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Question 2821Question →

A practical nurse (PN) is coordinating care with an assistive personnel (AP) for clients recovering from orthopedic surgeries on a rehabilitation unit. Which of the following task assignments indicate that the PN is delegating appropriately? Select all that apply.

Select all that apply

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Answer: Directing the AP to reapply sequential compression devices (SCDs) to a client's lower extremities; Assigning the AP to obtain routine morning vital signs on a stable client preparing for discharge; Instructing the AP to empty and record the drainage volume from a closed-wound suction device

Answer

The appropriate tasks to delegate to the AP are reapplying sequential compression devices, obtaining routine vital signs on a stable client, and emptying and recording output from a closed-wound drainage device.
The correct selections represent standard, routine tasks that have predictable outcomes and do not require independent nursing judgment, making them safe and appropriate to delegate to an AP.

Step-by-Step Solution

1
Review the established legal scope of practice for assistive personnel (AP).
APs are permitted to perform standard, unchanging tasks that have predictable outcomes and do not require nursing judgment.
Identifying the AP's capabilities and limitations is essential for safe and legal delegation.
2
Analyze each option to determine if it involves the nursing process (assessment, teaching, or evaluation).
Assessing pedal pulses, instructing on an incentive spirometer, and evaluating pain relief all involve elements of the nursing process.
Tasks requiring clinical reasoning or nursing judgment cannot be delegated to unlicensed personnel.
3
Select the task assignments that are routine and standard.
Reapplying SCDs, taking vital signs on a stable client, and emptying a surgical drain are identified as appropriate delegations.
These tasks involve basic care and data collection without requiring interpretation or independent clinical decision-making.

Key Concept

Delegation to Assistive Personnel requires assigning routine tasks that do not involve assessment, teaching, or evaluation.
Question 2822Question →

A practical nurse is providing home health care for a client with severe dysphagia. The client's spouse, who is the designated healthcare proxy, is preparing to sign a consent form for a percutaneous endoscopic gastrostomy tube placement. Right before signing, the spouse pauses and asks the nurse, "What are the exact chances of a site infection, and are there any other feeding methods we should try first?" Which action should the nurse take next?

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Answer: Withhold the document and contact the healthcare provider to speak with the spouse.

Answer

The correct action is to withhold the document and contact the healthcare provider to speak with the spouse.
The correct answer involves halting the signing process and contacting the provider. Obtaining informed consent is the sole responsibility of the healthcare provider who will perform the procedure. This duty involves thoroughly explaining the risks, benefits, and alternatives. The practical nurse's role is strictly limited to acting as a witness to the signature and verifying that the individual understands the procedure and is signing voluntarily. Because the proxy expressed hesitation and asked specific clinical questions about risks and alternative options, the nurse must ensure the provider addresses these knowledge gaps before allowing the legal document to be signed.

Step-by-Step Solution

1
Identify the practical nurse's legal role in the informed consent process.
The nurse's role is solely to witness the signature and verify that the client or proxy is signing voluntarily with full comprehension.
Scope of practice guidelines prohibit nurses from primarily explaining procedural risks, benefits, or treatment alternatives.
2
Evaluate the spouse's statements prior to signing.
The spouse is asking clinical questions about infection likelihood and alternative feeding methods.
This indicates a lack of complete understanding, meaning informed consent has not truly been achieved.
3
Determine the appropriate intervention based on the lack of comprehension.
The nurse must stop the signing process and contact the primary healthcare provider to address the spouse's questions.
Only the healthcare provider performing the procedure is legally authorized to explain risks and alternatives to achieve informed consent.

Key Concept

The practical nurse's role in informed consent is limited to witnessing the signature and verifying voluntary comprehension; any questions regarding risks, benefits, or alternatives must be directed to the healthcare provider.
Estimated Time:1m 0s
Question 2823Question →

A practical nurse is preparing to administer clindamycin to a pediatric client who weighs 24.2 lb24.2\text{ lb}. The healthcare provider prescribes clindamycin 15 mg/kg/day15\text{ mg/kg/day} intramuscularly (IM) divided into equal doses every 8 hours8\text{ hours}. The medication is supplied in a vial labeled 300 mg/2 mL300\text{ mg}/2\text{ mL}. How many mL will the practical nurse administer per dose? (Record the answer to the nearest tenth. Do not include units in your answer.)

Show answer & explanation

Answer: 0.4

Answer

0.4
The correct dose is calculated by sequentially converting weight to kilograms, finding the total daily dose, dividing by the administration frequency, and calculating the volume using the provided medication concentration. The resulting 0.366... mL0.366...\text{ mL} rounds to 0.4 mL0.4\text{ mL}.

