipment first.

The gloves are removed and discarded in the appropriate receptacle.

This prevents the transfer of pathogens from the hands to the face or hair during the removal of other PPE.

Remove face and eye protection.

The face shield is removed by handling only the clean headbands or ear pieces.

The front of the face shield is considered contaminated; handling only the back straps prevents hand contamination.

Remove the remaining body coverage.

The isolation gown is unfastened and rolled inside out into a bundle.

Rolling the gown inside out contains the MRSA pathogens present on the front and sleeves.

Maintain airborne protection while in the infectious environment.

The nurse exits the room and ensures the door is closed.

The N95 respirator must remain on while inside the airborne infection isolation room to filter aerosolized tuberculosis bacteria.

Remove respiratory protection in a safe area.

The N95 respirator is removed strictly outside the room and discarded.

This ensures the nurse is in a clean environment before exposing their respiratory tract to ambient air.

Key Concept

Standard CDC Sequence for Doffing PPE (Airborne and Contact Precautions)

Question 274Question →

A practical nurse is caring for a client who is 24 hours postoperative following a right-sided pneumonectomy for lung cancer. The client is currently in a supine position and states, "My back aches from lying flat. Can you help me turn onto my side?" Which of the following actions should the nurse take?

Turn the client onto their right side and elevate the head of the bed to a semi-Fowler's position.

Assist the client to turn onto their left side and place a support pillow behind their back.

Advise the client to remain flat in the supine position and administer a prescribed PRN analgesic.

Help the client into a prone position for 15 minutes to completely relieve pressure on the dorsal spine.

Show answer & explanation

Answer: Turn the client onto their right side and elevate the head of the bed to a semi-Fowler's position.

Answer

Turn the client onto their right side and elevate the head of the bed to a semi-Fowler's position.

Following a pneumonectomy, positioning the client on the operative side (the right side in this scenario) or supine is correct because it promotes full expansion and ventilation of the remaining functional lung. This positioning also uses gravity to keep the mediastinal structures in their proper midline position, preventing them from shifting into the empty pleural space, which could severely compromise cardiac output and respiratory status.

Step-by-Step Solution

Assess the specific surgical procedure the client underwent.

The client had a right-sided pneumonectomy (complete removal of the right lung).

Identifying the specific type of surgery is crucial because thoracic procedures, particularly lung removal, require unique and specific positioning precautions.

Evaluate the requested nursing intervention against physiological principles.

The client wants to turn on their side. Turning to the unoperated side (left) would compress the remaining functional lung.

Gravity and fluid shifts can compromise the single functioning lung and cause mediastinal structures to shift into the empty surgical space if positioned improperly.

Select the safest position to promote comfort and physiological stability.

Position the client on their right side (operative side) with the head of the bed elevated.

This relieves back pressure, maximizes the ventilation of the healthy left lung, and prevents mediastinal shift.

Key Concept

Postoperative Positioning: Pneumonectomy

Question 275Question →

A licensed practical nurse (LPN) is assessing a client who is 4 hours postoperative following a partial nephrectomy. Which of the following findings indicate a potential complication and should be immediately reported to the registered nurse (RN)? Select all that apply.

Select all that apply

A hemoglobin level of 7.1 g/dL (71 g/L)

A heart rate steadily increasing from 78 to 114 beats per minute

A total urine output of 40 mL over the last three hours

A serum potassium level of 4.3 mEq/L (4.3 mmol/L)

A blood pressure of 116/74 mmHg, previously 120/78 mmHg

Mild incisional pain rated 3 on a 0 to 10 scale during repositioning

Show answer & explanation

Answer: A hemoglobin level of 7.1 g/dL (71 g/L); A heart rate steadily increasing from 78 to 114 beats per minute; A total urine output of 40 mL over the last three hours

Answer

The LPN should immediately report the hemoglobin level of 7.1 g/dL, the heart rate increasing to 114 beats per minute, and the total urine output of 40 mL over three hours.

Following a partial nephrectomy, the client is at risk for hemorrhage and acute kidney injury. A low hemoglobin (7.1 g/dL), an unexplained increasing heart rate (114 bpm), and severe oliguria (40 mL over 3 hours) all point to active bleeding, fluid volume deficit, or renal compromise. These are critical findings that exceed the LPN's independent scope of practice and demand immediate RN escalation.

Step-by-Step Solution

Analyze the client's postoperative status and risk factors.

