Examkin

All practice questions

636 questions

All types2,933Multiple choice1,506Multiple select653Numeric68Matching70Ordering636
Question 261Question →

During a night shift on a medical-surgical unit, a practical nurse (PN) observes a registered nurse (RN) coworker exhibiting slurred speech, profound lethargy, and unsteady motor coordination while preparing a client's scheduled opioid analgesic. In what sequence must the PN execute the following actions to appropriately manage this legal and ethical situation? Arrange the steps from first (highest priority) to last (lowest priority).

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: 1) Intervene to stop the medication administration, 2) Report to the nursing supervisor, 3) Ensure the client receives the medication safely, and 4) Document the incident.
The sequence follows the prioritization framework of immediate client safety, communication with management, continuity of client care, and finally, administrative documentation. The PN's duty to protect the public mandates stopping the impaired nurse first.

Step-by-Step Solution

1
Intervene immediately to stop the coworker from administering the medication to the client.
The client is protected from receiving potentially unsafe care from an impaired provider.
According to the nursing code of ethics and state practice acts, the nurse's primary duty is to protect the client from harm. Stopping the immediate threat takes precedence over all other actions.
2
Report the objective observations of impairment directly to the charge nurse or nursing supervisor.
Facility management is alerted to the safety risk.
The PN must use the chain of command to report impaired practice. Supervisors possess the administrative authority to relieve the RN of duty, mandate testing, and ensure overall unit safety.
3
Collaborate with the charge nurse to ensure the client receives the prescribed analgesic from an unimpaired nurse.
The client's prescribed therapeutic regimen is maintained.
Continuity of care is essential. The client's need for the scheduled opioid analgesic remains valid and must be fulfilled safely once the impaired nurse is removed.
4
Submit a factual, objective incident report detailing the observed behaviors using the facility's documentation system.
A formal, legal record of the ethical breach and safety intervention is established.
Objective documentation provides a legal record for facility risk management and potential Board of Nursing investigations, but administrative tasks always follow direct client safety interventions.

Key Concept

The primary legal and ethical obligation of the practical nurse when encountering an impaired colleague is to ensure immediate client safety, followed by mandatory reporting through the proper facility chain of command.
Question 262Question →

After assisting a primary healthcare provider with an aerosol-generating procedure for a client with a novel respiratory virus requiring airborne, contact, and eye precautions, the practical nurse prepares to doff personal protective equipment (PPE). Arrange the following steps for safely removing the PPE in the correct chronological order.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: remove gloves, remove face shield, remove gown, exit the room, remove the N95 respirator, and finally perform hand hygiene.
According to standard infection control guidelines, PPE must be removed in a manner that prevents self-contamination. The most contaminated items (gloves) are removed first. Eye protection and gowns follow. For airborne precautions, respiratory protection (N95) must remain in place until the nurse has exited the isolation room and closed the door. Hand hygiene is always the final step.

Step-by-Step Solution

1
Remove gloves.
Hands are freed from the most contaminated protective barrier.
Gloves are removed first to avoid contaminating the face, head, and uniform when removing other PPE.
2
Remove face shield.
Eye protection is taken off without touching the contaminated front surface.
The front of the shield is contaminated; removing it by the headband minimizes cross-contamination.
3
Remove gown.
The gown is bundled inside out and discarded in the appropriate receptacle.
Rolling the gown inside out traps contaminants, protecting the nurse's underlying uniform.
4
Exit the negative-pressure room.
The nurse is now in a clean hallway or anteroom.
Airborne pathogens remain contained in the isolation room, and the nurse must leave before removing respiratory protection.
5
Remove N95 respirator.
The respirator is safely removed by the straps and discarded.
Handling only the straps prevents hand contamination, and doing this outside the room prevents inhalation of airborne droplets.
6
Perform hand hygiene.
Pathogens transferred to the hands during the doffing process are eradicated.
Hand hygiene is the essential final step to break the chain of infection.

Key Concept

PPE Doffing Sequence for Airborne, Contact, and Eye Precautions
Question 263Question →

During morning medication administration, a competent adult client declines their prescribed antihypertensive drug. The client tells the practical nurse (PN), 'That pill makes me feel lightheaded, so I refuse to swallow it today.' Arrange the PN's actions in the correct chronological order to advocate for the client's rights and ensure safety. All options must be used.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence of actions is to first withhold the medication, then collect vital signs, reinforce teaching, notify the healthcare provider, and finally document the event.
When a competent client refuses a prescribed treatment or medication, the practical nurse's immediate responsibility is to honor that right and withhold the dose to prevent any perception of coercion. Subsequently, because the client articulated a specific clinical symptom (feeling lightheaded), the nurse must prioritize data collection by obtaining vital signs to ensure the client is not experiencing an adverse event like severe hypotension. Once safety is verified, the nurse reinforces teaching so the client comprehends the medical risks associated with missing the dose. The nurse then communicates the client's decision and the assessment data to the healthcare provider for potential adjustments to the care plan. Finally, the nurse documents the entire chronological sequence in the health record to maintain legal compliance and continuity of care.