Step-by-Step Solution

1
Convert the client's weight from pounds to kilograms.
24.2÷2.2=11 kg24.2 \div 2.2 = 11\text{ kg}
The prescribed medication dosage is weight-based in kg, so the weight must be converted from pounds to kilograms.
2
Calculate the total daily dosage required.
11 kg×15 mg/kg=165 mg/day11\text{ kg} \times 15\text{ mg/kg} = 165\text{ mg/day}
Multiplying the client's weight in kg by the prescribed mg/kg/day provides the total amount of medication needed for 24 hours.
3
Determine the dose to be administered every 8 hours.
165 mg÷3=55 mg/dose165\text{ mg} \div 3 = 55\text{ mg/dose}
Medication ordered every 8 hours is given 3 times a day (24 / 8 = 3). Dividing the total daily dose by 3 gives the single dose amount.
4
Calculate the volume (mL) needed for the single dose.
55 mg×2 mL300 mg=0.3666... mL55\text{ mg} \times \frac{2\text{ mL}}{300\text{ mg}} = 0.3666...\text{ mL}
Using the formula (Desired / Have) x Volume, the needed dose is divided by the supplied concentration and multiplied by the supplied volume.
5
Round the final volume to the nearest tenth.
0.4 mL0.4\text{ mL}
Standard nursing administration and syringe measurement rules typically require rounding volumes less than 1 mL to the nearest hundredth or tenth depending on the syringe, but the prompt explicitly requested rounding to the nearest tenth.

Key Concept

Pediatric weight-based dosage calculation and parenteral volume computation
Question 2824Question →

A practical nurse is preparing to assist a client from a seated position on the edge of the bed to a standing position using a gait belt. Place the following nursing actions in the correct sequence to ensure safety and proper ergonomics. (Arrange the steps from first to last.)

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Answer

The correct sequence is: Verify the bed is locked and footwear is on, secure the gait belt, assume a wide stance, grasp the belt with an underhand grip, and use leg muscles to assist the client to stand.
Safe transfer protocols require a systematic approach emphasizing both environmental safety and proper body mechanics. First, the environment must be secured by locking the bed and applying non-skid footwear to prevent accidents. Second, the gait belt is applied to provide a secure handling mechanism. Third, the nurse must assume an ergonomic stance with a wide base of support before attempting to lift. Fourth, grasping the belt with an underhand grip ensures a secure hold without straining the nurse's wrists. Finally, the actual lifting motion is performed using the strong muscles of the legs while keeping the back straight, which is essential to prevent musculoskeletal injuries.

Step-by-Step Solution

1
Ensure environmental safety
Bed is immobilized and client has traction
Prevents unpredictable movement during the transfer.
2
Apply the assistive device
Gait belt is safely secured around the waist
Provides a safe handle for the nurse to hold during the transfer.
3
Assume an ergonomic stance
Nurse establishes a wide base of support
Lowers the center of gravity and increases physical stability.
4
Hold the equipment correctly
Gait belt is grasped with an underhand grip
Increases control and reduces musculoskeletal strain on the nurse.
5
Execute the transfer
Client is assisted to a standing position safely
Using leg muscles instead of back muscles prevents ergonomic injuries.

Key Concept

Proper body mechanics and safe equipment use during client transfers
Question 2825Question →

While documenting care on a computer on wheels in the hallway, a practical nurse is approached by a physician who asks to quickly check the morning laboratory results for a different client. The physician explains that their tablet has lost power and they need the results immediately to adjust a medication dosage. Which action should the nurse take?

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Answer: Log out of the electronic health record system so the physician can sign in with their own access credentials.

Answer

The nurse should log out of the electronic health record system so the physician can sign in with their own access credentials.
Logging out of the electronic health record (EHR) system ensures that the physician must log in with their own unique credentials. This maintains information security by creating an accurate audit trail of which specific individual accessed the client's protected health information. Nurses must never allow others to use their active login sessions.

Step-by-Step Solution

1
Analyze the physician's request in the context of the clinical environment.
The physician is requesting to view another client's laboratory results using the nurse's current, active computer session in a public hallway.
Identifying the setting and the nature of the request highlights potential information security and confidentiality risks.
2
Evaluate electronic health record (EHR) security principles.
Every healthcare provider must access the EHR using their own unique credentials to maintain an accurate audit trail of who viewed or modified a client's record.
Understanding legal and ethical requirements for electronic documentation is necessary to determine the correct action.
3
Select the appropriate nursing action.
Logging out allows the physician to log in securely with their own credentials, satisfying both the physician's need for the data and the facility's security policies.
This resolves the situation while strictly adhering to confidentiality and information security protocols.

Key Concept

Electronic Health Record (EHR) Security and Audit Trails
Question 2826Question →

A licensed practical nurse (LPN) is caring for an older adult client who is recovering from a major abdominal surgery. Which of the following actions by the nurse demonstrate an appropriate application of risk reduction principles? Select all that apply.

