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After assisting a healthcare provider with a bedside procedure for a client on droplet and contact precautions, a licensed practical nurse (LPN) is ready to exit the isolation room. The LPN is currently wearing gloves, an isolation gown, a face shield, and a surgical mask. In what order should the LPN remove the personal protective equipment (PPE) to prevent self-contamination? Arrange the actions in the correct chronological sequence from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence for removing personal protective equipment is: first remove the gloves, then the face shield, followed by the isolation gown, then the surgical mask, and finally perform hand hygiene.

According to standard Centers for Disease Control and Prevention (CDC) infection control guidelines, the most contaminated items should be removed first. Gloves are removed first, followed by the face shield or goggles handled by their clean back straps. The gown is then removed by pulling it away from the body and rolling it inside out. The mask is removed last, touching only the ties or ear loops, to maintain respiratory and mucous membrane protection until all other contaminated items are discarded. Hand hygiene must always be the final step after all PPE has been removed.

Step-by-Step Solution

Remove gloves

Hands are freed from the most heavily contaminated item.

Gloves touch the client and environment directly, carrying the highest pathogen load.

Remove face shield

Eye protection is safely removed without contaminating the face.

The outside of the shield is contaminated; handling it by the clean back strap protects the nurse.

Remove gown

The gown is safely bundled and discarded.

The gown front and sleeves are contaminated; pulling it inside out traps pathogens inside the bundle.

Remove surgical mask

Respiratory protection is safely removed.

The mask protects the mucous membranes during the removal of other items and is removed last.

Perform hand hygiene

Any residual pathogens on the hands are destroyed or washed away.

Hand hygiene is the crucial final step to ensure hands are safe before touching anything outside the isolation area.

Key Concept

Standard and Transmission-Based Precautions: PPE Doffing Sequence

Question 2782Question →

An 85-year-old client is admitted with pneumonia and is receiving intravenous antibiotics. While making bedside rounds, the practical nurse discovers the client is suddenly agitated, attempting to climb out of bed, and breathing at a rate of 28 breaths per minute. Which action should the practical nurse take first?

Measure the client's oxygen saturation and current vital signs.

Guide the client back into bed and dim the lights to calm their dementia.

Apply physical safety devices to prevent the client from leaving the bed.

Perform a comprehensive pain assessment using a standardized scale.

Show answer & explanation

Answer: Measure the client's oxygen saturation and current vital signs.

Answer

Measure the client's oxygen saturation and current vital signs.

Sudden onset of agitation and confusion, especially when accompanied by a high respiratory rate, is a classic presentation of hypoxia in older adults. The correct immediate response is to gather focused, objective data regarding the client's respiratory status (oxygen saturation and vital signs) to identify the severity of the physiological compromise.

Step-by-Step Solution

Recognize the clinical cues.

The client is demonstrating sudden agitation, restlessness, and tachypnea (28 breaths per minute).

Identifying abnormal physiological findings is the first step in clinical judgment.

Prioritize the cues using the ABC framework.

Tachypnea points directly to a potential breathing or oxygenation issue, which takes priority over behavioral or pain concerns.

Airway, Breathing, and Circulation are the most critical physiological needs.

Determine the appropriate initial nursing action.

The nurse must collect focused objective data (oxygen saturation and vital signs) to report to the registered nurse for immediate intervention.

Sudden confusion is often an early sign of hypoxia in older adults, requiring prompt physiological assessment rather than environmental modifications.

Key Concept

Prioritizing Physiological Assessment in Acute Changes

Question 2783Question →

A practical nurse (PN) is working in an outpatient oncology clinic. A client is preparing for a scheduled bone marrow biopsy. Which of the following actions by the PN represent appropriate legal and ethical responsibilities regarding the informed consent process? Select all that apply.

Select all that apply

Sign the informed consent form as a witness to the client's signature.

Verify that the client is signing the consent document voluntarily.

Explain the potential complications of the procedure if the client asks for clarification.

Describe alternative diagnostic options available if the client expresses hesitation.

Notify the healthcare provider if the client states they do not fully understand the procedure.

Conduct a formal assessment of the client's cognitive capacity to ensure legal competency.

Show answer & explanation

Answer: Sign the informed consent form as a witness to the client's signature.; Verify that the client is signing the consent document voluntarily.; Notify the healthcare provider if the client states they do not fully understand the procedure.

Answer

The correct actions include signing the form as a witness, verifying the client is signing voluntarily, and notifying the healthcare provider if the client does not fully understand the procedure.

The correct actions accurately reflect the practical nurse's legal scope of practice during informed consent. The nurse's role is strictly limited to serving as a witness to the physical signature, verifying that the client is signing voluntarily without coercion, and advocating for the client by notifying the healthcare provider if the client has unmet informational needs or questions.

Step-by-Step Solution

Identify the primary role of the practical nurse (PN) during the informed consent process.

The PN acts as a witness and a client advocate, verifying that the client is acting voluntarily.

The legal responsibility for obtaining consent and providing medical details rests entirely with the healthcare provider.

Evaluate the tasks related to providing medical information.