Step-by-Step Solution

1
Acknowledge and respect the refusal.
The medication is withheld immediately.
Competent clients possess the fundamental right to self-determination and can refuse any treatment.
2
Assess the client's clinical status.
Current blood pressure and heart rate are obtained.
The reported symptom of lightheadedness requires prompt investigation to ensure the client is hemodynamically stable.
3
Reinforce education.
The client receives clear information regarding the risks of refusal.
Clients must understand the potential health consequences to ensure their refusal is truly informed.
4
Notify the healthcare provider.
The provider is updated with the refusal and assessment findings.
The provider needs accurate data to decide if the medication regimen should be altered.
5
Document the event.
The electronic health record reflects all actions taken.
Accurate documentation serves as a legal record of client advocacy and nursing care.

Key Concept

Client Rights: Refusal of Treatment and Advocacy
Question 264Question →

The practical nurse is preparing to draw up a prescribed medication from a glass ampule. Arrange the following steps in the correct chronological order.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: tap the top of the ampule, place a gauze pad around the neck, snap the neck away from the body, attach a filter needle to withdraw the medication, and finally replace the filter needle with an administration needle.
Safe medication preparation from an ampule requires a specific sequence to prevent injury to the nurse and the client. First, fluid must be cleared from the neck to ensure an accurate dose. Second, the nurse protects their hands with a pad or swab. Third, the ampule is snapped safely away from the body. Fourth, a filter needle is used to draw up the medication, ensuring no glass particles enter the syringe. Finally, the filter needle is replaced with a regular needle for safe administration.

Step-by-Step Solution

1
Identify the first action required before opening the ampule.
Tap the top of the ampule lightly.
Medication often gets trapped in the top of the ampule and must be moved to the bottom chamber to ensure the full dose is available.
2
Determine the safety measures needed to open the glass ampule.
Place a gauze pad around the neck and snap it away from the body.
The gauze pad protects the nurse's fingers, and snapping away from the body prevents glass shards from flying toward the face.
3
Select the correct equipment to withdraw the medication.
Attach a filter needle and withdraw the medication.
Breaking a glass ampule can introduce microscopic glass shards into the fluid. A filter needle traps these particles so they do not enter the syringe.
4
Identify the final preparation step before giving the injection.
Replace the filter needle with an administration needle.
Filter needles are not designed for tissue injection and must be removed prior to administering the medication to the client.

Key Concept

Safe Preparation of Medication from an Ampule
Question 265Question →

A practical nurse is reinforcing hygiene instructions for a client who is 24 hours postpartum following a vaginal delivery with a second-degree perineal laceration. The nurse is reviewing the procedure for using a perineal squeeze bottle. Arrange the following steps in the correct chronological order.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence for perineal care is to first perform hand hygiene, then fill the squeeze bottle with warm water. Next, the client should spray the water from front to back, followed by gently blotting the area dry from front to back. Finally, the client should apply a clean perineal pad.
The sequence follows the principles of medical asepsis and safe wound care. The nurse must instruct the client to wash hands first to ensure asepsis. Preparing the equipment (filling the bottle) comes next. The actual cleansing must proceed from the least contaminated area (front/urinary meatus) to the most contaminated area (back/anus) to prevent urinary tract and perineal infections. Drying must follow the same directional principle using a gentle blotting motion to avoid disrupting the healing second-degree laceration. Finally, applying a clean pad protects the area and absorbs lochia.