The client had a partial nephrectomy, carrying a high risk for hemorrhage and renal impairment.

Identifying procedure-specific risks helps prioritize which assessments indicate life-threatening complications.

Evaluate the laboratory values.

The hemoglobin is critically low (7.1 g/dL), while the potassium is normal (4.3 mEq/L).

Differentiating between critical and expected lab findings ensures prompt escalation of potential hemorrhage.

Evaluate the vital signs and physical assessments.

The increasing heart rate (114 bpm) and oliguria (40 mL over 3 hours) are abnormal, while the minor blood pressure change and mild pain are expected.

Tachycardia and decreased urine output are classic early indicators of hypovolemic shock and kidney injury.

Key Concept

Recognizing Early Signs of Postoperative Complications

Question 276Question →

An older adult client is receiving treatment for a small bowel obstruction and has a nasogastric tube set to low continuous suction. Over the past six hours, the tube has drained 750 mL of gastric fluid. The assistive personnel reports that the client, who was previously alert and cooperative, is now persistently asking questions about a workplace they retired from two decades ago. The practical nurse enters the room and notes the client has a resting heart rate of 114 beats/min. Which action should the practical nurse take first?

Assess the client's blood pressure and alert the supervising registered nurse about the clinical changes.

Utilize therapeutic communication techniques to orient the client to the current time and place.

Auscultate all four abdominal quadrants to evaluate for the return of normal bowel activity.

Continue routine monitoring of the heart rate and record the total drainage volume in the chart.

Show answer & explanation

Answer: Assess the client's blood pressure and alert the supervising registered nurse about the clinical changes.

Answer

The practical nurse should prioritize assessing the client's blood pressure and alerting the supervising registered nurse about the clinical changes.

The correct action prioritizes the identification and management of a potential circulatory collapse. The client has experienced significant fluid loss via the nasogastric tube. The new onset of confusion indicates impaired cerebral perfusion, while the heart rate of 114 beats/min is a compensatory mechanism attempting to maintain cardiac output. This combination strongly suggests early hypovolemic shock. The practical nurse must immediately obtain the blood pressure to fully assess hemodynamic stability and alert the supervising nurse so that emergency fluid resuscitation can be initiated.

Step-by-Step Solution

Analyze the collective clinical data: 750 mL of gastric output, new-onset confusion, and unexplained tachycardia.

Identifies a pattern of significant fluid loss leading to potential hypoperfusion.

Large volumes of gastrointestinal drainage rapidly cause isotonic fluid volume deficit (hypovolemia) and electrolyte imbalances.

Determine the physiological cause of the sudden symptom onset.

Recognizes that the altered mental status and rising heart rate are early compensatory mechanisms for hypovolemic shock.

Decreased circulating blood volume reduces cerebral perfusion (causing confusion) and triggers the sympathetic nervous system to increase the heart rate in an attempt to maintain cardiac output.

Select the priority intervention based on the practical nurse scope of practice.

Prioritizes gathering complete hemodynamic data (blood pressure) and immediately escalating the care to the registered nurse.

Recognizing acute circulatory instability requires prompt reporting to facilitate immediate fluid resuscitation and prevent severe organ damage.

Key Concept

Hypovolemic Shock Recognition and Escalation

Question 277Question →

A 77-year-old client is resting in the surgical unit one day after an open cholecystectomy. Previously conversant and calm, the client abruptly becomes restless, fails to recognize visiting family members, and reports intense abdominal aching. The practical nurse evaluates the client and records a blood pressure of 96/60 mm Hg, a pulse of 108 beats per minute, respirations at 24 breaths per minute, and an oxygen saturation of 93% on room air. Which immediate interventions should the practical nurse prioritize? (Select all that apply.)

Select all that apply

Inspect the surgical incision site and surrounding abdomen for firmness, swelling, or active bleeding.

Urgently report the abrupt cognitive changes and current hemodynamic status to the charge nurse.

Verify the patency of the client's existing peripheral intravenous catheter.

Provide the prescribed breakthrough opioid medication to manage the severe abdominal pain.

Reassure the family that sudden confusion is a standard reaction to anesthesia in elderly clients.

Continue with the established vital sign routine because the recorded measurements are nearly within normal limits.

Show answer & explanation

Answer: Inspect the surgical incision site and surrounding abdomen for firmness, swelling, or active bleeding.; Urgently report the abrupt cognitive changes and current hemodynamic status to the charge nurse.; Verify the patency of the client's existing peripheral intravenous catheter.

