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Question 2881Question →

A practical nurse is caring for a client who is receiving continuous enteral nutrition via a nasogastric tube. The client suddenly begins coughing vigorously, becomes tachypneic, and appears cyanotic. Arrange the following nursing actions in the correct priority order to reduce the client's risk for further complications. (Place the first action at the top and the last action at the bottom.)

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Answer

The correct priority sequence is to first stop the continuous enteral feeding, then turn the client to a lateral side-lying position, next auscultate lung sounds and measure oxygen saturation, and finally notify the supervising Registered Nurse (RN).
When a client exhibits sudden respiratory distress during an enteral feeding, active aspiration is highly suspected. The sequence of actions follows the principle of neutralizing the immediate threat first. The nurse must stop the pump to prevent further aspiration. Next, repositioning the client laterally protects the airway and facilitates drainage. Only after these immediate physical safeguards are in place should the nurse obtain focused assessment data (vital signs, lung sounds) to accurately report the client's condition to the supervising RN for further medical orders.

Step-by-Step Solution

1
Recognize the signs of active aspiration (coughing, cyanosis) and immediately turn off the enteral feeding pump.
Halts the introduction of additional formula into the client's lungs.
Eliminating the cause of the immediate threat is always the highest priority in emergency risk reduction.
2
Reposition the client into a lateral (side-lying) position.
Uses gravity to help clear the airway.
Prevents further downward movement of aspirated fluid and promotes outward drainage of secretions.
3
Perform a focused respiratory assessment, including oxygen saturation and lung auscultation.
Provides objective baseline data regarding the extent of respiratory compromise.
Assessment data is necessary to determine the client's current status only after the immediate airway threat is neutralized.
4
Escalate the findings to the Registered Nurse (RN).
Initiates further medical management.
The practical nurse must report critical changes so the RN can implement advanced interventions, such as ordering a chest radiograph or prescribing oxygen therapy.

Key Concept

In emergency situations such as active aspiration, the practical nurse must prioritize immediate independent interventions that remove the risk (stopping feeding) and protect the airway (positioning) before collecting assessment data or notifying the healthcare team.
Question 2882Question →

A practical nurse (PN) is monitoring a client who is receiving a transfusion of packed red blood cells. Fifteen minutes into the transfusion, the client reports sudden lower back pain, chills, and dyspnea. Place the following nursing actions in the correct order of priority.

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Answer

1. Stop the blood transfusion immediately. 2. Initiate an infusion of 0.9% sodium chloride using new intravenous tubing. 3. Obtain a full set of vital signs and assess the client's respiratory status. 4. Notify the charge nurse and the prescribing healthcare provider. 5. Prepare to return the blood bag, tags, and administration set to the blood bank.
In the event of a suspected blood transfusion reaction, the absolute first priority is to stop the transfusion to prevent further administration of incompatible blood. The second step is to maintain a patent IV line for emergency medications and fluid resuscitation; this must be done with 0.9% sodium chloride and completely new tubing to avoid pushing remaining blood from the old tubing into the client. Once the source of harm is stopped and access is secured, the nurse must assess the client's vital signs and respiratory status to gather data. This clinical data is then immediately reported to the charge nurse and healthcare provider. Finally, as a follow-up administrative and diagnostic measure, the remaining blood, tags, and tubing are sent to the blood bank for investigation.

Step-by-Step Solution

1
Recognize the signs of a severe adverse therapy response.
The client is experiencing a potential acute hemolytic transfusion reaction, indicated by lower back pain, chills, and dyspnea.
Early recognition dictates the immediate cessation of the offending agent.
2
Prioritize direct interventions based on removing the source of harm and supporting circulation.
Stopping the transfusion prevents further exposure. Starting normal saline with completely new tubing maintains hemodynamic stability without pushing more blood into the client.
Client safety is the highest priority; flushing the old tubing would actively harm the client.
3
Gather specific clinical data before escalating communication.
Vital signs and respiratory assessment provide a precise baseline of the client's compromised state.
The healthcare provider requires current, objective data to prescribe appropriate emergency pharmacological interventions.
4
Escalate the situation and perform required administrative follow-up.
The charge nurse and provider are notified, and the blood materials are prepared for the blood bank.
Interprofessional communication ensures timely medical intervention, and the blood bank must investigate the cause of the transfusion reaction.

Key Concept

Prioritization of nursing interventions during an acute blood transfusion reaction
Question 2883Question →

A practical nurse is caring for a client receiving continuous bladder irrigation following a transurethral resection of the prostate. The client suddenly reports severe lower abdominal cramping, and the nurse observes that there is no fluid draining into the urinary collection bag. In what order should the practical nurse perform the following actions? (Arrange from first to last)

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Answer

The correct sequence is: Inspect the tubing, clamp the infusion, palpate the bladder, and then notify the registered nurse.
When a client on continuous bladder irrigation experiences sudden pain and a lack of output, an obstruction is highly likely. The nurse must first perform the quickest non-invasive check by inspecting the drainage tubing for kinks. If the tubing is clear, the blockage is internal (often a blood clot). The immediate safety priority is to clamp the flow of irrigation to prevent bladder rupture from continuous fluid input. After securing the client's safety, the nurse assesses the physical impact by palpating the bladder to gauge distention. Finally, the nurse reports these comprehensive findings to the registered nurse, who can initiate advanced interventions like manual irrigation to clear the clot.