Step-by-Step Solution

1
Perform hand hygiene
Hands are free of pathogens
Reduces the risk of introducing infection to the perineal wound
2
Fill the squeeze bottle with warm water
The cleansing tool is prepared
Warm water promotes tissue comfort and vasodilation for healing
3
Spray the perineal area from front to back
Blood and lochia are cleansed away
The front-to-back direction prevents fecal contamination of the vagina and urethra
4
Blot the area gently from front to back
The perineum is dried safely
Blotting prevents mechanical trauma to the sutures while maintaining infection control
5
Apply a clean perineal pad
The area is protected
Absorbs ongoing lochia discharge and protects the healing tissue

Key Concept

Postpartum Perineal Care and Infection Prevention
Question 266Question →

A practical nurse is assisting a client with left-sided hemiparesis to transfer from the bed to a wheelchair. In what order should the nurse perform the following actions? Arrange the steps from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

First, position the wheelchair on the right side. Second, lock the wheels. Third, assist the client to sit on the edge of the bed. Fourth, secure the transfer belt. Finally, pivot the client into the wheelchair.
Safe transfer protocols require organizing the environment first (placing the chair on the strong side), securing the equipment (locking wheels), moving the client to a stable intermediate position (dangling), applying safety devices (transfer belt), and finally executing the movement leading with the strong side.

Step-by-Step Solution

1
Identify the client's physical limitations and determine equipment placement.
The client has left-sided weakness, meaning the right side is strong. The wheelchair is placed on the strong side.
Transfers should always lead with the client's strong side to maximize stability and minimize fall risk.
2
Secure the transfer environment.
Both the bed and the wheelchair wheels are locked.
Equipment must be immobilized before the client shifts their weight to prevent the bed or chair from moving.
3
Determine the physical sequence for moving the client safely.
Sit the client on the bed, apply the transfer belt, and then pivot to the chair.
The client must be seated safely before the safety belt can be properly applied, and the belt must be secured before attempting to bear weight or pivot.

Key Concept

Safe client transfer techniques and mobility assistance
Question 267Question →

A practical nurse (PN) is preparing to collect focused data on the uterine fundus and lochia of a client who delivered a healthy newborn 4 hours ago. In what order should the PN perform the following actions? Arrange the steps from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence ensures accuracy and safety: first, have the client empty their bladder, then position them supine with flexed knees, put on gloves and expose the pad, support the lower uterine segment, and finally palpate the fundus.
Postpartum data collection of the fundus and lochia follows a specific sequence for accuracy and safety. Emptying the bladder must happen first because a full bladder displaces the uterus. Proper positioning relaxes abdominal muscles for comfort. Donning gloves and exposing the pad ensures the PN can observe the lochia expelled during palpation. Supporting the lower uterine segment is a critical safety step to prevent uterine inversion. Finally, palpating the fundus allows the PN to evaluate its tone and height.

Step-by-Step Solution

1
Determine the prerequisite for accurate postpartum abdominal data collection.
The client must empty their bladder first.
A distended bladder pushes the uterus up and to the side, causing a falsely high fundal measurement and potentially mimicking uterine atony.
2
Identify the correct anatomical position for the procedure.
The client should be positioned flat and supine with knees flexed.
Flexing the knees reduces tension on the abdominal muscles, allowing the PN's hands to press deeply enough to locate the fundus without causing excessive pain.
3
Prepare for exposure to bodily fluids.
Don gloves and uncover the perineal pad.
Palpating the fundus often causes a gush of lochia. The PN must be prepared to observe this fluid and follow standard precautions.
4
Establish safety before applying pressure.
Anchor the lower uterine segment by placing one hand just above the symphysis pubis.
Pushing on the top of the uterus without supporting the bottom can cause uterine inversion, a life-threatening emergency.
5
Execute the physical data collection.
Palpate the fundus with the dominant hand.
This evaluates whether the uterus is contracted (firm) or boggy, which is the primary goal of the technique.

Key Concept

Accurate and safe postpartum fundal data collection requires emptying the bladder first to prevent uterine displacement, followed by proper positioning and anchoring of the lower uterine segment to prevent uterine inversion during palpation.
Question 268Question →

A practical nurse is caring for a client who is 1 day postoperative following a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigation (CBI). The client suddenly reports severe lower abdominal cramping and a feeling of extreme bladder fullness. The nurse observes that irrigation fluid is infusing into the bladder, but there is no output in the catheter drainage bag. In what order should the practical nurse perform the following actions? Arrange the actions from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

1. Inspect the catheter drainage tubing for kinks, 2. Stop the continuous bladder irrigation, 3. Manually irrigate the urinary catheter, 4. Notify the registered nurse, 5. Administer a prescribed antispasmodic medication
When a client receiving continuous bladder irrigation (CBI) develops severe cramping and a lack of urinary output, it strongly indicates a catheter obstruction, most likely due to a blood clot. The first nursing action is to assess for simple mechanical issues like kinked tubing. If none are found, the CBI must be stopped immediately to prevent further fluid from infusing into an obstructed bladder, which could cause serious trauma or rupture. Next, the nurse should manually irrigate the catheter to clear the clot. Once the immediate danger is addressed and flow is restored (or if irrigation fails), the RN or provider is notified. Finally, an antispasmodic can be administered, as it is only safe to treat a bladder spasm after confirming the bladder is draining properly.