The PN cannot explain risks, complications, or alternative diagnostics.

Providing primary education about the procedure is outside the PN scope of practice.

Determine the appropriate nursing intervention when a client lacks understanding or expresses hesitation.

The PN must stop the consent process and notify the healthcare provider.

Ensuring the client is fully informed before signing is critical, and any knowledge gaps must be addressed by the provider.

Evaluate the task of assessing cognitive capacity.

Formal assessment of cognitive capacity is excluded from the PN's legal responsibilities.

Determining legal competency requires advanced clinical assessment skills that belong to the registered nurse (RN) or provider.

Key Concept

The practical nurse's role in informed consent is limited to witnessing the signature, verifying voluntary agreement, and advocating for the client if further clarification from the provider is needed.

Question 2784Question →

A nursing team on a maternal-newborn unit is organizing client care for the shift. Match each specific clinical task to the healthcare team member whose legal scope of practice and role makes them the most appropriate person to perform it.

Click a left item, then click its matching right item

Show answer & explanation

Answer

Initiating teaching matches to the RN; administering subcutaneous medications matches to the LPN/VN; assisting with basic hygiene matches to the UAP; and explaining surgical risks matches to the PHCP.

Each healthcare team member operates within a specific legal scope of practice. The RN handles complex assessments and primary teaching. The LPN/VN cares for stable clients and administers routine therapies. The UAP performs basic activities of daily living and routine hygiene tasks. The PHCP is solely responsible for obtaining informed consent by actively explaining procedural risks.

Step-by-Step Solution

Evaluate the task of initiating a primary teaching plan for a newly diagnosed condition.

Match this task to the Registered Nurse (RN).

Initial comprehensive teaching requires advanced assessment of learning barriers and needs, which is exclusively within the RN's scope of practice.

Evaluate the task of administering a routine subcutaneous anticoagulant.

Match this task to the Licensed Practical Nurse (LPN/VN).

Routine medication administration for stable, predictable clients falls squarely within the accepted scope of practice for the LPN/VN.

Evaluate the task of assisting a stable client with routine perineal care.

Match this task to the Unlicensed Assistive Personnel (UAP).

Basic hygiene assistance and activities of daily living for stable clients are standard tasks that do not require nursing judgment and can be safely delegated to UAP.

Evaluate the task of explaining complications and alternatives for an upcoming procedure.

Match this task to the Primary Healthcare Provider (PHCP).

While nurses may witness the signing of an informed consent document, only the provider performing the procedure can legally explain the risks and alternatives.

Key Concept

Delegation and Legal Scope of Practice

Question 2785Question →

A licensed practical nurse (LPN) is providing care for a client admitted with bilateral pneumonia who is receiving intravenous antibiotics. Which of the following actions by the LPN demonstrate appropriate risk reduction principles and safe practice? Select all that apply.

Select all that apply

Verifying the client's identity using their full name and date of birth before administering a scheduled oral antipyretic.

Waiting until the end of the shift to communicate a morning serum potassium level of

2.8

mEq/L (

2.8

mmol/L) to the registered nurse.

Accepting a delegated task from the charge nurse to perform an initial comprehensive admission assessment on a newly arrived client.

Elevating the head of the client's bed to a semi-Fowler's position to promote optimal lung expansion and airway clearance.

Attributing a new resting heart rate of

114

bpm and a blood pressure of

96/54

mm Hg to anxiety without further escalation.

Promptly notifying the registered nurse that the client's oxygen saturation has declined from

96\%

89\%

on room air.

Show answer & explanation

Answer: Verifying the client's identity using their full name and date of birth before administering a scheduled oral antipyretic.; Elevating the head of the client's bed to a semi-Fowler's position to promote optimal lung expansion and airway clearance.; Promptly notifying the registered nurse that the client's oxygen saturation has declined from $96\%$ to $89\%$ on room air.

Answer

The correct actions are verifying the client's identity using two identifiers, elevating the head of the bed, and promptly notifying the registered nurse about the decreased oxygen saturation.

Verifying identity using two distinct identifiers ensures correct medication administration and prevents errors. Elevating the head of the bed is an independent nursing intervention that facilitates optimal respiratory function for a client with pneumonia. Finally, promptly reporting an oxygen saturation drop from 96% to 89% allows for timely assessment and potential adjustment of respiratory support to prevent further hypoxia.

Step-by-Step Solution

Evaluate each action for adherence to the LPN scope of practice and risk reduction principles.

Identify actions that promote client safety and correctly escalate abnormal findings.

The LPN is responsible for identifying potential complications, safely administering care, and communicating changes in client status to the RN.

Analyze the laboratory and vital sign data provided in the options.

Determine that a potassium level of 2.8 mEq/L and an oxygen saturation of 89% are critical abnormalities requiring immediate escalation.

Hypokalemia and hypoxia pose immediate risks to the client's physiological stability.

Review the nursing actions for scope of practice and medication safety.

Determine that initial comprehensive assessments are outside the LPN scope, and utilizing two identifiers is required for medication administration.

