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Question 2861Question →

An older adult client is recovering on the telemetry unit 2 hours after a cardiac catheterization performed via the right femoral artery approach. During rounding, the client reports the sudden onset of a dull, continuous ache in the lower right back. The insertion site dressing remains clean and dry with no visible hematoma. Current vital signs reveal a blood pressure of 102/58 mmHg and a heart rate of 108 bpm, compared to a baseline of 134/76 mmHg and 72 bpm upon arrival. Based on these findings, what is the priority action for the practical nurse?

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Answer: Immediately report the findings to the supervising registered nurse.

Answer

Immediately report the findings to the supervising registered nurse.
The correct action is to immediately escalate the situation. Following a femoral cardiac catheterization, bleeding can occur internally into the retroperitoneal space. Because the blood pools backward, the external groin dressing will remain dry, but the client will experience back or flank pain as the blood irritates the tissues. The shifting vital signs (rising heart rate, falling blood pressure) are early indicators of hypovolemic shock. This is a medical emergency requiring immediate RN and provider intervention.

Step-by-Step Solution

1
Analyze the client's current symptoms and procedural history.
The client had a right femoral arterial puncture and is now experiencing new-onset lower right back pain.
Connecting post-procedural history to new symptoms is critical for identifying potential complications.
2
Evaluate the vital sign trends.
The heart rate has increased from 72 to 108 bpm, and the blood pressure has decreased from 134/76 to 102/58 mmHg.
Trending vital signs helps identify early physiological decline before overt shock occurs.
3
Synthesize the findings to identify the underlying risk.
The hidden nature of the bleeding (dry dressing) combined with back pain and borderline shock vitals strongly indicates a retroperitoneal hemorrhage.
Blood leaking from the posterior femoral artery tracks into the retroperitoneal space, causing back or flank pain without visible external bleeding.
4
Determine the appropriate practical nurse (PN) action.
The PN must immediately escalate the findings to the registered nurse (RN).
A retroperitoneal hemorrhage is a life-threatening emergency that requires advanced RN assessment, provider notification, and potential surgical or medical intervention beyond the PN scope.

Key Concept

Recognition and escalation of early shock and retroperitoneal bleeding following femoral arterial procedures.
Question 2862Question →

A practical nurse is caring for an older adult client who requires continuous supplemental oxygen via a nasal cannula. The client is increasingly restless and repeatedly removes the oxygen tubing from their nares, causing their oxygen saturation to drop. Which action should the nurse take first to maintain safety and prevent injury?

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Answer: Provide a tactile diversion, such as a folded washcloth, for the client to hold and manipulate.

Answer

Provide a tactile diversion, such as a folded washcloth, for the client to hold and manipulate.
The correct action demonstrates adherence to the principle of using the least restrictive alternative. By giving the client a safe object to hold, the nurse redirects the restless behavior and occupies the client's hands, thereby protecting the airway equipment without violating the client's autonomy or safety.

Step-by-Step Solution

1
Assess the client's immediate safety need.
The client is experiencing dropping oxygen saturation due to repeatedly removing the nasal cannula.
Identifying the root cause of the risk (pulling at the tubing due to restlessness) is required to select an appropriate intervention.
2
Determine the least restrictive intervention.
The nurse selects a tactile diversion to keep the client's hands occupied.
Nursing standards mandate that non-pharmacological, least-restrictive alternatives must be attempted before physical or chemical restraints are used.

Key Concept

Least Restrictive Alternatives and Injury Prevention
Question 2863Question →

A practical nurse is monitoring a client who was recently admitted with a deep vein thrombosis (DVT) in the left lower extremity. Which new clinical finding should the nurse identify as the highest priority to report to the charge nurse immediately?

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Answer: Sudden onset of tachypnea, a dry cough, and feelings of apprehension

Answer

The sudden onset of tachypnea, a dry cough, and feelings of apprehension indicates a medical emergency.
The development of sudden tachypnea (rapid breathing), a dry cough, and apprehension in a client with a DVT strongly suggests a pulmonary embolism (PE). A PE occurs when a portion of the clot breaks off and travels to the lungs, compromising airway and breathing. According to the ABC (Airway, Breathing, Circulation) framework, this is a life-threatening medical emergency requiring immediate intervention and reporting.

Step-by-Step Solution

1
Analyze the client's current diagnosis and potential complications.
The client has a DVT, which carries a high risk of part of the clot dislodging and traveling to the lungs, causing a pulmonary embolism (PE).
Understanding the pathophysiology of DVT is essential to anticipate life-threatening complications.
2
Evaluate each clinical finding against the ABC (Airway, Breathing, Circulation) prioritization framework.
Respiratory distress (tachypnea, cough) is a 'Breathing' issue, whereas pain, warmth, and edema are localized 'Circulation' issues.
The ABC framework dictates that airway and breathing issues are the highest clinical priority.
3
Determine which finding is an expected symptom versus an emergent complication.
Pain, warmth, and edema are expected localized signs of DVT. Sudden tachypnea and apprehension are unexpected signs indicating a systemic complication (PE).
Nurses must differentiate between expected disease manifestations and acute physiological deterioration to escalate care appropriately.