Step-by-Step Solution

1
Inspect the catheter drainage tubing for kinks or external compression
Rules out simple, easily reversible mechanical blockages.
This is the least invasive and fastest method to potentially restore flow before taking further steps.
2
Stop the continuous bladder irrigation (CBI) infusion
Halts the accumulation of additional fluid in the bladder.
Prevents bladder overdistention and potential rupture when the outflow is visibly blocked.
3
Manually irrigate the urinary catheter with sterile normal saline
Dislodges obstructing blood clots within the catheter.
A common complication of a TURP procedure is clot retention; manual irrigation is the standard acute intervention to clear it.
4
Notify the registered nurse (RN) or healthcare provider
Escalates the complication for advanced collaborative care.
Ensures the healthcare team is fully aware of the obstruction and can intervene medically if manual irrigation is unsuccessful.
5
Administer a prescribed antispasmodic medication
Relieves postoperative bladder spasms.
Symptom management medication is safely given only after ensuring the pain is not caused by an active fluid obstruction.

Key Concept

Prioritization of care and safety interventions for a postoperative TURP client experiencing continuous bladder irrigation obstruction.
Question 269Question →

While preparing a hospitalized client for an upcoming abdominal surgery, the healthcare provider (HCP) obtains a signature on the consent document and departs the unit. Shortly after, the client expresses confusion, stating to the practical nurse (PN), 'I signed it, but I have no idea what they are actually cutting out.' In which chronological order should the PN perform the following interventions to protect the client's rights?

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first gather data regarding the client's understanding, then withhold any sedating medications to protect legal competence, followed by notifying the healthcare provider to explain the procedure, and finally documenting all actions in the medical record.
The practical nurse (PN) must follow the nursing process and act within their legal scope of practice to advocate for the client. First, the PN gathers data to confirm the knowledge deficit. Second, the PN protects the client's right to informed consent by withholding sedatives that would impair decision-making. Third, the PN advocates by notifying the healthcare provider, who holds the legal responsibility for explaining the surgery. Finally, all findings and actions are documented.

Step-by-Step Solution

1
Gather data regarding the client's understanding of the surgery.
The PN identifies the exact nature of the client's knowledge deficit.
Data collection is the first step of the nursing process and is necessary to determine the appropriate intervention.
2
Withhold preoperative sedatives.
The client remains cognitively intact and capable of making legal decisions.
Administering sedatives would render the client legally incompetent to provide or revoke informed consent, violating their rights.
3
Notify the healthcare provider.
The provider is informed of the issue and returns to educate the client.
It is strictly within the provider's scope of practice, not the PN's, to explain surgical procedures and obtain informed consent.
4
Document the event.
A chronological, legal record of the advocacy actions is created.
Documentation should reflect the objective findings, interventions taken to protect the client, and the communication with the provider.

Key Concept

Client Rights, Informed Consent, and the Practical Nurse's Scope of Practice
Question 270Question →

A client with confirmed rubeola and a severe Clostridioides difficile infection requires a linen change. Before crossing the threshold of the negative-pressure isolation room, the practical nurse must don the necessary personal protective equipment (PPE). Arrange the donning steps in the correct chronological order.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence for donning the required PPE is to first perform hand hygiene with soap and water, followed by putting on the isolation gown, applying the N95 respirator, securing the face shield, and finally donning the gloves.
Following the standardized CDC sequence for donning PPE is essential to prevent self-contamination and ensure maximum barrier protection. The presence of Clostridioides difficile requires hand hygiene with soap and water, as alcohol-based rubs are ineffective against its spores. After hand hygiene, the gown is applied first as the foundational barrier. The N95 respirator is applied next to establish a secure seal against the face to protect against airborne rubeola. The face shield follows, resting over the respirator to protect the eyes from splashes. Finally, gloves are applied last so their cuffs can be pulled securely over the gown sleeves, ensuring continuous coverage.