Select all that apply

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Answer: Withholding a scheduled dose of furosemide and alerting the registered nurse about a serum potassium level of 2.8 mEq/L.; Promptly notifying the registered nurse when the client's heart rate increases to 115 beats per minute and blood pressure drops to 90/58 mm Hg.; Verifying the client's name and date of birth against the medical record prior to obtaining a blood specimen.

Answer

The correct actions include withholding furosemide for a critically low potassium level, reporting subtle but concerning changes in vital signs, and verifying two client identifiers prior to drawing blood.
The correct actions demonstrate proactive risk reduction. Severe hypokalemia (2.8 mEq/L) requires holding potassium-wasting diuretics and notifying the RN to prevent arrhythmias. Tachycardia combined with hypotension is an early sign of shock that requires immediate escalation. Finally, using two distinct identifiers before any procedure is a fundamental safety standard that reduces the risk of errors.

Step-by-Step Solution

1
Analyze each action to determine if it mitigates or increases the client's risk for postoperative complications.
Identify actions that promote safety and rapid intervention.
Reduction of risk potential requires the nurse to anticipate complications and act proactively.
2
Evaluate the laboratory values and vital signs presented in the options.
Recognize that a potassium of 2.8 mEq/L and hemoglobin of 6.7 g/dL are critical. Note that a rising heart rate with dropping blood pressure indicates potential shock.
Accurate interpretation of clinical data is necessary to determine when to escalate care.
3
Select the options that reflect safe, evidence-based nursing practice.
The correct choices involve escalating critical labs and vital signs, and performing proper client identification.
These actions directly align with the LPN's role in reducing risk potential.

Key Concept

Reduction of Risk Potential through vital sign monitoring, critical lab escalation, and proper client identification.
Estimated Time:1m 30s
Question 2827Question →

A practical nurse (PN) is caring for a client with a central venous catheter (CVC). Upon entering the room, the PN discovers that the intravenous tubing has accidentally disconnected from the CVC hub. The client is suddenly dyspneic, coughing, and appears cyanotic. Suspecting a central line air embolism, in what order should the PN implement the following actions? Arrange the steps from first to last.

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Answer

The correct sequence is to first clamp the catheter, position the client in a left lateral Trendelenburg position, activate the rapid response system, administer oxygen, and finally obtain vital signs.
In a suspected central line air embolism, the absolute first step is source control: clamping the catheter to prevent further air entry. Second, the client must be placed in Durant's maneuver (left lateral decubitus with Trendelenburg) to trap the air bubble in the apex of the right ventricle, keeping it away from the pulmonary outflow tract. Third, the nurse must activate the rapid response system to mobilize advanced help. Fourth, administering 100% oxygen treats ischemia and helps reduce the size of the air embolus by promoting nitrogen washout. Finally, obtaining vital signs provides essential baseline data for the arriving emergency team.

Step-by-Step Solution

1
Clamp the exposed central venous catheter immediately.
Stops further air entry into the circulation.
Source control is the absolute top priority to prevent cardiovascular collapse.
2
Place the client on their left side with the head of the bed lowered.
Traps the air bubble in the right ventricle.
This specific position (Durant's maneuver) prevents the embolus from migrating to the pulmonary artery and causing a right ventricular outflow tract obstruction.
3
Activate the facility's rapid response system.
Summons the emergency medical team.
The client requires advanced interventions (e.g., provider aspiration of air) beyond the PN scope, making advanced support critical once immediate physical safeguards are in place.
4
Administer high-flow supplemental oxygen via a non-rebreather mask.
Promotes nitrogen washout and increases blood oxygenation.
High-flow oxygen decreases the size of the air bubble and treats the severe hypoxia caused by the embolism.
5
Obtain a complete set of vital signs and pulse oximetry.
Establishes a hemodynamic baseline.
Allows the arriving rapid response team to immediately assess the severity of shock and evaluate the client's response to the initial interventions.

Key Concept

Emergency Management of a Central Venous Catheter Air Embolism
Question 2828Question →

A client in the preoperative holding area of an ambulatory care center is scheduled for an elective lithotripsy. After the surgeon has explained the procedure and left the area, the client tells the practical nurse (PN), "I changed my mind. I am too scared and do not want to go through with this surgery." In what order should the PN perform the following actions? (Arrange from first action to last action)

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Answer

The correct sequence is to first confirm the client's decision, then ensure safety by stopping preoperative preparations, followed by notifying the appropriate providers, and finally documenting the event.
When a client revokes informed consent, the nursing process guides the PN's prioritization. First, the PN must assess and confirm the client's statement to ensure clear communication. Second, the PN must immediately implement safety measures by halting any procedures or medications (such as sedatives) related to the canceled surgery, as administering them would constitute battery. Third, the PN must notify the RN and the surgeon, as it is the provider's responsibility to discuss the risks of refusing the procedure and formally cancel the medical orders. Finally, after all immediate actions and notifications are complete, the PN documents the entire event objectively in the medical record.