Key Concept

Prioritization of care and recognition of pulmonary embolism as a complication of DVT
Question 2864Question →

A practical nurse (PN) is caring for a conscious client with diabetes mellitus who suddenly reports feeling shaky and appears diaphoretic. Arrange the following nursing actions in the correct priority sequence to manage this situation and reduce the risk of severe complications. All options must be used.

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Answer

The correct sequence is to first check the blood glucose, administer a fast-acting carbohydrate, recheck in 15 minutes, provide a stabilizing snack, and finally document the event.
The correct sequence follows the standard 'Rule of 15' for hypoglycemia management combined with the nursing process. Assessment (checking blood glucose) must precede intervention. The immediate intervention is a simple carbohydrate to rapidly raise blood sugar. Evaluation (rechecking in 15 minutes) determines if further acute treatment is needed. Once stable, a complex snack prevents recurrence, and final documentation records the resolved incident.

Step-by-Step Solution

1
Obtain a capillary blood glucose reading.
Confirms if the client's symptoms are due to hypoglycemia.
Assessment is always the first step in the nursing process to ensure interventions are appropriate.
2
Administer 4 ounces (120 mL) of a fast-acting carbohydrate.
Rapidly increases the client's blood glucose level.
This follows the 'Rule of 15' for treating symptomatic hypoglycemia in a conscious client.
3
Wait 15 minutes and reassess the capillary blood glucose level.
Evaluates the client's response to the simple carbohydrate.
It takes approximately 15 minutes for the simple carbohydrate to absorb and affect the capillary glucose level. If it remains low, the treatment must be repeated.
4
Provide a complex carbohydrate and protein snack.
Maintains the blood glucose level over a longer period.
Simple carbohydrates cause a rapid spike and subsequent drop; complex carbohydrates and protein stabilize the level until the next meal.
5
Document the client's symptoms, interventions, and blood glucose results.
Provides an accurate legal and medical record of the event.
Documentation occurs after patient care is completed and the client is stable.

Key Concept

Management of Hypoglycemia (Rule of 15)
Question 2865Question →

A practical nurse is collecting data from a client who is 6 hours postoperative following a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigation (CBI). Which of the following findings indicate a potential complication that requires immediate notification to the registered nurse? (Select all that apply)

Select all that apply

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Answer: A sudden transition of irrigation drainage from light pink to bright red with large, thick clots.; A resting heart rate of 118 beats/min118\text{ beats/min} and a blood pressure of 88/54 mm Hg88/54\text{ mm Hg}.; Client report of severe, continuous lower abdominal cramping that is unrelieved by the prescribed antispasmodic medication.

Answer

The findings requiring immediate notification are the bright red drainage with large clots, the vital signs indicating shock (heart rate 118, BP 88/54), and the severe unrelieved abdominal cramping.
The correct findings represent three major life-threatening complications of a transurethral resection of the prostate (TURP): active arterial hemorrhage (indicated by bright red drainage with thick clots), systemic hypovolemic shock (indicated by tachycardia and hypotension), and severe catheter obstruction or bladder rupture (indicated by severe, unrelieved cramping). These findings require immediate escalation to the registered nurse to prevent permanent injury or death.

Step-by-Step Solution

1
Analyze the client's surgical procedure (TURP with CBI) to identify high-risk postoperative complications.
The primary risks include hemorrhage, catheter obstruction by clots, and fluid volume imbalances.
Understanding the specific risks of the procedure provides the framework for evaluating clinical data.
2
Evaluate each clinical finding to determine if it represents an expected postoperative outcome or a critical deviation.
Light pink drainage, normal hemoglobin, and the urge to void are expected. Bright red blood, hypotension with tachycardia, and unrelieved severe pain are abnormal.
The practical nurse must differentiate between normal physiological responses to the catheter and life-threatening emergencies.
3
Select the findings that pose an immediate risk to the client's airway, breathing, circulation, or organ integrity.
The correct selections relate directly to hemorrhage/shock (circulation) and severe obstruction.
Findings that threaten ABCs require immediate escalation to the registered nurse for rapid medical intervention.

Key Concept

Postoperative TURP complications and continuous bladder irrigation management.
Question 2866Question →

A practical nurse is gathering data on an older adult client who returned to the surgical unit 4 hours ago after a colon resection. The client's baseline vital signs were a blood pressure of 136/82 mm Hg and a pulse of 74 beats/min. Currently, the blood pressure is 108/66 mm Hg with a pulse of 102 beats/min. The client is continuously picking at the bed linens and complains of incisional pain. What is the priority nursing action?