Step-by-Step Solution

1
Wash hands with soap and water rather than an alcohol-based sanitizer.
Hands are cleansed of pathogens, including resilient C. difficile spores.
Hand hygiene must occur before handling clean PPE. Soap and water are mandatory because alcohol sanitizers are ineffective against C. difficile spores.
2
Put on the fluid-resistant gown and fasten all ties.
The nurse's uniform and torso are protected from infectious contact.
The gown is the largest PPE item and forms the base layer of protection, so it is applied immediately after hand hygiene.
3
Position the N95 respirator over the nose and mouth, secure it, and check the seal.
The nurse is protected against airborne rubeola particles.
The respirator must be applied directly against the skin to ensure an airtight seal before any eye protection is added.
4
Place the face shield over the eyes and face.
Mucous membranes are protected from potential fluid splashes.
Eye protection is placed over the respirator to ensure it does not interfere with the respirator's seal on the face.
5
Put on gloves, pulling the edges over the gown cuffs.
The hands and wrists are completely sealed against contact contamination.
Gloves must go on last to ensure they overlap the gown sleeves, preventing any exposed skin at the wrists.

Key Concept

Standardized CDC sequence for donning personal protective equipment (PPE) combined with organism-specific precautions
Question 271Question →

A practical nurse is preparing to enter the room of a client who requires airborne and contact precautions. In what order should the nurse don the following personal protective equipment (PPE)? Arrange the items in the correct sequence from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct donning sequence is: isolation gown, followed by the N95 respirator, then the face shield or goggles, and finally the clean gloves.
According to standard infection control guidelines, personal protective equipment should be donned in a specific sequence to ensure maximum protection and prevent contamination. The gown is put on first to cover the body, followed by respiratory protection (such as an N95 respirator), then eye protection (goggles or a face shield), and finally gloves. The gloves must be put on last so they can cover the cuffs of the gown, ensuring no skin is exposed.

Step-by-Step Solution

1
Put on the isolation gown.
The torso and clothing are covered.
The gown serves as the base layer of contact protection and must be secured before adding other items.
2
Put on the N95 respirator.
The airway is protected.
Respiratory protection is established before facial protection to ensure a proper seal against the skin.
3
Put on the face shield or goggles.
The mucous membranes of the eyes are protected.
Eye protection sits over the respirator straps and face.
4
Put on clean gloves.
The hands are protected and the gown cuffs are sealed.
Gloves must go on last so they can be extended over the gown cuffs, preventing any skin exposure at the wrists.

Key Concept

Standard Sequence for Donning Personal Protective Equipment (PPE)
Estimated Time:45s
Question 272Question →

A practical nurse (PN) is preparing to delegate assistance with ambulation to an unlicensed assistive personnel (UAP) for a client who is two days postoperative. Arrange the steps of the delegation process in the correct chronological order.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence for the delegation process is: 1) Assess appropriateness and client stability, 2) Communicate clear instructions, 3) Supervise the delegate, and 4) Evaluate the client's outcome.
The National Council of State Boards of Nursing (NCSBN) outlines a standard delegation process. The PN must first assess the client to ensure stability and verify the task is appropriate for the UAP. Next, the PN communicates clear expectations and guidelines for the task. The PN then supervises the execution of the task, and finally evaluates the client's response and verifies task completion.

Step-by-Step Solution

1
Identify the initial requirement before any task is assigned.
Assess the client's current stability and appropriateness of the task.
The Five Rights of Delegation require the right task and right circumstances, which can only be determined through initial data collection.
2
Determine the next action after confirming the task can be safely delegated.
Communicate clear instructions.
The delegate needs to know exactly what to do, how to do it, and what abnormalities to report, satisfying Right Direction and Communication.
3
Identify the PN's responsibility while the task is occurring.
Supervise the UAP.
The PN retains accountability and must ensure safe execution through proper supervision.
4
Determine the final phase of the delegation process.
Evaluate the client's response.
The nursing process concludes with evaluating whether the intervention was successful and well-tolerated by the client.

Key Concept

The chronological steps of the delegation process: Assess, Communicate, Supervise, and Evaluate.
Question 273Question →

A practical nurse (PN) is caring for a client who states, "I want to read everything written in my medical chart right now." To properly advocate for the client's rights while following standard procedures, in what order should the PN perform the following actions? Arrange the actions from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first acknowledge the client's legal right to their medical records, then explain the facility's policy for access, provide the necessary written request form, and finally notify the charge nurse or medical records department.
The correct order prioritizes immediate therapeutic communication and validation of the client's legal rights, followed by necessary education regarding facility policy. Once the client understands the process, the nurse facilitates the action by providing the correct form, and finally ensures continuity of care by notifying the chain of command.