Step-by-Step Solution

1
Confirm the client's decision to withdraw consent.
The PN verifies the client's intent to cancel the surgery.
Assessment is always the first step to ensure an accurate understanding of the client's wishes before taking action.
2
Stop preoperative preparations and withhold sedatives.
The client is protected from receiving unnecessary or mind-altering medications.
Immediate safety actions must be taken once consent is revoked to uphold the client's right to refuse treatment.
3
Notify the surgeon and supervising RN.
The healthcare team is made aware of the change in the client's consent status.
Communicating with the provider is essential because it is their legal scope and responsibility to address the medical consequences of refusing treatment.
4
Document the event in the medical record.
A legal record of the consent revocation and subsequent actions is created.
Accurate and timely documentation is required to maintain the legal and historical record of care.

Key Concept

Informed Consent Revocation and PN Scope of Practice
Question 2829Question →

A resident in a long-term care facility is receiving treatment for a urinary tract infection. During the evening shift, the resident becomes highly agitated, paces the hallways, and repeatedly attempts to open the secured exit doors. Which actions should the practical nurse implement to ensure the resident's safety? Select all that apply.

Select all that apply

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Answer: Redirect the resident to a quiet, supervised area with a simple, familiar activity.; Ensure the resident's walking path is well-lit and clear of clutter.; Assign a staff member to provide continuous one-to-one observation.

Answer

The correct actions are to redirect the resident to a quiet area with a familiar activity, ensure the walking path is well-lit and clear of clutter, and assign a staff member to provide continuous one-to-one observation.
The correct interventions prioritize client safety while strictly adhering to the principle of using the least restrictive environment. Redirecting the client, removing environmental hazards, and implementing continuous observation prevent falls and elopement without inappropriately resorting to physical restraints.

Step-by-Step Solution

1
Identify the primary safety risks associated with the resident's behavior.
The resident is agitated, pacing, and attempting to exit the facility, which creates a high risk for elopement, falls, and injury.
Recognizing specific hazards determines which interventions will be most effective and urgently needed.
2
Select interventions that prioritize safety using the least restrictive methods.
Redirection, modifying the environment to remove hazards, and providing one-to-one observation directly address the safety risks without unlawfully restricting the resident's freedom.
Nursing standards require exhausting all non-pharmacological and non-physical restraint alternatives first.
3
Eliminate inappropriate or out-of-scope actions.
Applying a vest restraint, assuming the behavior is normal aging, and delegating complex assessments to a UAP are eliminated.
These actions violate restraint protocols, demonstrate a failure to recognize acute delirium, and breach delegation guidelines.

Key Concept

Prioritizing least restrictive interventions and environmental safety for an agitated, wandering client.
Question 2830Question →

An older adult resident residing in an extended care facility is receiving intravenous antibiotic therapy for a severe soft tissue infection. The nursing assistant informs the practical nurse that the resident, who is usually alert and cooperative, is suddenly thrashing in bed and speaking incoherently. Upon evaluation, the nurse observes pale, diaphoretic skin with a heart rate of 118 beats per minute and a blood pressure of 92/54 mm Hg (baseline 136/80 mm Hg). Which intervention should the practical nurse implement immediately?

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Answer: Immediately alert the supervising nurse to the acute changes in the resident's condition.

Answer

The practical nurse must immediately alert the supervising nurse to the acute changes in the resident's condition.
The correct action is to immediately escalate the findings to the supervising nurse. The resident's sudden confusion, diaphoresis, tachycardia, and significant drop in blood pressure in the presence of an active infection are hallmark signs of septic shock. This is a life-threatening physiological adaptation that requires rapid medical intervention, which must be initiated and overseen by a registered nurse or healthcare provider.

Step-by-Step Solution

1
Analyze the resident's baseline data and current presentation.
The resident has a known infection and is suddenly confused, tachycardic (118 bpm), and hypotensive (92/54 mm Hg) compared to baseline.
Identifying acute deviations from baseline is essential for early recognition of life-threatening complications.
2
Correlate the clinical findings to potential pathophysiological processes.
The combination of a primary infection, new-onset altered mental status, increased heart rate, and decreased blood pressure strongly indicates early septic shock.
Septic shock causes systemic vasodilation, leading to hypotension and compensatory tachycardia, which subsequently decreases cerebral perfusion (causing confusion).
3
Determine the priority action within the practical nurse's scope of practice.
The highest priority is to escalate the findings to the supervising registered nurse or healthcare provider.
Septic shock is a medical emergency requiring urgent interventions outside the practical nursing scope, such as prescribing fluid boluses or ordering vasopressors.