LPNs perform focused, not initial comprehensive, assessments. Two distinct client identifiers are required for safe medication administration.

Key Concept

The practical nurse plays a critical role in reducing risk potential by recognizing and escalating abnormal clinical findings, adhering strictly to medication administration rights, and working within their defined scope of practice.

Question 2786Question →

Match each scenario regarding a request for a client's health information with the correct confidentiality determination based on privacy regulations.

Click a left item, then click its matching right item

Show answer & explanation

Answer

Court order to legal mandate; Employer call to cannot confirm/deny; Respiratory therapist to direct clinical treatment; Sibling request to client must authorize.

Each scenario was correctly evaluated based on the principles of HIPAA and client privacy rights. Disclosures are only permitted for direct care, legal mandates, or with explicit client authorization.

Step-by-Step Solution

Analyze the request from the law enforcement officer with a court order.

Determine that a court order represents a legal mandate.

Privacy laws include specific exceptions for judicial processes and legal requirements.

Evaluate the employer's phone call inquiring about an employee's admission.

Identify this as an impermissible disclosure.

Without explicit consent, healthcare workers cannot confirm or deny a client's presence to an employer.

Assess the respiratory therapist's request for an x-ray report.

Recognize this as a permissible disclosure for treatment.

Providers on the client's direct care team require access to pertinent medical data to deliver safe, effective care.

Consider the sibling's request for medical details while the client is away.

Identify this as an impermissible disclosure without prior consent.

Alert and competent clients have the right to decide which family members receive updates regarding their condition.

Key Concept

Information disclosure is permissible only for direct treatment, payment, or healthcare operations, or when legally mandated; all other disclosures require explicit client consent.

Question 2787Question →

The nursing staff is providing care for a 78-year-old client who is receiving continuous intravenous (IV) hydration therapy for severe gastroenteritis. The client has a documented medical history of congestive heart failure. Upon entering the room, the nurse notes the client is increasingly restless, has developed a frequent moist cough, and reports feeling 'like I cannot catch my breath.' Which immediate actions should the practical nurse take? Select all that apply.

Select all that apply

Check the client's peripheral oxygen saturation using a pulse oximeter

Assist the client into an upright sitting position in bed

Attribute the client's new onset of restlessness to expected age-related cognitive changes

Listen to the anterior and posterior lung fields for abnormal breath sounds

Complete a comprehensive peripheral vascular assessment before evaluating respiratory status

Administer a rapid intravenous push of a loop diuretic to reduce systemic fluid volume

Show answer & explanation

Answer: Check the client's peripheral oxygen saturation using a pulse oximeter; Assist the client into an upright sitting position in bed; Listen to the anterior and posterior lung fields for abnormal breath sounds

Answer

The correct actions are to assist the client into an upright sitting position, check peripheral oxygen saturation, and listen to the lung fields for abnormal breath sounds.

When a client with heart failure receives IV fluids and develops a moist cough and shortness of breath, it strongly indicates fluid volume overload and pulmonary edema. The immediate priority is to support breathing by sitting the client upright. The practical nurse must also promptly collect essential respiratory data, including oxygen saturation and lung auscultation, so accurate information can be immediately reported to the registered nurse or provider for advanced orders.

Step-by-Step Solution

Analyze the client's clinical presentation.

The client has a history of heart failure, is receiving IV fluids, and is now showing signs of fluid volume overload and pulmonary edema (moist cough, dyspnea, restlessness).

Identifying the underlying complication directs the priority of nursing care.

Apply the Airway, Breathing, Circulation (ABC) prioritization framework.

Interventions must immediately address the client's breathing difficulties before assessing secondary body systems.

Airway and breathing are always the highest priority in acute status changes.

Determine the actions that fall within the practical nurse's scope of practice.

The PN can reposition the client to ease breathing and collect focused respiratory data (SpO2, lung sounds) to urgently report to the RN.

The PN must act rapidly but safely, avoiding interventions that require RN-level credentials (like IV push medications).

Key Concept

Prioritization and Scope of Practice during Acute Pulmonary Edema

Estimated Time:1m 30s

Question 2788Question →

While providing morning hygiene, a practical nurse is evaluating the comfort and body alignment of a client who underwent a left above-the-knee amputation 48 hours ago. To prevent a common joint complication associated with this surgery, which positioning technique is most appropriate for the nurse to implement?

Assisting the client to lie flat on their abdomen for short intervals multiple times a day

Propping the residual limb continuously on a folded blanket while the client rests in bed

Encouraging the client to sit upright in a bedside armchair for prolonged periods

Securing a wedge cushion between the client's thighs to keep the legs spread apart

Show answer & explanation

Answer: Assisting the client to lie flat on their abdomen for short intervals multiple times a day

Answer

The correct action is to assist the client to lie flat on their abdomen for short intervals multiple times a day.

Assisting the client into a prone position (lying flat on the abdomen) for 20 to 30 minutes several times a day is crucial after an above-the-knee amputation. This position fully extends the hip joint, helping to prevent hip flexion contractures that can severely impair future mobility and prosthetic fitting.