Step-by-Step Solution

1
Acknowledge the client's right.
The client feels heard and validated.
Therapeutic communication and advocacy require immediate validation of fundamental client rights before explaining restrictions or rules.
2
Explain the facility's policy.
The client understands that access cannot happen "right now."
Managing expectations prevents escalation and educates the client on how to properly exercise their rights safely.
3
Provide the formal request form.
The client takes actionable steps to obtain the chart.
Verbal requests are generally insufficient for medical records; formal documentation is legally required by most facilities.
4
Notify the charge nurse and relevant departments.
The healthcare team is aware of the client's actions.
Maintaining the chain of command ensures the request is tracked and fulfilled appropriately without disrupting immediate client care.

Key Concept

Under HIPAA and the Patient's Bill of Rights, clients have a legal right to view their medical records. The Practical Nurse advocates for this right by supporting the request while ensuring facility protocols are followed.
Question 274Question →

A client who is scheduled for a cholecystectomy later today tells the practical nurse (PN), 'I am still confused about what they are actually removing.' The PN has the consent documentation in hand for the client to sign. Arrange the following nursing actions in the correct sequence from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first withhold the consent document, then contact the surgeon regarding the knowledge deficit, allow the surgeon to educate the client, and finally witness the signature.
The correct sequence ensures the client's legal rights and safety are protected. When a client expresses a lack of understanding, the immediate priority is to stop them from signing a legally binding document. Because explaining a surgical procedure is outside the PN's scope of practice, the nurse must then notify the healthcare provider. The provider must return to explain the procedure and answer the client's questions. Only after the client's understanding is confirmed can the PN ethically and legally witness the voluntary signature on the informed consent form.

Step-by-Step Solution

1
Evaluate the client's statement regarding their lack of understanding.
The PN recognizes that the legal criteria for informed consent have not been met.
Informed consent legally requires the client to fully comprehend the procedure, its risks, and benefits before signing any forms.
2
Halt the signing process and contact the healthcare provider.
The client does not sign the form, and the operating surgeon is made aware of the knowledge deficit.
A practical nurse cannot legally obtain informed consent or explain surgical procedures; this duty belongs strictly to the provider performing the intervention.
3
Wait for the provider to provide the necessary education and then proceed as a witness.
The client receives the required information, understands the procedure, and signs the document with the PN acting as a witness.
The PN's legal and ethical role is solely to witness that the signature is authentic, the client is competent, and the consent is given voluntarily.

Key Concept

Informed Consent and the Practical Nurse Scope of Practice
Question 275Question →

A practical nurse is assisting with a 4-year-old child brought to a community urgent care center with a spiral fracture of the humerus. The caregiver's explanation of how the injury occurred is inconsistent with the child's developmental abilities. Arrange the following nursing actions in the correct sequence from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first assess the child for immediate physiological danger, then interview the child privately, followed by notifying the healthcare provider and supervisor, contacting child protective services, and finally documenting the entire event objectively.
In cases of suspected abuse, the nursing process requires that assessment for life-threatening injuries is the absolute first priority. After ensuring immediate physical safety, the nurse must secure a safe environment by interviewing the client away from the potential abuser. Once critical information is gathered, the nurse notifies the attending healthcare provider and facility leadership to coordinate care. Subsequently, a mandatory external report must be made to child protective services to fulfill legal obligations. Finally, objective and comprehensive documentation of the entire incident, including direct quotes and injury descriptions, completes the nursing intervention.

Step-by-Step Solution

1
Prioritize physiological safety.
The child is assessed for other injuries or distress.
Maslow's hierarchy of needs and standard nursing protocols dictate that physiological stability must be secured before addressing psychosocial or legal concerns.
2
Create a safe environment for disclosure.
The child is interviewed without the caregiver present.
The caregiver may be the perpetrator of the abuse; separating them prevents intimidation and allows the child to answer questions honestly.
3
Escalate findings via the chain of command.
The provider and clinical supervisor are informed of the discrepancies.
Collaboration is needed for further medical evaluation and to formally initiate the facility's suspected abuse protocols.
4
Fulfill legal obligations.
Child protective services is contacted.
Nurses are mandatory reporters of suspected child abuse and must report to external authorities to ensure the long-term safety of the vulnerable client.
5
Create a legal record.
Objective data and all reporting actions are charted in the medical record.
Thorough documentation is essential for potential legal proceedings and continuity of care, which is finalized after immediate safety and reporting are handled.