Answer

The correct interventions are to inspect the surgical site for bleeding, report the changes to the charge nurse, and verify intravenous patency.

The client is exhibiting classic signs of early shock (mild hypotension, tachycardia, tachypnea) and poor cerebral perfusion (sudden agitation and delirium) following abdominal surgery. The practical nurse must prioritize assessing for the source of potential bleeding, ensuring an open intravenous line is ready for rapid fluid resuscitation, and immediately escalating these critical findings to the supervising registered nurse.

Step-by-Step Solution

Analyze the client's clinical presentation.

The combination of sudden agitation, abdominal pain, mild hypotension (96/60 mm Hg), tachycardia (108 bpm), and tachypnea (24 breaths/min) is identified.

Recognizing early physiological deviations is essential to identify high-risk complications like hypovolemic shock or internal bleeding.

Prioritize actions based on the ABCs (Airway, Breathing, Circulation).

Interventions that address potential circulatory collapse and physiological safety are selected over pain management.

In emergent scenarios, stabilizing systemic perfusion and oxygenation supersedes secondary issues like discomfort.

Select interventions within the practical nurse scope of practice.

Data collection (inspecting the abdomen), ensuring safety (verifying IV access), and escalating care (reporting to the RN) are chosen.

The practical nurse must gather focused data and prepare the client for rapid medical intervention while collaborating with the healthcare team.

Key Concept

Recognizing early signs of shock and physiological delirium in the postoperative older adult.

Estimated Time:1m 30s

Question 278Question →

A practical nurse is preparing to transfer a client who has left-sided hemiparesis following a cerebrovascular accident from the bed to a wheelchair. In what order should the nurse perform the following actions? (Move the steps into the correct chronological order.)

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: Position the wheelchair on the right side and lock wheels, assist to a sitting position on the edge of the bed, secure the transfer belt, brace the left knee, and finally assist to stand and pivot on the right leg.

Safe transfer of a client with hemiparesis requires strict adherence to biomechanical principles. The environment must be prepared first by placing the wheelchair on the strong (right) side to ensure the client pivots toward their strength. The client is then brought to a sitting position to stabilize blood pressure. A transfer belt is applied next for a secure hold. Before standing, the nurse must brace the weak (left) knee to prevent it from collapsing. Finally, the client uses their strong side to pivot and stabilize themselves in the wheelchair.

Step-by-Step Solution

Determine the client's strong and weak sides based on the diagnosis of left-sided hemiparesis.

The left side is weak, and the right side is strong.

Transfers must always be initiated toward the client's strong side for safety and stability.

Place the equipment (wheelchair) in the optimal position.

The wheelchair is placed on the right side at a 45-degree angle and locked.

Equipment must be ready and secure before moving the client.

Prepare the client physically for the transfer.

The client is assisted to a dangling position with feet flat, and the transfer belt is applied.

Dangling prevents orthostatic hypotension, and flat feet provide a solid base. The belt ensures a safe grip for the nurse.

Position yourself to protect the client's weak extremities.

The nurse faces the client and braces the left knee.

Hemiparetic extremities can buckle easily under weight; bracing provides external support.

Execute the pivot transfer.

The client pivots on the strong right leg and reaches with the strong right hand.

Pivoting on the strong side allows the client to bear their own weight safely and control their descent into the chair.

Key Concept

Safe Client Transfer Principles and Hemiparesis Precautions

Question 279Question →

A practical nurse is providing care for several clients who require specific infection control measures on a medical-surgical unit. Which action demonstrates the correct application of transmission-based precautions?

Removing the isolation gown and gloves inside the room prior to exiting the room of a client diagnosed with scabies.

Wearing a fit-tested N95 respirator mask while obtaining vital signs for a client diagnosed with seasonal influenza.

Placing a client with an intact, localized herpes zoster rash in an airborne infection isolation room with negative air pressure.

Transporting a client with active pulmonary tuberculosis through the hallway while the nurse wears an N95 respirator and the client remains unmasked.

Show answer & explanation

Answer: Removing the isolation gown and gloves inside the room prior to exiting the room of a client diagnosed with scabies.

Answer

Removing the isolation gown and gloves inside the room prior to exiting the room of a client diagnosed with scabies.