Key Concept

Early Recognition of Shock and Priority Escalation
Question 2831Question →

A client who is recovering from abdominal surgery is preparing to move from the bed to a bedside chair for the first time. In what sequence should the nurse perform the following actions to ensure a safe transfer? Arrange the steps in the correct chronological order.

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Answer

The correct sequence begins with preparing the environment (placing and locking the chair), followed by elevating the head of the bed, assisting the client to dangle their legs, monitoring for dizziness, and finally applying a transfer belt before standing.
Safe client mobilization requires a systematic approach. The nurse must first secure the environment by locking the chair in the optimal position. Next, the client is brought upright gradually by elevating the head of the bed and then pivoting to a dangling position. This gradual movement is crucial for post-operative clients to prevent orthostatic hypotension. The nurse must then verify the client's stability by checking for dizziness before applying the gait belt and initiating the weight-bearing phase of the transfer.

Step-by-Step Solution

1
Prepare the environment and equipment.
The destination chair is positioned correctly and secured.
Ensuring the chair is locked and appropriately angled guarantees a safe landing point and prevents the equipment from rolling during the transfer.
2
Raise the head of the bed.
The client is moved into an initial upright position.
Elevating the head minimizes physical exertion for the client and protects the abdominal incision from excess strain while transitioning.
3
Assist the client to a dangling position on the edge of the bed.
The client's legs are dependent, allowing the cardiovascular system to adjust.
Gradual position changes are essential in post-operative care to prevent a sudden drop in blood pressure.
4
Evaluate the client for orthostatic changes.
The nurse confirms the client is stable enough to stand.
Dizziness or syncope can lead to severe injury if the client is allowed to bear weight while hemodynamically unstable.
5
Apply a gait belt and assist with the stand-and-pivot maneuver.
The client is safely moved into the chair.
A transfer belt provides the nurse with a firm, safe hold on the client's center of gravity without pulling on their arms or shoulders.

Key Concept

Safe Client Transfer and Mobility
Question 2832Question →

Following a percutaneous liver biopsy, a client's electronic health record displays the following vital sign progression:

TimepointBlood Pressure (mm Hg)Apical Pulse (beats/min)
Pre-procedure128/7672
1 hour post-procedure116/7088
2 hours post-procedure (Current)102/64104

The client currently appears pale and states, "I feel a little dizzy when I turn my head." Which immediate action should the practical nurse take?

Show answer & explanation

Answer: Notify the registered nurse of the vital sign trends and client symptoms

Answer

The correct action is to notify the registered nurse of the vital sign trends and client symptoms.
The client's trending vital signs (decreasing blood pressure and increasing heart rate) combined with pallor and dizziness strongly indicate early hypovolemic shock, a potential and life-threatening complication of internal hemorrhage following a liver biopsy. The practical nurse must immediately escalate these critical findings to the registered nurse or healthcare provider to ensure rapid medical intervention.

Step-by-Step Solution

1
Analyze the vital sign trends over the two-hour post-procedure period.
Blood pressure dropped from 128/76 to 102/64 mm Hg, and the heart rate increased from 72 to 104 beats/min.
Comparing current data to baseline is essential to identify early physiological deterioration.
2
Correlate the vital sign changes with the client's physical symptoms and recent procedure.
The combination of tachycardia, relative hypotension, pallor, and dizziness after a highly vascular liver biopsy suggests internal bleeding.
Recognizing the systemic signs of hypovolemic shock allows for prompt escalation and risk reduction.
3
Determine the safest and most appropriate nursing intervention within the practical nurse scope.
The most critical action is to immediately notify the registered nurse or healthcare provider.
Suspected internal hemorrhage is a life-threatening emergency requiring advanced assessment and medical orders beyond the practical nurse's independent scope.

Key Concept

Early Recognition of Hypovolemic Shock
Question 2833Question →

An adult client is restricted to bed rest due to an acute deep venous thrombosis (DVT) in the right calf. The client reports dull, aching leg pain and requests a bed bath. When providing hygiene and comfort measures, which action by the practical nurse is the priority?

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Answer: Maintain the affected extremity supported on a soft wedge cushion above the level of the heart during the bathing process.

Answer

Maintain the affected extremity supported on a soft wedge cushion above the level of the heart during the bathing process.
Elevating the affected extremity above the level of the heart uses gravity to passively promote venous return. This safely reduces tissue edema and alleviates the client's aching discomfort without mechanically disturbing the acute thrombus. It is the gold standard for basic comfort and safety when caring for a client with a deep vein thrombosis.