Key Concept

Mandatory Reporting and Prioritization in Suspected Abuse
Question 276Question →

A practical nurse discovers a small fire burning in a client's bedside wastebasket. The client is currently in bed nearby. In what order should the nurse perform the following actions according to standard fire safety protocols?

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct order is to first relocate the client to safety, then activate the fire alarm, next close the door to the room, and finally attempt to extinguish the fire.
The standard sequence for responding to a fire in a healthcare facility is guided by the RACE mnemonic: Rescue clients in immediate danger, Alarm (activate the facility's fire response system), Confine the fire by closing doors, and Extinguish the fire if it is small and safe to do so.

Step-by-Step Solution

1
Relocate the client to a safe area away from the fire.
The client is protected from immediate harm.
Life safety and client protection (Rescue) is always the highest priority in any emergency situation.
2
Activate the facility fire alarm system.
The emergency response team and fire department are formally notified.
Once immediate life safety is secured, sounding the alarm (Alarm) ensures that appropriate, facility-wide help arrives quickly.
3
Close the door to the client's room.
The fire and smoke are contained to the room of origin.
Closing doors (Confine) restricts the oxygen supply to the fire and protects the rest of the facility from dangerous smoke spread.
4
Attempt to put out the fire using an appropriate extinguisher.
The small fire is addressed.
Only after the previous steps are completed should staff attempt to extinguish the fire (Extinguish), and only if they are not placing themselves in danger.

Key Concept

RACE Fire Response Protocol
Question 277Question →

While conducting hourly rounds, a practical nurse finds a resident sitting on the bathroom floor. The resident states, "I slipped on a wet spot." Arrange the following nursing actions in the correct sequence from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first assess the client for injuries, call for assistance from staff, safely assist the client back to bed, notify the healthcare provider, and finally complete the facility incident report.
Post-fall protocols dictate that the nurse must first assess the client for any injuries before attempting to move them. Once the assessment is clear, the nurse should call for help to ensure a safe transfer back to bed. After the client is safe and stabilized in bed, the healthcare provider is notified of the event. Finally, administrative duties such as the incident report are completed.

Step-by-Step Solution

1
Determine the highest priority action using the nursing process.
Assessing the client for injuries must occur first.
Moving a client with an unidentified fracture or spinal injury could cause severe harm. Assessment always precedes physical intervention.
2
Identify the next immediate need for client safety.
Calling for assistance is the second step.
Safe lifting requires adequate personnel. The nurse should not attempt to lift the client alone, which prevents injury to both the client and the nurse.
3
Determine the subsequent physical intervention.
Assisting the client back to bed.
Once help arrives and the client is deemed safe to move, they should be returned to a safe and comfortable environment.
4
Identify the necessary post-incident communication.
Notifying the healthcare provider.
The provider must be informed of the fall and current assessment findings to evaluate the need for further medical orders.
5
Identify the final administrative step.
Completing the incident report.
Documentation of the variance is required by facility policy but is the lowest priority compared to direct, immediate client care.

Key Concept

Post-fall management prioritizes immediate client assessment before any movement or administrative tasks to prevent further injury.
Question 278Question →

An experienced practical nurse (PN) is floated to a busy acute medical unit. Upon reviewing the shift assignment, the PN notes that one assigned client is experiencing acute respiratory distress and requires continuous titration of intravenous (IV) vasoactive medications. Arrange the steps the PN must take to safely and professionally resolve this out-of-scope assignment in the correct sequential order.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first approach the charge nurse, articulate the scope of practice issue, request a safe reassignment, escalate to the supervisor if unresolved, and finally file a formal report.
When a PN receives an unsafe or out-of-scope assignment, they must follow a structured process to protect the client and their license. The process begins with the immediate chain of command (the charge nurse), requires clear articulation of scope of practice limitations, attempts collaborative reassignment, escalates to higher management only if unresolved, and concludes with formal documentation after the client's safety is secured.

Step-by-Step Solution

1
Approach the delegating charge nurse to communicate concerns about the assigned client's acuity.
Initiates communication with the immediate supervisor.
Professional conflict resolution requires addressing the issue first with the person directly responsible for the delegation.
2
Clearly articulate that the continuous titration of IV vasoactive medications exceeds the PN legal scope of practice.
Provides objective justification for refusing the assignment.
The PN must clarify that the refusal is based on legal scope of practice boundaries, not personal preference.
3
Request a reassignment to a stable client whose care requirements match the PN's legal competencies.
Offers a constructive solution to the staffing issue.
The PN remains willing to work and contribute to the team by caring for clients who are stable with predictable outcomes.
4
Escalate the situation to the nursing supervisor if the charge nurse declines to alter the assignment.
Involves higher nursing administration.
If the charge nurse insists on an unsafe assignment, the PN must invoke the chain of command to prevent patient harm.
5
File an objective formal report documenting the unsafe assignment request according to facility protocols.
Creates a permanent administrative record of the event.
Documentation protects the nurse's license and helps the facility track and address inappropriate delegation practices.