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Answer: Notify the registered nurse of the client's current clinical status.

Answer

Notify the registered nurse of the client's current clinical status.
The correct action is to notify the registered nurse immediately because the client is exhibiting classic early signs of hypovolemic shock, including a narrowing pulse pressure, dropping blood pressure, increasing heart rate, and restlessness (altered mental status due to decreased cerebral perfusion). Immediate escalation is required to initiate fluid resuscitation or identify the source of bleeding.

Step-by-Step Solution

1
Analyze the baseline versus current vital signs and physical findings.
The blood pressure has dropped, the heart rate has increased, and the client is showing signs of altered mental status (picking at linens).
Comparing current data to baseline is essential to identify trends indicating deterioration.
2
Determine the pathophysiological meaning of these findings.
The combination of tachycardia, dropping blood pressure, and restlessness indicates potential hypovolemic shock or internal bleeding.
Recognizing early shock allows for prompt intervention before cardiovascular collapse occurs.
3
Select the appropriate nursing action based on prioritization and scope of practice.
The priority is to immediately escalate these findings to the registered nurse for advanced assessment and collaborative intervention.
Circulation issues take precedence over pain management, and a practical nurse must report critical changes to the registered nurse.

Key Concept

Prioritization in early shock recognition
Question 2867Question →

An 82-year-old client is admitted to the acute care facility for treatment of a severe urinary tract infection. During the shift assessment, the practical nurse (PN) notes the client is restless and disoriented to place, which is a change from baseline. The client's heart rate is 118 beats per minute, respirations are 26 breaths per minute, blood pressure is 92/54 mm Hg, and oral temperature is 96.4°F (35.8°C). Which actions should the PN take? Select all that apply.

Select all that apply

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Answer: Notify the registered nurse (RN) immediately regarding the client's assessment findings.; Verify the patency of the client's current intravenous access site.; Prepare to assist the RN with administering a rapid isotonic fluid bolus.

Answer

The correct actions are to immediately notify the RN regarding the findings, verify the patency of the intravenous access, and prepare to assist with a rapid isotonic fluid bolus.
The client's presentation of tachycardia, tachypnea, hypotension, hypothermia, and acute confusion in the presence of an infection indicates early septic shock. The practical nurse must prioritize life-saving circulation support. This involves immediately notifying the RN to initiate emergency protocols, ensuring patent IV access for medication delivery, and preparing for rapid volume expansion with isotonic fluids to restore blood pressure and organ perfusion.

Step-by-Step Solution

1
Analyze the clinical data.
The client has a known infection and is presenting with tachycardia, tachypnea, hypotension, hypothermia, and new-onset disorientation.
Identifying abnormal findings is the first step in clinical judgment.
2
Interpret the meaning of the combined findings.
The constellation of symptoms indicates systemic inflammatory response syndrome (SIRS) progressing into early septic shock with compromised tissue perfusion.
Older adults may present with atypical signs of sepsis, such as hypothermia and altered mental status, rather than a high fever.
3
Determine the appropriate PN interventions based on priorities.
The priority is to recognize the emergency, escalate care to the RN, and prepare for immediate resuscitative measures like fluid volume expansion.
Airway, breathing, and circulation (ABC) take precedence. Interventions must aim to rapidly restore hemodynamic stability.

Key Concept

Recognizing and prioritizing care for septic shock and physiological decompensation in older adults.
Estimated Time:1m 30s
Question 2868Question →

A practical nurse (PN) is preparing to mix and administer 5 units of regular insulin and 15 units of NPH insulin in a single syringe for a client with diabetes mellitus. In what order should the PN perform the following steps to prepare the medication? Arrange the actions from first to last.

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Answer

The correct sequence is to roll the NPH vial, inject air into the NPH vial, inject air into the regular insulin vial, withdraw the regular insulin, and finally withdraw the NPH insulin.
The standard procedure for mixing insulins involves drawing up the clear (regular) insulin before the cloudy (NPH) insulin. This 'clear before cloudy' sequence prevents the intermediate-acting NPH insulin from inadvertently mixing into and modifying the action of the short-acting regular insulin vial. Air is injected into both vials beforehand to equalize pressure and facilitate withdrawal.

Step-by-Step Solution

1
Identify the need to mix a suspension (NPH) and a solution (regular insulin).
The NPH vial is gently rolled.
Rolling resuspends the particles without introducing air bubbles.
2
Pressurize the vials by injecting air.
Inject 15 units of air into the NPH vial, then 5 units of air into the regular insulin vial.
Injecting air prevents a vacuum. The cloudy insulin is pressurized first to avoid contaminating the clear insulin later.
3
Withdraw the insulin doses.
Withdraw 5 units of regular insulin, then 15 units of NPH insulin.
Drawing clear before cloudy prevents intermediate-acting insulin from inadvertently mixing into the short-acting insulin vial.