Scabies requires Contact Precautions. To prevent the spread of the infestation to other areas of the healthcare facility, the nurse must remove the contaminated gown and gloves inside the client's room and perform hand hygiene immediately before crossing the threshold into the hallway.

Step-by-Step Solution

Determine the correct transmission-based precaution for scabies.

Scabies is transmitted via direct skin-to-skin contact, requiring Contact Precautions.

Identifying the transmission route is necessary to apply the correct protective measures.

Evaluate the procedural standards for Contact Precautions.

Standards dictate that the gown and gloves must be removed inside the client's room before leaving.

Removing contaminated PPE inside the room prevents the spread of pathogens to the hallway and other hospital areas.

Evaluate the remaining options for adherence to infection control protocols.

The other actions apply inappropriately escalated precautions (N95 for influenza, airborne room for localized shingles) or omit critical source control (unmasked TB client during transport).

Verifying why the distractors are incorrect confirms that the scabies PPE doffing procedure is the only appropriate action.

Key Concept

Transmission-Based Precautions Implementation

Question 280Question →

The clinical educator is evaluating a practical nurse (PN) during a medication administration pass on a step-down telemetry unit. The PN is managing multiple clients with complex medication regimens. Which of the following observed actions indicate that the PN is practicing safely and within the legal scope of practice? Select all that apply.

Select all that apply

The PN checks the apical pulse of a client prescribed oral digoxin and, noting a rate of

54\text{ beats per minute}

, holds the medication and alerts the charge nurse.

The PN tells a client receiving atorvastatin to immediately report any unexplained muscle tenderness or weakness before taking the next dose.

The PN asks a registered nurse to independently verify a weight-based dosage calculation for a pediatric client's oral antibiotic suspension.

The PN responds to a client's sudden

10/10

incisional pain by administering a PRN order of intravenous (IV) push hydromorphone.

The PN hands a client their morning oral medications and then scans the barcode on the client's wristband as the client swallows the pills.

The PN views a morning chemistry panel showing a potassium level of

2.9\text{ mEq/L}

(

2.9\text{ mmol/L}

) and proceeds to administer the client's scheduled dose of oral furosemide.

Show answer & explanation

Answer: The PN checks the apical pulse of a client prescribed oral digoxin and, noting a rate of $54\text{ beats per minute}$ , holds the medication and alerts the charge nurse.; The PN tells a client receiving atorvastatin to immediately report any unexplained muscle tenderness or weakness before taking the next dose.; The PN asks a registered nurse to independently verify a weight-based dosage calculation for a pediatric client's oral antibiotic suspension.

Answer

The correct actions indicating safe practice include holding digoxin for a bradycardic pulse, reinforcing teaching about atorvastatin adverse effects, and asking a registered nurse to verify a weight-based pediatric medication calculation.

The correct actions demonstrate safe pharmacological care within the practical nurse's legal boundaries. Assessing an apical pulse and withholding digoxin for a heart rate below 60 beats per minute prevents potential toxicity and symptomatic bradycardia. Practical nurses are responsible for reinforcing client education, making the instruction about statin-induced myopathy appropriate. Furthermore, having an independent double-check for weight-based pediatric calculations is a standard safety protocol to prevent critical dosage errors.

Step-by-Step Solution

Analyze the role of the practical nurse regarding medication administration and client safety.

The PN must administer medications safely, recognize abnormal physiological findings, escalate critical issues, and stay strictly within their designated scope of practice.

Scope of practice guidelines and legal regulations dictate the boundaries of safe care for the PN.

Evaluate the options describing medication administration and pre-assessment monitoring.

Withholding digoxin for a pulse of 54 bpm is correct because the pulse is below the safe threshold of 60 bpm. Administering furosemide with a critically low potassium level of 2.9 mEq/L is a dangerous error.

The PN is responsible for checking pre-administration vital signs and recognizing critical laboratory values that contraindicate a medication.

Evaluate the options regarding the scope of practice limits (teaching, IV administration, verification).

Reinforcing teaching and asking for calculation double-checks are within scope. However, administering IV push hydromorphone is outside the PN's scope.

IV push medications and initial client education require RN-level advanced assessment and clinical judgment.

Evaluate the option regarding medication administration safety rights.

Scanning the barcode after administration is an incorrect and unsafe practice.

Scanning must occur immediately prior to administration to ensure the right patient receives the right medication, preventing fatal errors.

Key Concept

Practical Nursing Scope of Practice in Pharmacological Therapies

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