Step-by-Step Solution

Identify the primary complication risk associated with an above-the-knee amputation.

The most common and debilitating positioning complication is a hip flexion contracture.

Surgical trauma and natural resting positions tend to pull the hip flexor muscles inward and upward.

Evaluate how different body positions affect the hip joint.

Sitting and elevating the limb flex the hip, whereas lying prone fully extends the hip joint.

Extension counteracts the tendency of the flexor muscles to shorten and tighten.

Select the intervention that promotes hip extension.

Lying flat on the abdomen is identified as the correct positioning strategy.

Prone positioning stretches the flexor muscles and maintains proper joint alignment.

Key Concept

Post-Amputation Positioning and Contracture Prevention

Question 2789Question →

An adult client who is immobile and 24 hours post-operative from a gastrostomy tube placement is receiving continuous enteral nutrition. When planning basic care and comfort measures, which actions should the licensed practical nurse (LPN) implement? Select all that apply.

Select all that apply

Maintain the head of the bed elevated at 30 to 45 degrees continuously.

Pause the enteral feeding pump prior to lowering the head of the bed for repositioning.

Apply a moisture barrier cream to the perineal skin after cleansing incontinent episodes.

Lower the head of the bed to a flat, supine position for one hour after morning care while the feeding infuses.

Complete the initial comprehensive skin assessment of a newly discovered pressure injury on the sacrum.

Administer a prescribed as-needed analgesic for joint stiffness before clearing loud, gurgling respiratory secretions.

Show answer & explanation

Answer: Maintain the head of the bed elevated at 30 to 45 degrees continuously.; Pause the enteral feeding pump prior to lowering the head of the bed for repositioning.; Apply a moisture barrier cream to the perineal skin after cleansing incontinent episodes.

Answer

The appropriate actions for the LPN to implement are maintaining the head of the bed elevated at 30 to 45 degrees, pausing the feeding pump before lowering the head of the bed, and applying a moisture barrier cream after incontinence care.

Maintaining the head of the bed elevated at 30 to 45 degrees is essential to prevent regurgitation and aspiration during continuous enteral feedings. If the head of the bed must be lowered for turning or repositioning, the feeding pump must be paused first to protect the client's airway. Applying a moisture barrier cream to the perineal area after cleansing is a fundamental comfort measure that protects vulnerable skin from breakdown due to incontinence and immobility.

Step-by-Step Solution

Analyze the client's clinical presentation.

The client is immobile, post-operative, and receiving continuous enteral nutrition.

Identifying risk factors such as aspiration and skin breakdown guides the selection of safe basic care interventions.

Evaluate basic care and comfort interventions for safety and scope of practice.

Elevating the head of the bed, pausing feeds before repositioning, and applying moisture barrier creams are within the LPN scope and directly promote safety and skin integrity.

These actions prevent aspiration and manage moisture, which are critical basic care elements.

Identify and exclude contraindicated or out-of-scope actions.

Positioning the client flat while feeding, performing initial comprehensive assessments, and delaying airway clearance for pain management are unsafe or outside the LPN scope of practice.

LPNs must adhere to ABC prioritization, proper post-procedure positioning to protect the airway, and scope of practice limitations.

Key Concept

Basic Care and Comfort for Enteral Nutrition and Immobility

Question 2790Question →

A practical nurse (PN) is assisting with the care of a client who is receiving an intermittent intravenous (IV) infusion of vancomycin. The client suddenly reports intense itching, and the PN observes a bright red rash on the client's face, neck, and upper chest. The client's blood pressure has dropped to $88/58\text{ mmHg}$ . Which action should the PN take first?

Continue the infusion and document the rash and blood pressure as an expected reaction.

Elevate the head of the bed for comfort and ask the client to rate the itching on a pain scale.

Stop the vancomycin infusion immediately and alert the registered nurse (RN).

Prepare to administer an intravenous push of epinephrine per the facility's anaphylaxis protocol.

Show answer & explanation

Answer: Stop the vancomycin infusion immediately and alert the registered nurse (RN).

Answer

The correct action is to stop the vancomycin infusion immediately and alert the registered nurse (RN).

The client is exhibiting signs of Red Man Syndrome or a severe hypersensitivity reaction to vancomycin, characterized by flushing, an upper body rash, and significant hypotension. The first and most critical action is to stop the offending infusion to prevent further circulatory compromise. The PN must then immediately notify the RN, as managing an acute, unstable client requires RN-level assessment and intervention.

Step-by-Step Solution

Assess the client's clinical presentation.

The client has intense itching, a bright red rash on the upper body, and hypotension (

88/58\text{ mmHg}

Identifying these symptoms is crucial for recognizing Red Man Syndrome or a severe hypersensitivity reaction.

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

The hypotension indicates a circulatory threat.

In any emergent drug reaction causing hemodynamic instability, the source must be removed immediately.

Act within the practical nurse (PN) scope of practice.

The PN stops the IV infusion and immediately escalates the situation to the RN.

The PN can independently stop a harmful infusion but must collaborate with the RN for further assessment and emergency IV push interventions.