Key Concept

Mixing Insulins (Clear Before Cloudy)
Question 2869Question →

A client is recovering on a surgical unit two days after an open cholecystectomy. The nursing care plan specifies using a powered standing-assist lift for transfers to the chair. The client is currently confused, highly agitated, and attempting to pull at their surgical drain. An unlicensed assistive personnel (UAP) is waiting to assist with the scheduled transfer. Which action should the practical nurse take?

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Answer: Cancel the transfer, lower the bed to its lowest position, and activate the electronic bed alarm.

Answer

Cancel the transfer, lower the bed to its lowest position, and activate the electronic bed alarm.
A powered standing-assist lift requires the client to be cooperative, able to bear some weight, and follow instructions. Attempting to transfer an agitated and confused client with this equipment violates ergonomic safety principles and risks injury to both the client and staff. Implementing a bed alarm and lowering the bed are appropriate, scope-compliant safety measures.

Step-by-Step Solution

1
Evaluate the client's current cognitive and physical status against the requirements for the prescribed transfer equipment.
The client is confused and agitated, meaning they cannot safely participate in a standing-assist transfer.
Standing-assist lifts require the client to bear partial weight and cooperate; using it on an agitated client violates ergonomic and safety guidelines.
2
Identify the safest alternative intervention within the PN scope of practice to protect the client and staff.
The nurse chooses to delay the transfer, lower the bed, and apply a bed alarm.
These actions prevent falls and equipment-related injuries without using unauthorized restraints or exceeding the practical nursing scope of practice.

Key Concept

Ergonomics and Safe Use of Equipment: Patient Readiness for Lifts
Question 2870Question →

A practical nurse (PN) and an unlicensed assistive personnel (UAP) are preparing to move an alert, partially mobile client up in bed using a draw sheet. In what order should the team perform the following actions to ensure client safety and maintain proper body mechanics? Arrange the actions in the correct sequence.

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Answer

The correct sequence is: Adjust the bed height and position, place a pillow at the headboard, position the client's arms and legs, roll the draw sheet close to the client, and finally shift weight to move the client.
The correct sequence prioritizes environmental preparation and staff ergonomics first, followed by client safety and positioning, and concludes with the physical transfer using proper body mechanics. By flattening and raising the bed, nurses avoid working against gravity and bending over. Padding the headboard protects the client from injury. Having the client bend their knees allows them to assist, significantly reducing the physical load. Finally, securing the draw sheet close to the body and shifting weight ensures the use of strong leg muscles instead of the vulnerable back muscles.

Step-by-Step Solution

1
Prepare the physical environment by adjusting the bed.
The bed is flat and raised to the nurses' waist height.
Flattening the bed reduces gravity resistance. Raising the bed to waist height maintains the nurses' center of gravity and prevents back strain.
2
Protect the client's head by relocating the pillow.
A pillow is positioned vertically against the headboard.
This prevents the client's head from accidentally striking the hard headboard surface during the upward movement.
3
Prepare the client for the movement.
The client crosses their arms and bends their knees, placing their feet flat on the mattress.
Crossing the arms reduces surface friction. Bending the knees allows the client to push down with their feet, assisting the nurses and reducing the physical load.
4
Establish a secure, ergonomic grip.
The draw sheet is rolled tightly against both sides of the client's body.
A close grip keeps the weight of the client near the nurses' center of gravity, significantly reducing strain on the lower back.
5
Execute the movement using large muscle groups.
The nurses shift their weight from their back leg to their front leg, gliding the client up the bed.
Using a weight-shifting rocking motion employs the strong muscles of the thighs and legs rather than the weaker back muscles.

Key Concept

Proper body mechanics and safe client handling techniques
Estimated Time:1m 30s
Question 2871Question →

While assisting a client who has left-sided hemiparesis to move from the bed to a wheelchair, a practical nurse must ensure proper mechanics and safety. In what order should the nurse perform the following actions? Arrange the steps from first to last.

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Answer

The correct sequence is to first position the wheelchair on the strong side and lock it, assist the client to a sitting position on the edge of the bed, apply a transfer belt, instruct the client to pivot on their strong leg, and finally have them lower into the chair using the armrests.
Transferring a client with hemiparesis requires maximizing the use of their strong side to maintain stability and prevent falls. The wheelchair must first be secured on the strong side. The client is then brought to a sitting position to prevent orthostatic hypotension and ensure balance. A transfer belt is applied for safety before any weight-bearing occurs. The client then pivots on their strong leg and carefully lowers into the chair using the armrests for support.