Key Concept

Client Care Assignments and Collaboration
Question 279Question →

Upon arriving for a shift on an orthopedic unit, a practical nurse (PN) is assigned a client who has just developed acute respiratory failure and requires immediate continuous intravenous sedation. Arrange the following collaborative actions the PN should take in the correct chronological order to safely manage this assignment.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence requires the PN to first recognize the scope limitation, notify the charge nurse, request reassignment to an RN, offer to assist with a stable client to support the team, and finally accept the modified safe assignment.
This sequence represents the standard professional protocol for a practical nurse refusing an unsafe assignment. It moves logically from internal cognitive recognition (identifying the scope issue) to verbal communication (notifying the charge nurse), followed by active collaboration (requesting RN reassignment and offering help with stable clients), and concludes with the resolution of the conflict (accepting the safe assignment).

Step-by-Step Solution

1
Determine if the assigned tasks align with the PN scope of practice.
The PN identifies that continuous IV sedation and respiratory failure management are out of scope.
A nurse must never accept an assignment that requires skills or knowledge beyond their legal practice boundaries.
2
Report the unsafe assignment to the charge nurse.
The chain of command is activated to address the safety risk.
The delegator (charge nurse) must be made aware immediately so that alternative staffing arrangements can be made.
3
Advocate for the client's safety through reassignment.
The PN explicitly requests that an RN assume care of the client.
Unstable clients with unpredictable outcomes require the comprehensive assessment and critical thinking skills of an RN.
4
Collaborate with the nursing team to redistribute the workload.
The PN offers to care for a stable client previously assigned to the RN.
Teamwork and collaboration ensure that all clients on the unit receive care despite the sudden shift in assignments.
5
Proceed with the shift using the revised assignment.
The PN begins caring for a safe, appropriate group of clients.
Once the assignment conflict is resolved legally and safely, routine care delivery can commence.

Key Concept

Scope of Practice and Safe Client Care Assignments
Question 280Question →

After completing wound care and administering oral medications for a client on both contact and droplet precautions, a practical nurse prepares to exit the isolation room. The nurse is currently wearing gloves, an isolation gown, a face shield, and a surgical mask. Arrange the steps for doffing the personal protective equipment in the correct sequence according to standard infection control guidelines.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence for removing the personal protective equipment is: first remove the gloves, second remove the face shield, third remove the isolation gown, fourth remove the surgical mask, and finally perform hand hygiene.
According to the Centers for Disease Control and Prevention (CDC) guidelines, the standard order for doffing personal protective equipment (PPE) is designed to remove the most contaminated items first while protecting the face and respiratory system until the end. Gloves are removed first, followed by the face shield (handling only the clean back pieces). The gown is removed next by pulling it away from the body and rolling it inside out. The mask is removed last to ensure continuous respiratory protection while handling the contaminated gown. Finally, hand hygiene is performed immediately after removing all PPE to eliminate any potential contamination that occurred during the doffing process.

Step-by-Step Solution

1
Identify and remove the most contaminated item of PPE.
The gloves are removed first.
Gloves touch the client and the immediate environment directly, making them the most contaminated. Removing them first prevents cross-contamination to the face or body when removing other items.
2
Remove the protective eyewear.
The face shield is removed second.
The front of the face shield is contaminated. Removing it by the clean headband prevents facial contamination while the gown and mask still provide protection.
3
Remove the isolation gown.
The gown is removed third.
The gown's front and sleeves are contaminated. Touching only the inside, the nurse unfastens it and rolls it away from the body into a bundle.
4
Remove the respiratory protection.
The surgical mask is removed fourth.
The mask protects the respiratory tract from any aerosolized particles that might have been disturbed while removing the gown. It is removed by the clean strings.
5
Eliminate any residual pathogens on the hands.
Hand hygiene is performed last.
Hand hygiene is always the final step in the doffing procedure to remove any pathogens inadvertently transferred to the hands.

Key Concept

Standard and Transmission-Based Precautions: PPE Doffing Sequence
PreviousPage 14 / 32Next
All practice questions — NCLEX-PN | Examkin