Step-by-Step Solution

1
Identify the client's primary diagnosis and associated risks.
The client has an acute DVT in the right calf, presenting a severe risk for thrombus dislodgement and subsequent pulmonary embolism.
Understanding the underlying pathology is essential before performing any physical manipulation during hygiene care.
2
Evaluate the proposed hygiene and positioning interventions against safety contraindications.
Massaging the leg (firm upward strokes), applying popliteal pressure (blanket behind the knee), and performing active range-of-motion on the affected leg are identified as dangerous.
These actions increase mechanical pressure or muscle contraction around the vein, which can break the acute clot loose into the bloodstream.
3
Select the intervention that provides basic comfort and safety.
Elevating the leg on a wedge pillow is chosen as the safest and most effective action.
Elevation uses gravity to reduce venous congestion and localized pain without applying direct physical manipulation to the affected calf.

Key Concept

Basic Care and Immobility Precautions for DVT
Question 2834Question →

An older adult client with type 2 diabetes mellitus is scheduled to undergo a computed tomography (CT) scan of the abdomen with intravenous contrast in two hours. The practical nurse is reviewing the client's morning laboratory results, which reveal a serum creatinine level of 2.2 mg/dL2.2\ \text{mg/dL} (194 μmol/L194\ \mu\text{mol/L}) and a blood urea nitrogen (BUN) of 35 mg/dL35\ \text{mg/dL} (12.5 mmol/L12.5\ \text{mmol/L}). What is the priority action for the practical nurse?

Show answer & explanation

Answer: Report the abnormal renal function tests to the supervising registered nurse or provider immediately.

Answer

The priority action is to immediately report the abnormal renal function tests to the supervising registered nurse or provider.
The correct answer is to report the abnormal laboratory results. A serum creatinine of 2.2 mg/dL2.2\ \text{mg/dL} indicates significantly impaired renal function. Intravenous contrast is nephrotoxic and can cause permanent kidney damage if administered to a client with an already elevated creatinine level. The provider must be notified immediately so the procedure can be canceled, postponed, or performed without contrast.

Step-by-Step Solution

1
Identify the planned procedure and its associated risks.
The client is scheduled for a CT scan with intravenous contrast, which is known to be nephrotoxic.
Understanding the nature of the procedure is essential for identifying potential complications.
2
Analyze the provided laboratory data.
The serum creatinine (2.2 mg/dL2.2\ \text{mg/dL}) and BUN (35 mg/dL35\ \text{mg/dL}) are significantly elevated.
Elevated creatinine and BUN indicate impaired renal function or acute kidney injury.
3
Synthesize the data to determine the clinical risk.
Administering IV contrast to a client with existing renal impairment places them at high risk for contrast-induced nephropathy. Furthermore, the client takes metformin for diabetes, which increases the risk of lactic acidosis if given alongside contrast.
Connecting the client's underlying condition and laboratory values to the procedural risks guides safe nursing practice.
4
Select the appropriate nursing intervention within the practical nurse scope of practice.
The practical nurse must immediately notify the registered nurse or healthcare provider to halt the procedure and re-evaluate the plan of care.
Timely escalation of critical findings is a primary responsibility to prevent adverse client outcomes.

Key Concept

Prevention of Contrast-Induced Nephropathy
Estimated Time:1m 0s
Question 2835Question →

A practical nurse receives report on an older adult client who has developed profuse, watery diarrhea and recently tested positive for a Clostridioides difficile infection. What specific infection control measures must the nurse implement during this client's care? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Put on a clean isolation gown and gloves before entering the client's room.; Wash hands thoroughly with soap and water immediately upon exiting the client's room.; Use a dedicated blood pressure cuff and stethoscope that remain inside the client's room.

Answer

The nurse must don a gown and gloves before entering, wash hands with soap and water upon exiting, and use dedicated room equipment.
Clostridioides difficile requires strict contact precautions because it is transmitted through the fecal-oral route and contact with contaminated environments. Evidence-based guidelines require the use of a private room, donning a gown and gloves upon entry to the room, using dedicated disposable or room-restricted equipment, and strictly performing hand hygiene with soap and water, as alcohol-based sanitizers do not eradicate C. diff spores.

Step-by-Step Solution

1
Identify the mode of transmission for the diagnosed pathogen.
Clostridioides difficile is transmitted via the fecal-oral route and through contact with contaminated surfaces or equipment.
Understanding the transmission route determines the correct isolation precautions.
2
Determine the required transmission-based precautions.
Strict contact precautions are necessary, which include a private room, gown, and gloves.
Contact precautions prevent the spread of infectious agents transmitted by direct or indirect contact with the client or their environment.
3
Select interventions that specifically address the unique characteristics of C. diff.
Handwashing with soap and water (not alcohol sanitizers) and using sporicidal cleaning agents are required.
C. diff produces spores that are highly resistant to standard alcohol-based hand sanitizers and conventional disinfectants.