Step-by-Step Solution

1
Determine the correct placement of the wheelchair.
The wheelchair is placed on the client's right (strong) side at a 45-degree angle and the brakes are locked.
Placing the chair on the unaffected side allows the client to use their strong arm and leg to assist with the transfer, and locking the brakes prevents the chair from sliding.
2
Prepare the client for standing.
The client is assisted to a sitting position on the edge of the bed with feet flat on the floor.
Sitting on the edge of the bed allows the client to stabilize their blood pressure (preventing orthostatic hypotension) and gain balance before standing.
3
Apply safety equipment.
A transfer belt is placed securely around the client's waist.
The transfer belt provides the nurse with a safe way to support the client's center of gravity during the transfer without pulling on the client's limbs.
4
Execute the transfer movement.
The client stands, bearing weight on the right leg, and pivots toward the wheelchair.
Pivoting on the strong leg ensures stability and allows the client to move safely toward the seat.
5
Complete the transfer.
The client reaches for the armrests and lowers into the chair.
Using the armrests provides upper body support and control while lowering into the chair.

Key Concept

Safe transfer techniques and mobility assistance for clients with hemiparesis
Question 2872Question →

A 74-year-old client is recovering on the orthopedic unit following surgical fixation of a fractured pelvis. The practical nurse (PN) observes that the client, who was previously calm and oriented, is now highly agitated, picking at their intravenous (IV) tubing, and has a resting apical pulse of 116 beats per minute. Which actions should the PN implement immediately? Select all that apply.

Select all that apply

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Answer: Apply a pulse oximeter to evaluate the client's oxygen saturation level; Inspect the surgical incision site and underlying linens for pooling blood; Obtain a complete set of vital signs including blood pressure and respiratory rate

Answer

The correct actions are to apply a pulse oximeter, inspect the surgical site for bleeding, and obtain a complete set of vital signs.
Sudden onset of agitation and tachycardia in a postoperative orthopedic client strongly suggests inadequate tissue perfusion. This is most likely secondary to hypovolemic shock (from hemorrhage) or hypoxia (such as from a pulmonary embolism or respiratory depression). The PN must immediately gather objective data regarding the client's ABCs (Airway, Breathing, Circulation) by checking oxygen saturation, obtaining comprehensive vital signs, and assessing for overt signs of bleeding. These findings will dictate the urgent medical interventions needed by the registered nurse and provider.

Step-by-Step Solution

1
Analyze the clinical cues
The client has sudden onset agitation, confusion, and an elevated heart rate (116 bpm).
In a postoperative orthopedic client, these are classic early signs of physiological decompensation, specifically hypoxia or hypovolemic shock.
2
Prioritize data collection related to Airway, Breathing, and Circulation (ABCs)
The PN must immediately check oxygen saturation and obtain comprehensive vital signs.
These assessments provide immediate, objective data regarding the client's respiratory and hemodynamic stability.
3
Identify specific surgical risks
The PN must inspect the surgical site and underneath the client for pooling blood.
Pelvic fractures have a high risk of massive hidden hemorrhage, which directly causes hypovolemic shock.
4
Eliminate unsafe or delayed interventions
Do not administer opioids, do not dismiss the confusion as normal, and do not delay reassessment.
Giving opioids masks critical symptoms, dismissing confusion ignores a life-threatening change, and delaying care puts the client at risk for severe shock and death.

Key Concept

Early recognition of hypovolemic shock and hypoxia
Question 2873Question →

A practical nurse (PN) is preparing to assist a client with their morning meal. The client is 48 hours postoperative following a carotid endarterectomy and has residual dysphagia from a previous cerebrovascular accident (CVA). The client is also reporting mild shoulder pain. Which action is the priority for the PN to ensure safe and comfortable care?

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Answer: Position the client upright at a 90-degree angle and instruct them to tuck their chin when swallowing.

Answer

Positioning the client upright at a 90-degree angle and instructing them to tuck their chin when swallowing.
Clients with dysphagia are at a high risk for aspiration. Placing the client in a high-Fowler's position (90-degree angle) utilizes gravity to facilitate safe swallowing, while the chin-tuck maneuver anatomically narrows the airway opening. Together, these actions direct food and fluids safely into the esophagus and prevent aspiration.

Step-by-Step Solution

1
Identify the client's primary risk factor based on the provided medical history.
The client has residual dysphagia (difficulty swallowing) and is recovering from surgery.
Dysphagia places the client at a high risk for aspiration during any oral intake.
2
Determine the priority of care using the Airway, Breathing, Circulation (ABC) framework.
Protecting the airway from aspiration takes immediate precedence over secondary issues such as mild shoulder pain or surgical rest.
Aspiration can lead to severe airway obstruction or aspiration pneumonia, which are life-threatening complications.
3
Select the nursing intervention that best protects the airway while facilitating basic care and feeding.
Placing the client in a high-Fowler's position (90 degrees) and utilizing the chin-tuck maneuver.
This anatomical positioning utilizes gravity to direct food toward the esophagus while narrowing the airway opening, thereby minimizing the risk of aspiration.