Key Concept

Prioritization and Scope of Practice in Adverse Medication Reactions

Question 2791Question →

A practical nurse is utilizing a powered sit-to-stand mechanical lift to move a client with bilateral lower extremity weakness from the edge of the bed into a recliner. The client is capable of bearing partial weight and can follow instructions. Which action must the nurse perform to ensure the safe operation of this ergonomic equipment?

Verify that both of the client's feet are flat on the footplate and their shins are in direct contact with the knee block.

Instruct the client to keep their arms hanging loosely outside the support sling to minimize skin shearing.

Direct the unlicensed assistive personnel (UAP) to evaluate whether the client has adequate trunk control for the transfer.

Secure a waist restraint around the client and the vertical lift mast to provide extra stability during the pivoting motion.

Show answer & explanation

Answer: Verify that both of the client's feet are flat on the footplate and their shins are in direct contact with the knee block.

Answer

The nurse must verify that both of the client's feet are flat on the footplate and their shins are in direct contact with the knee block.

For a powered sit-to-stand lift to function safely, the client's lower body must be anchored correctly. Placing the feet flat on the footplate and bracing the shins against the knee pad prevents the client's legs from sliding or buckling during the lifting process. This maintains proper ergonomics, shifting the client's center of gravity safely while the machine elevates them.

Step-by-Step Solution

Assess the requirements for safely operating a powered sit-to-stand mechanical lift.

The lift requires the client to be able to bear partial weight, follow commands, and have a stable base of support on the equipment's platform.

To ensure the client meets the physical criteria for the equipment and to prevent falls during the transfer process.

Identify the correct ergonomic positioning for a client using this specific device.

The client's feet must be firmly planted on the footplate with their shins braced against the padded knee guard.

This specific body mechanics setup locks the lower extremities in place, providing the necessary leverage and stabilization as the machine lifts the client into a standing position.

Key Concept

Safe Operation of Mechanical Lifts and Proper Ergonomic Positioning

Question 2792Question →

During a shift, a practical nurse (PN) finds a client with a history of generalized weakness wandering the unit hallway barefoot. The client is visibly confused about the location of their room. Which of the following actions should the PN take to promote safety and prevent injury? Select all that apply.

Select all that apply

Escort the client safely back to their room and gently reorient them to their surroundings.

Assist the client in putting on non-slip footwear to reduce the immediate risk of a fall.

Ask passing visitors in the hallway if they recognize the client to quickly locate their room.

Apply a soft belt restraint to the client's chair once returned to the room to prevent further wandering.

Ensure the client's room environment is well-lit and the floor is free of clutter.

Assume the disorientation is a normal aspect of aging and omit reporting it to the charge nurse.

Show answer & explanation

Answer: Escort the client safely back to their room and gently reorient them to their surroundings.; Assist the client in putting on non-slip footwear to reduce the immediate risk of a fall.; Ensure the client's room environment is well-lit and the floor is free of clutter.

Answer

The correct actions are to escort and reorient the client, assist them with non-slip footwear, and ensure their room is well-lit and clutter-free.

The correct interventions focus on immediate hazard reduction and promoting a safe environment using the least restrictive methods. Providing non-slip footwear directly addresses the physical risk of falling while barefoot. Guiding the client back to a familiar room, providing gentle reorientation, and ensuring the space is well-lit and clutter-free are proactive environmental safety measures that protect the client from injury without compromising their dignity or independence.

Step-by-Step Solution

Identify the immediate safety hazards presented in the scenario.

The client is at high risk for a fall due to weakness and walking barefoot, and is at risk for environmental injury due to confusion and wandering.

Recognizing physical and cognitive risk factors is the first step in prioritizing safety interventions.

Select interventions that immediately address the physical and environmental risks.

Providing non-slip footwear addresses the physical fall risk. Escorting the client to their room, reorienting them, and ensuring a well-lit, clutter-free environment address the environmental hazards.

Nurses must implement proactive, least restrictive measures to maintain a safe care environment.

Eliminate interventions that violate safety, legal, or ethical standards.

Using restraints, breaching confidentiality by asking visitors, and dismissing the confusion as normal aging are incorrect and unsafe actions.

These actions violate the principles of least restrictive care, HIPAA regulations, and proper clinical judgment regarding acute delirium.

Key Concept

Fall Prevention and Safety Promotion

Question 2793Question →

Following a left femoral cardiac catheterization, an older adult client is admitted to the medical-surgical unit with orders for strict bed rest. The practical nurse (PN) is organizing the client's care to ensure safety and comfort. Which actions should the PN incorporate into the daily care plan? Select all that apply.

Select all that apply

Ensure the client's left leg remains completely straight and flat against the mattress.

Elevate the head of the bed to a 60-degree angle while the client is eating.

Use a fracture pan instead of a standard bedpan for urinary or bowel elimination.

Assist the client to sit on the edge of the bed with their legs dangling for comfort.

Offer frequent oral fluids and water to assist in flushing out the contrast dye.

Place a wedge cushion under the left knee to promote slight joint flexion.