Key Concept

Strict Contact Precautions and Spore Eradication
Question 2836Question →

A practical nurse (PN) is collecting data on a client who is 24 hours postoperative following an abdominal hysterectomy. The client reports an incisional pain level of 8 on a 0 to 10 scale and requests their prescribed as-needed (PRN) oral hydrocodone-acetaminophen. The PN notes the client is restless with pale, cool skin. The client's vital signs are: blood pressure 92/54 mm Hg, apical pulse 118 beats/minute, and respirations 22 breaths/minute. Which of the following actions should the PN take first?

Show answer & explanation

Answer: Withhold the hydrocodone-acetaminophen and immediately notify the registered nurse.

Answer

The practical nurse should withhold the hydrocodone-acetaminophen and immediately notify the registered nurse.
The client's clinical presentation (tachycardia, hypotension, restlessness, pale and cool skin) strongly suggests hypovolemic shock, a serious postoperative complication. Opioid analgesics like hydrocodone can cause vasodilation and further lower blood pressure. Therefore, administering the medication is unsafe. The practical nurse is acting correctly within their scope of practice by withholding the contraindicated medication and immediately reporting the critical change in condition to the registered nurse for advanced assessment and intervention.

Step-by-Step Solution

1
Analyze the client's clinical presentation and vital signs.
The client has a low blood pressure (92/54 mm Hg), elevated heart rate (118 beats/minute), elevated respiratory rate (22 breaths/minute), restlessness, and pale, cool skin.
Data collection is the first step in the nursing process to determine the client's current physiological status.
2
Interpret the clinical findings in the context of the postoperative period.
These findings are early signs of hypovolemia or hemorrhage, which is a life-threatening complication of an abdominal hysterectomy.
Recognizing signs of shock is critical for prioritizing care based on the Airway, Breathing, Circulation (ABC) framework.
3
Evaluate the safety of administering the prescribed medication.
Hydrocodone-acetaminophen is an opioid, which can cause vasodilation and further decrease blood pressure, making it contraindicated in this unstable state.
The nurse must ensure pharmacological therapies are safe to administer based on current client data.
4
Determine the appropriate action within the practical nurse scope of practice.
The nurse must withhold the unsafe medication and immediately communicate the critical findings to the registered nurse.
Practical nurses are responsible for withholding medications that pose a risk and reporting abnormal findings to the directing RN or provider.

Key Concept

Recognizing signs of hypovolemic shock and appropriately withholding contraindicated medications while escalating care within the practical nursing scope of practice.
Question 2837Question →

A practical nurse is receiving a client who has just returned to the medical-surgical unit following a percutaneous liver biopsy. Which position should the nurse assist the client into immediately after the procedure?

Show answer & explanation

Answer: Right side-lying position with a small towel or pillow under the puncture site

Answer

The client should be placed in a right side-lying position with a small towel or pillow under the puncture site.
The correct position is on the right side because the liver is located on the right side of the body. Resting on the right side with a small towel or pillow under the puncture site applies direct, sustained pressure to the liver capsule, which is crucial for preventing post-procedure hemorrhage.

Step-by-Step Solution

1
Identify the procedure performed and its anatomical location.
The client had a percutaneous liver biopsy; the liver is located in the right upper quadrant of the abdomen.
Understanding the anatomical site is necessary to determine the appropriate post-procedure care.
2
Determine the primary risk associated with the procedure.
The liver is highly vascular, making hemorrhage the most significant immediate post-procedure complication.
Prioritizing interventions based on the highest risk guides safe positioning.
3
Select the position that mitigates the identified risk.
Positioning the client on the right side applies external pressure to the biopsy site, promoting hemostasis.
Mechanical pressure on the puncture site helps prevent bleeding.

Key Concept

Post-procedure positioning for hemostasis
Question 2838Question →

A nursing team consisting of a Registered Nurse (RN), a Practical Nurse (PN), and an Assistive Personnel (AP) is receiving client assignments on a medical-surgical unit. Match each client care activity to the most appropriate team member and rationale based on their legal scope of practice.

Click a left item, then click its matching right item

Items

Performing an initial admission assessment on a client experiencing acute respiratory distress.
Administering a scheduled oral antibiotic and performing a routine sterile dressing change.
Providing a bed bath, oral care, and assisting with feeding for a client with chronic hemiparesis.
Developing a comprehensive discharge teaching plan for a client with a new colostomy.