Key Concept

Aspiration Precautions and Dysphagia Management
Question 2874Question →

A practical nurse (PN) is preparing to administer a prescribed dose of inhaled fluticasone via a metered-dose inhaler (MDI) with a spacer to a client with chronic asthma. Arrange the following steps for administering this medication in the correct chronological order.

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Answer

The correct sequence is: shake and attach the inhaler, instruct the client to exhale completely, seal the lips tightly around the spacer mouthpiece, depress the canister to release medication, have the client inhale slowly and hold their breath, and finally, rinse the mouth and spit.
Administering a corticosteroid via an MDI with a spacer requires a precise sequence to ensure maximum medication delivery to the lungs and to minimize local adverse effects. The sequence begins with device preparation (shaking and attaching). Next, the client must be prepared by exhaling completely to allow for a maximal inspiratory volume. Once the lungs are emptied, a tight seal is made around the mouthpiece to prevent leakage. Only then is the canister depressed to suspend the medication in the spacer. The client then inhales slowly and holds their breath for 10 seconds, allowing the particles to settle deeply in the bronchioles. Because fluticasone is a corticosteroid, the final and mandatory step is rinsing the mouth and spitting to prevent oral candidiasis.

Step-by-Step Solution

1
Shake the metered-dose inhaler vigorously and insert it into the end of the spacer.
The medication is uniformly mixed and the device is assembled.
Inhaled suspensions can separate; shaking ensures the client receives an accurate, measured dose.
2
Instruct the client to exhale completely to empty the lungs.
The client's lungs are emptied of residual volume.
Starting with empty lungs maximizes the volume of the subsequent inhalation, drawing the medication deeper into the respiratory tract.
3
Place the spacer mouthpiece into the client's mouth and ensure the lips are sealed tightly around it.
A closed system is created between the spacer and the client's airway.
A tight seal prevents the aerosolized medication from escaping out of the mouth during release.
4
Depress the inhaler canister once to release the medication into the spacer chamber.
One dose of medication is suspended inside the spacer.
The spacer holds the medication in a fine cloud, removing the need for the client to perfectly coordinate pressing the canister with inhaling.
5
Instruct the client to inhale slowly and deeply, then hold their breath for 10 seconds.
The medication travels to the lower airways and settles.
Slow inhalation prevents turbulent airflow from depositing medication in the back of the throat. Holding the breath maximizes absorption in the lungs.
6
Assist the client to rinse their mouth with water and spit it out.
Residual medication is cleared from the oropharynx.
Fluticasone is an inhaled corticosteroid. Leaving residue in the mouth increases the risk of oral fungal infections (candidiasis) and systemic absorption.

Key Concept

Safe Administration Sequence for Inhaled Corticosteroids via MDI with Spacer
Question 2875Question →

A practical nurse (PN) is preparing to enter the room of a client placed on airborne and contact precautions for disseminated herpes zoster. The PN has gathered the necessary personal protective equipment (PPE). Arrange the following steps for donning the PPE in the correct sequential order.

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Answer

The correct donning sequence is: Hand hygiene, Isolation gown, N95 respirator, Face shield, and finally Gloves.
According to standard infection control guidelines, personal protective equipment (PPE) must be donned in a specific sequence to maximize protection. The sequence begins with hand hygiene to ensure clean hands are used to handle the equipment. Next, the gown is applied to protect the body, followed by the respirator (which requires a direct seal to the face). Eye protection is added over the respirator. Finally, gloves are donned last so they can be pulled up over the cuffs of the gown, ensuring no skin is exposed.

Step-by-Step Solution

1
Perform hand hygiene.
Hands are clean before touching any equipment.
Prevents the transfer of pathogens to the clean PPE.
2
Put on the isolation gown.
The nurse's torso and clothing are fully covered.
Provides a primary body barrier against contact contaminants.
3
Don the N95 respirator.
The respiratory tract is protected with a secure seal.
Filters airborne particles; applying it before eye protection ensures the straps do not compromise the seal.
4
Place the face shield.
The eyes and upper face are shielded.
Protects mucous membranes from splashes and droplets without interfering with the respirator.
5
Put on clean gloves.
Hands and wrists are completely covered.
Applying gloves last allows them to be pulled over the gown cuffs, completing the protective barrier.

Key Concept

Personal Protective Equipment (PPE) Donning Sequence
Question 2876Question →

A practical nurse obtains a liquid stool sample from a client who is isolated for a severe Clostridioides difficile infection. The nurse needs to prepare the sample for immediate transport to the microbiology laboratory. Which action demonstrates strict adherence to standard and transmission-based precautions?