Show answer & explanation

Answer: Ensure the client's left leg remains completely straight and flat against the mattress.; Use a fracture pan instead of a standard bedpan for urinary or bowel elimination.; Offer frequent oral fluids and water to assist in flushing out the contrast dye.

Answer

The correct actions are to ensure the left leg remains completely straight, use a fracture pan for elimination, and offer frequent oral fluids.

Proper care for a client following a femoral cardiac catheterization prioritizes preventing hemorrhage at the arterial puncture site while meeting basic physiological needs. Keeping the affected leg completely straight prevents dislodging the clot at the femoral artery site. Using a fracture pan minimizes movement of the hips and back, avoiding undue stress on the puncture site during elimination. Finally, encouraging oral fluids is an essential basic care measure to help the kidneys excrete the nephrotoxic contrast medium used during the procedure.

Step-by-Step Solution

Analyze the client's clinical situation and primary risk factors.

The client had a left femoral cardiac catheterization and is on strict bed rest, placing them at high risk for arterial bleeding at the puncture site.

Identifying the highest risk complication guides the selection of safe positioning and comfort measures.

Evaluate each basic care and mobility intervention for safety regarding the femoral puncture site.

Interventions that keep the hip and leg straight (flat leg, fracture pan) are safe, while interventions that bend the hip or leg (high fowlers, dangling, knee cushions) are dangerous.

Any flexion of the affected hip (bending past 30 degrees) or increased pressure can dislodge the clot at the femoral artery.

Identify interventions that address systemic procedural recovery needs.

Encouraging oral fluids helps clear the contrast dye used during the catheterization.

Contrast dye is nephrotoxic, and maintaining adequate hydration is a fundamental comfort and safety measure for the LPN to implement.

Key Concept

Post-procedural positioning and basic comfort care following femoral cardiac catheterization.

Question 2794Question →

Following a multi-disciplinary care conference on an orthopedic unit, the charge registered nurse (RN) distributes pending tasks to the nursing staff. Which of the following tasks delegated to the practical nurse (PN) is within their legal scope of practice?

Reinforcing previous physical therapy instructions regarding walker use for a client recovering from a hip arthroplasty

Formulating the initial nursing care plan for a client who just arrived from the post-anesthesia care unit

Explaining the potential risks and alternative treatments of a procedure to a client before witnessing the consent form

Providing a detailed clinical update about a client's unexpected biopsy results to visiting extended family members

Show answer & explanation

Answer: Reinforcing previous physical therapy instructions regarding walker use for a client recovering from a hip arthroplasty

Answer

Reinforcing previous physical therapy instructions regarding walker use for a client recovering from a hip arthroplasty

The correct choice is reinforcing previous physical therapy instructions. Practical nurses are legally permitted and encouraged to reinforce education and safety instructions that have already been established by a registered nurse or other licensed healthcare professional.

Step-by-Step Solution

Analyze each delegated task against the legal scope of practice for a practical nurse.

Identified which tasks require RN or provider licensure versus those appropriate for a PN.

Safe assignment acceptance requires understanding professional boundaries and licensure limits.

Evaluate the requirement for initial assessment, primary teaching, and confidentiality in each option.

Options involving initial care plans, explaining surgical risks, and sharing unauthorized medical information were ruled out.

Initial assessment, primary teaching, and discussing sensitive diagnoses exceed PN boundaries or violate privacy laws.

Key Concept

Practical Nurse Scope of Practice and Safe Task Acceptance

Question 2795Question →

A practical nurse is preparing to administer a large-volume cleansing enema to an adult client who is experiencing constipation. In what order should the nurse perform the following actions? (Arrange from first to last)

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first position the client, lubricate the tubing, insert it into the rectum, elevate the container to start the flow, and monitor the client by clamping the tube if cramping occurs.

Administering a cleansing enema requires a systematic approach to ensure safety and comfort. The client must first be positioned correctly in the left lateral Sims' position to allow gravity to assist the fluid flow into the sigmoid colon. Next, the nurse lubricates the tubing to prevent mucosal injury and gently inserts it safely into the rectum. Once the tube is securely in place, the container is elevated to the proper height to control the fluid's hydrostatic pressure. Finally, the nurse monitors the client continuously during instillation and clamps the tubing if cramping occurs to allow the colon to relax.

Step-by-Step Solution

Position the client in the left lateral Sims' position.

The client is properly aligned to facilitate fluid flow.

Gravity aids the flow of solution into the sigmoid colon and descending colon.

Lubricate the tip of the rectal tube with water-soluble jelly.

The tube is ready for smooth insertion.

Lubrication minimizes friction, preventing tissue injury and discomfort.

Gently insert the tubing 3 to 4 inches (7.5 to 10 cm) into the rectum.

The tube passes the internal sphincter and enters the rectum safely.

This depth ensures the fluid is delivered past the sphincter without risking intestinal perforation.

Elevate the enema container 12 to 18 inches (30 to 45 cm) above the anus.

Fluid begins to instill at a safe, controlled rate.

The height determines the fluid pressure. Staying within this range prevents rapid distention and mucosal injury.

Clamp the tubing temporarily if the client reports abdominal cramping.