Matches

Show answer & explanation

Answer

Assessment of the unstable client and initial teaching plan development are assigned to the RN. Routine medication administration and sterile dressing changes on a stable client are assigned to the PN. Basic hygiene and feeding for a chronic, stable client are delegated to the AP.
Safe delegation requires matching the complexity of the task and the stability of the client to the provider's scope of practice. The RN handles unstable clients, comprehensive assessments, and initial teaching. The PN manages stable clients, standard medication administration, and routine sterile procedures. The AP handles standard activities of daily living for stable clients.

Step-by-Step Solution

1
Analyze the acuity and stability of each client.
The client in respiratory distress is unstable. The post-operative client, the client with hemiparesis, and the client with a new colostomy are physiologically stable.
Client stability determines whether care requires the comprehensive assessment skills of an RN or the focused assessment skills of a PN.
2
Determine the complexity and scope of each task.
Initial assessment and care planning require an RN. Initial teaching requires an RN. Sterile dressing changes and oral medications require a licensed nurse (PN or RN). Routine hygiene and feeding do not require a license.
Tasks must be matched to the legal scope of practice for each team member.
3
Assign the most appropriate team member to each task based on the Five Rights of Delegation.
Unstable assessment matches to the RN. Initial teaching matches to the RN. Stable sterile dressing and oral medications match to the PN. Routine activities of daily living match to the AP.
This process ensures safe, effective, and legally compliant client care assignments.

Key Concept

Delegation and Scope of Practice Based on Client Acuity
Question 2839Question →

A pediatric client arrives at the primary care clinic for a scheduled measles, mumps, and rubella (MMR) vaccine. During the initial data collection, the guardian reports that the child has been taking a prescribed high-dose oral corticosteroid for the past two weeks to treat a severe asthma exacerbation. Which action is the priority for the practical nurse?

Show answer & explanation

Answer: Withhold the vaccine and report the client's current medication therapy to the healthcare provider.

Answer

The correct action is to withhold the vaccine and report the client's current medication therapy to the healthcare provider.
The MMR vaccine is a live-attenuated virus vaccine. High-dose systemic corticosteroids cause immunosuppression, which is a strict contraindication for receiving live vaccines due to the risk of severe infection. The practical nurse must prioritize client safety by recognizing this contraindication, withholding the vaccine, and reporting the finding to the healthcare provider.

Step-by-Step Solution

1
Analyze the client's current medication therapy in relation to the scheduled procedure.
The client is taking a high-dose oral corticosteroid, which causes systemic immunosuppression.
Identifying current medications is essential to prevent adverse drug interactions or complications.
2
Determine the characteristics of the scheduled vaccine.
The MMR vaccine is a live-attenuated virus vaccine.
Live vaccines carry a risk of causing active infection if administered to a client with a weakened immune system.
3
Apply the practical nursing scope of practice to the clinical finding.
The practical nurse must recognize the contraindication, withhold the administration, and promptly notify the provider or registered nurse.
Ensuring client safety by withholding contraindicated medications and reporting significant clinical data is a critical responsibility.

Key Concept

Immunization contraindications and safe medication administration within the practical nurse's scope of practice.
Question 2840Question →

A practical nurse (PN) on a progressive care unit is preparing a client for a scheduled cardiac catheterization. The informed consent form is already signed and placed in the medical record. While assisting the client into a hospital gown, the client states, 'I am so nervous about them putting that tube down my throat to look at my heart again.' Which action should the PN take?

Show answer & explanation

Answer: Notify the healthcare provider that the client requires further explanation regarding the procedure.

Answer

Notify the healthcare provider that the client requires further explanation regarding the procedure.
Informed consent is only valid when the client fully understands the procedure, its risks, benefits, and alternatives. The client's statement demonstrates a clear misunderstanding of a cardiac catheterization. Because it is the healthcare provider's legal responsibility to explain the procedure, the PN must halt the preoperative process and notify the provider to clarify the information.

Step-by-Step Solution

1
Analyze the client's statement.
The client believes a tube will be put down their throat (likely confusing the procedure with a transesophageal echocardiogram or endoscopy), indicating they do not understand what a cardiac catheterization entails.
Identifying client misunderstandings is crucial for ensuring that informed consent is truly informed and valid.
2
Determine the legal responsibility of the practical nurse (PN).
The PN's role is to witness the signature and verify voluntary consent, not to explain the procedure itself.
Explaining the risks, benefits, and details of a procedure is strictly the responsibility of the healthcare provider performing it.
3
Select the appropriate nursing action.
The PN must notify the healthcare provider so they can return and clarify the procedure for the client before any further preoperative steps are taken.
This ensures legal compliance and prioritizes client advocacy and safety.

Key Concept

The practical nurse's role in informed consent is limited to witnessing the signature and ensuring the client voluntarily agrees. If a client demonstrates a lack of understanding, the provider must be notified to provide further explanation.
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