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Answer: Placing the securely sealed specimen container into a biohazard transport bag while still inside the client's room.

Answer

The correct action is to place the securely sealed specimen container into a biohazard transport bag while still inside the client's room.
To prevent environmental contamination, all biological specimens must be placed inside a leak-proof biohazard bag at the point of origin, which is inside the client's room. This ensures that the outside of the transport bag remains completely clean, allowing the nurse to handle it safely with bare, washed hands during transport to the laboratory.

Step-by-Step Solution

1
Identify the pathogen and its specific transmission risks.
Clostridioides difficile is a spore-forming bacterium spread via contact. Spores are highly resilient and are not killed by alcohol.
Determines the necessary environmental and chemical precautions required for safe handling.
2
Determine the correct procedure for handling hazardous biological specimens.
Specimens must be secured in a secondary container (biohazard bag) to prevent leakage or contamination of the transport environment.
Standard precautions mandate containing all potentially infectious materials during transit.
3
Evaluate the safest location for packaging the specimen.
The specimen must be placed into the biohazard bag inside the client's room before crossing the threshold.
Packaging the specimen at the point of origin prevents carrying a contaminated primary container through clean hospital areas.
4
Review the distractors for safety violations.
Wearing PPE in hallways, using alcohol on spores, and moving unbagged items to a nurses' station are severe infection control breaches.
Confirms the selection of the correct, safe action.

Key Concept

Safe handling and transport of biohazardous specimens under contact precautions.
Estimated Time:1m 15s
Question 2877Question →

A practical nurse is preparing to enter the room of an infant diagnosed with respiratory syncytial virus (RSV). The facility policy requires both contact and droplet precautions. Arrange the steps for donning the required personal protective equipment (PPE) in the correct sequence.

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Answer

The correct sequence for donning PPE is: Gown, Mask, Goggles/Face Shield, and then Gloves.
The Centers for Disease Control and Prevention (CDC) sequence for donning PPE is designed to maximize protection and minimize the risk of self-contamination during the process. The correct order is gown, mask or respirator, goggles or face shield, and finally gloves. The gown is applied first to cover the torso and arms. The mask is applied next to protect the respiratory system. Eye protection is then added. Gloves are always donned last so they can be securely pulled over the cuffs of the gown, completing the continuous barrier.

Step-by-Step Solution

1
Don the isolation gown.
The nurse's torso, arms, and clothing are covered.
Applying the gown first prevents contamination of the uniform and allows for unrestricted movement when securing the remaining PPE.
2
Don the surgical mask.
The respiratory tract is protected from large respiratory droplets.
The mask must be secured before eye protection to ensure a proper fit over the nose bridge.
3
Don goggles or a face shield.
The eyes are protected from potential splashes or respiratory secretions.
Eye protection rests over the upper edge of the mask to provide complete facial coverage.
4
Don procedure gloves.
The hands are protected and the gown cuffs are sealed tightly.
Gloves must be placed last so they can be pulled up and over the cuffs of the gown, preventing any exposed skin at the wrists.

Key Concept

Standard and Transmission-Based Precautions
Estimated Time:1m 0s
Question 2878Question →

A practical nurse (PN) is reviewing the medication administration record for a client who is prescribed oral cephalexin for a wound infection. The client's medical history indicates a severe anaphylactic allergy to penicillin. Which of the following actions should the PN take?

Show answer & explanation

Answer: Withhold the cephalexin and promptly notify the registered nurse (RN) or healthcare provider.

Answer

The correct action is to withhold the medication and notify the RN or healthcare provider because cephalosporins, such as cephalexin, have a known risk of cross-sensitivity in clients with severe penicillin allergies.
The correct response prioritizes client safety by preventing a potential life-threatening allergic reaction. Cephalosporins (like cephalexin) and penicillins share a beta-lactam ring structure, meaning clients with a severe penicillin allergy have a significant risk of cross-anaphylaxis. The practical nurse must recognize this contraindication, withhold the scheduled dose, and communicate the finding to the supervising nurse or provider for a potential prescription change.

Step-by-Step Solution

1
Review the prescribed medication and the client's medical history.
The client is prescribed cephalexin and has a known anaphylactic allergy to penicillin.
Comparing new prescriptions against documented allergies is an essential safety check before any medication administration.
2
Analyze the pharmacological relationship between the prescribed drug and the allergen.
Cephalexin is a cephalosporin antibiotic, which shares a similar beta-lactam ring structure with penicillins.
Clients with severe penicillin allergies are at a significant risk for cross-sensitivity and may experience anaphylaxis if given a cephalosporin.
3
Determine the appropriate and safe nursing intervention within the practical nurse scope of practice.
The medication must be withheld and the finding escalated to the registered nurse or prescribing provider.
Withholding a contraindicated medication prevents patient harm, and notifying the provider allows for an alternative, safe antibiotic to be prescribed.