The flow of fluid stops, relieving client discomfort.

Stopping the flow allows bowel spasms to subside before resuming the enema at a slower rate.

Key Concept

The procedural steps for administering a large-volume cleansing enema prioritize anatomical alignment, safety, and client comfort.

Question 2796Question →

A practical nurse (PN) is eating lunch in the facility cafeteria with an assistive personnel (AP) from the same unit. The AP begins discussing the challenging behavior of a client they cared for that morning, referring to the client by their room number and medical diagnosis. Which of the following is the most appropriate action by the PN?

Remain silent and avoid contributing to the discussion to maintain personal compliance with privacy rules.

Advise the AP to speak more softly to prevent people at nearby tables from hearing the details.

Interrupt the conversation and remind the AP that client details must not be discussed in public areas.

Allow the AP to finish the story, but report the incident to the unit manager upon returning from lunch.

Show answer & explanation

Answer: Interrupt the conversation and remind the AP that client details must not be discussed in public areas.

Answer

Interrupt the conversation and remind the AP that client details must not be discussed in public areas.

The priority action when a confidentiality breach is actively occurring is to stop it immediately. By interrupting the conversation and reminding the assistive personnel about privacy rules, the practical nurse fulfills their legal and ethical obligation to protect client information from being overheard by others in a public space.

Step-by-Step Solution

Identify the environment and the nature of the information being shared.

The AP is sharing protected health information (room number, diagnosis, behavioral details) in a public cafeteria.

Recognizing a confidentiality breach is the first step in determining the necessary intervention.

Determine the priority nursing action to address the breach.

The immediate priority is to stop the ongoing unauthorized disclosure of information.

Delaying action or ignoring the situation allows the breach to continue, which violates privacy laws (such as HIPAA) and facility policy.

Key Concept

Confidentiality and Information Security

Question 2797Question →

A client with disseminated herpes zoster is admitted to the medical-surgical unit. Which infection control measures should be incorporated into the care plan? Select all that apply.

Select all that apply

Place the client in a private, negative-pressure airborne infection isolation room.

Assign an unlicensed assistive personnel to perform the initial assessment of the skin lesions.

Don an N95 respirator, isolation gown, and clean gloves prior to entering the client's room.

Doff the N95 respirator inside the client's room after removing the isolation gown and gloves.

Keep reusable, noncritical medical equipment dedicated solely for this client's use inside the room.

Show answer & explanation

Answer: Place the client in a private, negative-pressure airborne infection isolation room.; Don an N95 respirator, isolation gown, and clean gloves prior to entering the client's room.; Keep reusable, noncritical medical equipment dedicated solely for this client's use inside the room.

Answer

The correct actions are placing the client in a negative-pressure room, donning an N95 respirator, gown, and gloves before entry, and dedicating noncritical equipment to the client's room.

Disseminated herpes zoster requires both airborne and contact precautions because the virus can be transmitted through respiratory droplets and direct contact with lesions. Implementing a negative-pressure room, using an N95 respirator along with a gown and gloves, and dedicating equipment to the client effectively disrupts both chains of transmission.

Step-by-Step Solution

Identify the required transmission-based precautions for disseminated herpes zoster.

Airborne and Contact precautions are identified.

The virus can spread through respiratory aerosols and direct contact with active lesions.

Select interventions that comply with Airborne precautions.

A negative-pressure airborne infection isolation room is selected, and donning an N95 respirator before entry is required.

These measures prevent the inhalation and spread of suspended infectious droplets.

Select interventions that comply with Contact precautions.

Donning a gown and gloves before entry, and keeping dedicated noncritical equipment in the room are selected.

These measures prevent pathogen transmission via direct or indirect contact with the client or their environment.

Evaluate the remaining options against safety protocols and scope of practice.

Delegating the initial assessment to an unlicensed assistive personnel is rejected, and removing the N95 inside the room is rejected.

Assessments require nursing judgment, and removing respiratory protection inside an airborne isolation room breaks safety protocols.

Key Concept

Airborne and Contact Precautions

Estimated Time:1m 30s

Question 2798Question →

Fifteen minutes after a registered nurse (RN) initiates an intravenous (IV) vancomycin infusion for a client with a severe soft tissue infection, the practical nurse (PN) responds to the client's call light. The client states, "My face and chest feel like they are burning and itching." The PN observes profound erythema over the client's face, neck, and upper torso. The client's blood pressure is $122/78\text{ mmHg}$ , and respirations are unlabored at $16\text{ breaths/min}$ . Which action should the PN take first?

Inform the client that this is an expected reaction to the medication and offer a cool washcloth to soothe the skin.

Recalculate the intravenous drip rate to determine if the medication is infusing too rapidly.

Stop the vancomycin infusion immediately and notify the RN.

Scan the client's identification band and check the electronic health record for undocumented drug allergies.

Show answer & explanation

Answer: Stop the vancomycin infusion immediately and notify the RN.

Answer

The immediate priority action is to stop the vancomycin infusion and notify the registered nurse.

The client is exhibiting signs of Red Man Syndrome, a rate-dependent infusion reaction to vancomycin characterized by intense flushing, erythema, and itching of the face, neck, and upper torso. Although the client's vital signs are currently stable, the immediate priority is to stop the infusion to prevent further histamine release, which could lead to severe hypotension. The practical nurse (PN) must then immediately notify the registered nurse (RN) to assess the client and determine the next steps, which typically involve administering an antihistamine and restarting the infusion at a significantly slower rate.

Step-by-Step Solution

Assess the client's clinical presentation and vital signs.

The client has intense flushing and itching of the upper body, but stable blood pressure and unlabored respirations.

To differentiate between true anaphylaxis (which typically involves respiratory distress or severe hypotension) and a rate-related infusion reaction.

Identify the complication.

The findings indicate Red Man Syndrome, an adverse reaction caused by rapid infusion of vancomycin.

Recognizing the specific adverse effect dictates the appropriate nursing intervention.

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

The PN must stop the infusion immediately.

Removing the causative agent prevents the reaction from progressing to severe hypotension or shock. The PN has the authority and responsibility to stop a harmful infusion.

Escalate the situation.

Notify the RN immediately.

The RN is required to perform a comprehensive assessment, notify the provider if necessary, and manage the restart of the infusion at a slower rate.

Key Concept

Vancomycin Infusion Reactions (Red Man Syndrome)

Question 2799Question →

A practical nurse (PN) enters a client's room and observes the client coughing forcefully and clutching their chest. The client is receiving continuous enteral nutrition via a nasogastric (NG) tube. The client appears cyanotic around the lips, and the pulse oximeter reads 86% on room air. 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: Turn off the continuous enteral feeding pump, Elevate the head of the bed to a high-Fowler's position, Apply supplemental oxygen, Auscultate the client's bilateral lung sounds, and Notify the supervising registered nurse (RN).

In any acute respiratory emergency involving enteral feeding, the first step is to remove the noxious stimulus by stopping the pump to prevent further aspiration. Following the ABCs (Airway, Breathing, Circulation), the nurse should then position the client to maximize lung expansion and apply oxygen to treat the hypoxia. Once these immediate life-saving measures are applied, the PN should collect focused data (lung sounds) so that a complete and accurate report can be given when notifying the supervising RN.

Step-by-Step Solution

Turn off the continuous enteral feeding pump.

The flow of enteral formula is halted immediately.

This is the most critical action to prevent further aspiration of formula into the airway.

Elevate the head of the bed to a high-Fowler's position.

The client is placed in an upright position.

This maximizes lung expansion and utilizes gravity to minimize the risk of further reflux.

Apply supplemental oxygen per facility emergency protocol.

Oxygen delivery to the lungs is increased.

This treats the immediate hypoxia evidenced by cyanosis and a pulse oximetry reading of 86%.

Auscultate the client's bilateral lung sounds.

Clinical data regarding the respiratory status is collected.

The PN must gather baseline data on the extent of the complication (e.g., presence of crackles) before calling for assistance.

Notify the supervising registered nurse (RN) of the status change.

The healthcare team is alerted to the client's deterioration.

With the client stabilized and initial data collected, the RN and healthcare provider can evaluate the client for further interventions like chest x-rays or suctioning.

Key Concept

Prioritization of care during an acute aspiration event focuses on airway protection first (stopping the cause), followed by breathing support (positioning and oxygen), data collection, and then escalation.

Question 2800Question →

A pediatric client with a respiratory tract infection has an order for amoxicillin suspension. The medical record indicates the child weighs $16\text{ kg}$ . The prescribed dose is $45\text{ mg/kg/day}$ , divided equally and given every $12\text{ hours}$ . The dispensed bottle contains a concentration of $250\text{ mg}/5\text{ mL}$ . How many mL should be prepared for a single administration?

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

Show answer & explanation

Answer: 7.2

Answer

7.2

The correct volume is calculated by first determining the total daily dose based on the client's weight (

16\text{ kg} \times 45\text{ mg/kg/day} = 720\text{ mg/day}

). This total is then divided into two doses because the medication is scheduled every

12

hours, resulting in

360\text{ mg}

per dose. Using the available concentration of

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

, the required volume is (

\frac{360}{250} \times 5 = 7.2\text{ mL}

Step-by-Step Solution

Calculate the total daily dose in milligrams.

16\text{ kg} \times 45\text{ mg/kg/day} = 720\text{ mg/day}

The prescription provides a weight-based rate for a full 24-hour period, which must be determined first.

Determine the amount of medication required for a single dose.

720\text{ mg} \div 2\text{ doses} = 360\text{ mg/dose}

The medication is ordered every

12

hours, meaning it is administered

2

times per day.

Calculate the liquid volume needed to deliver the single dose.

\frac{360\text{ mg}}{250\text{ mg}} \times 5\text{ mL} = 7.2\text{ mL}

This determines the required milliliter volume of the supplied suspension that contains the target dose of

360\text{ mg}

Key Concept

Weight-based pediatric dosage calculation and liquid volume conversion

Estimated Time:2m 0s

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