Key Concept

Cephalosporin and Penicillin Cross-Sensitivity
Question 2879Question →

During the morning medication pass at a long-term care facility, a practical nurse reviews the electronic health record of a resident diagnosed with heart failure. The resident is scheduled to receive oral doses of digoxin and furosemide. Morning laboratory results indicate a serum potassium of 3.1 mEq/L (3.1 mmol/L) and a serum digoxin level of 1.3 ng/mL (1.66 nmol/L). The resident's current vital signs are blood pressure 102/58 mm Hg, heart rate 94 beats per minute, and respiratory rate 18 breaths per minute. Which action should the nurse prioritize to minimize the risk of complications?

Show answer & explanation

Answer: Withhold the scheduled doses of both medications and immediately report the clinical findings to the supervising registered nurse.

Answer

The practical nurse should prioritize withholding both the digoxin and furosemide and immediately escalating the abnormal laboratory and vital sign findings to the supervising registered nurse.
The correct answer involves withholding both medications and notifying the registered nurse. A serum potassium level of 3.1 mEq/L indicates hypokalemia (normal is 3.5-5.0 mEq/L). Hypokalemia significantly increases the myocardium's sensitivity to digoxin, placing the client at high risk for fatal dysrhythmias and toxicity, even when the serum digoxin level (1.3 ng/mL) is strictly within the normal therapeutic range (0.5-2.0 ng/mL). Furthermore, administering furosemide, a loop diuretic, would exacerbate the hypokalemia. The borderline vital signs (blood pressure 102/58 mm Hg, heart rate 94 bpm) may indicate early volume depletion or decreased cardiac output. The safest action within the practical nurse's scope is to withhold the medications and escalate the critical findings.

Step-by-Step Solution

1
Analyze the morning laboratory results against normal reference ranges.
The potassium level of 3.1 mEq/L is critically low (hypokalemia). The digoxin level of 1.3 ng/mL is within the normal therapeutic range.
Identifying abnormal values is the critical first step in risk reduction.
2
Evaluate the pharmacological interactions between the prescribed medications and current laboratory values.
Furosemide causes potassium wasting, which will worsen the hypokalemia. Hypokalemia increases the risk of digoxin toxicity even at normal serum levels.
Understanding drug-lab interactions prevents the administration of potentially lethal medications.
3
Analyze the client's vital signs for early signs of decompensation.
The blood pressure of 102/58 mm Hg and heart rate of 94 beats per minute are borderline and may indicate volume depletion or early dysrhythmia.
Recognizing subtle physiological changes helps identify emerging complications.
4
Determine the appropriate nursing intervention within the practical nurse's scope of practice.
The nurse must withhold both medications to prevent patient harm and immediately notify the registered nurse.
Escalating critical findings ensures the client receives appropriate medical intervention and maintains patient safety.

Key Concept

Reduction of Risk Potential: Recognizing Critical Drug-Laboratory Interactions and Escalating Care
Question 2880Question →

While observing an adolescent client on the surgical unit who had a tonsillectomy earlier in the day, the practical nurse notes that the client is restless and swallowing repeatedly. The continuous monitor shows a current heart rate of 118118 beats per minute, compared to a baseline of 8282 beats per minute. Which action should the practical nurse take FIRST?

Show answer & explanation

Answer: Examine the back of the client's throat using a penlight to check for active bleeding.

Answer

The priority action is to directly assess the surgical site for active bleeding.
Frequent swallowing, clearing of the throat, restlessness, and unexplained tachycardia (a heart rate of 118118 beats per minute) in a post-tonsillectomy client are classic early signs of hemorrhage. Because blood dripping down the back of the throat triggers the swallowing reflex, the priority action for the practical nurse is to directly assess the surgical site using a penlight. This immediate data collection is essential for determining the next steps to protect the airway and circulation before notifying the registered nurse.

Step-by-Step Solution

1
Analyze the clinical cues presented by the client.
The client exhibits restlessness, repeated swallowing, and tachycardia (heart rate of 118118 beats per minute).
Identifying abnormal findings is the first step in clinical judgment.
2
Correlate the symptoms with potential postoperative complications.
These specific signs strongly indicate postoperative hemorrhage, which is a medical emergency that compromises the airway.
Connecting symptoms to the surgical context (tonsillectomy) reveals the highest risk to the client's safety.
3
Determine the highest priority action based on the Airway, Breathing, Circulation (ABC) framework.
The nurse must visually inspect the throat to confirm bleeding before escalating to the registered nurse or provider.
Direct assessment provides the necessary clinical data to initiate emergency protocols and protect the client's airway.

Key Concept

Early recognition of hemorrhage and airway protection in postoperative tonsillectomy clients.
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