Step-by-Step Solution

1
Check the external equipment for simple mechanical issues.
Rules out kinks, clamped tubes, or dependent loops as the cause of the obstruction.
This is the fastest, least invasive assessment and can immediately resolve the issue if a kink is found.
2
Halt the continuous bladder irrigation flow.
Prevents any additional fluid from entering the obstructed bladder.
If fluid continues to enter a blocked bladder, it will cause severe pain and risks bladder trauma or rupture. Stopping the harm is the immediate priority.
3
Assess the client physically by palpating the suprapubic area.
Provides objective clinical data regarding the extent of urinary retention.
Physical assessment determines the severity of the client's physiological response to the obstruction.
4
Report the findings to the supervising registered nurse.
Initiates collaborative care for resolving internal obstructions.
Interventions like manual bladder irrigation to remove blood clots typically require RN execution or specific provider orders.

Key Concept

Prioritization in Acute Obstruction
Question 2884Question →

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

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Answer

The correct sequence begins with positioning the client, followed by lubricating the tube, inserting it to the correct depth, initiating the flow at the proper height, and finally monitoring for and managing any discomfort such as cramping.
The procedure follows a logical and safe progression: preparation of the client (positioning), equipment preparation (lubrication), safe execution (insertion and controlled fluid flow), and continuous evaluation (monitoring for and responding to cramps).

Step-by-Step Solution

1
Position the client in the left lateral Sims' position.
The client's anatomy is optimally aligned to receive the fluid.
Gravity and the natural anatomical curve of the descending colon help retain the fluid and allow it to flow deeply into the bowel.
2
Lubricate the enema tip.
The tube surface is smoothed.
Lubrication prevents friction and mucosal tearing during insertion through the anal sphincters.
3
Insert the tube 3 to 4 inches into the rectum.
The tube safely passes the internal and external sphincters.
Ensures the fluid is delivered directly into the rectum and not expelled immediately.
4
Elevate the bag 12 to 18 inches and unclamp.
The solution begins to flow steadily into the bowel.
Provides adequate, safe hydrostatic pressure for fluid instillation without causing excessive force.
5
Monitor for cramping and lower or clamp the bag if it occurs.
The flow is adjusted based on client tolerance.
Rapid bowel distention causes severe pain; clamping or lowering the bag slows the instillation rate and relieves cramping.

Key Concept

Administration of a Cleansing Enema
Question 2885Question →

During morning rounds, a client with a history of a T4 spinal cord injury suddenly reports a severe, pounding headache. The practical nurse observes that the client is experiencing profuse sweating above the level of the chest and exhibits nasal congestion. Which immediate interventions are appropriate for this client? Select all that apply.

Select all that apply

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Answer: Raise the head of the bed to a high Fowler's position.; Obtain the client's blood pressure reading immediately.; Check the urinary catheter and drainage tubing for any obstructions.

Answer

The correct immediate actions are to raise the head of the bed, obtain a blood pressure reading, and check the urinary catheter for obstructions.
The client is exhibiting classic signs of autonomic dysreflexia, a severe hypertensive crisis triggered by a noxious stimulus below the level of the spinal cord injury (T4). Elevating the head of the bed immediately helps lower blood pressure through orthostasis. Obtaining a blood pressure reading confirms the hypertensive crisis and establishes a baseline, while checking the urinary system addresses the most common cause of the syndrome (bladder distention from a kinked or blocked catheter).

Step-by-Step Solution

1
Identify the clinical presentation.
The client's symptoms (pounding headache, profuse diaphoresis above the injury level, nasal congestion) in the context of a T4 spinal cord injury indicate autonomic dysreflexia.
Recognizing the syndrome is the critical first step in clinical judgment for a sudden client status change.
2
Prioritize immediate circulation and safety interventions.
Raising the head of the bed utilizes orthostatic pressure to help lower the blood pressure quickly.
This is a rapid, non-pharmacological way to mitigate the extreme hypertensive crisis.
3
Collect objective data and attempt to identify the trigger.
The nurse checks the blood pressure to confirm the severity of hypertension and inspects the urinary catheter.
Bladder distention is the most frequent noxious stimulus causing this reflex; removing the trigger is essential to resolving autonomic dysreflexia.

Key Concept

Autonomic dysreflexia is a medical emergency characterized by sudden, extreme hypertension in clients with spinal cord injuries above T6, requiring immediate positioning, data collection, and removal of the triggering stimulus.
Question 2886Question →

A practical nurse (PN) is assigned to care for a client who returned to the medical-surgical unit one hour ago following an esophagogastroduodenoscopy (EGD) with a gastric biopsy. The client is resting quietly and reports mild throat soreness. The PN records the following vital signs: blood pressure 106/62 mm Hg, heart rate 108 beats/minute, and respiratory rate 18 breaths/minute. The client's pre-procedure vital signs were blood pressure 144/82 mm Hg, heart rate 72 beats/minute, and respiratory rate 16 breaths/minute. Which action should the PN take first?

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Answer: Notify the supervising registered nurse immediately.

Answer

The priority action is to immediately notify the supervising registered nurse about the client's vital sign changes.
The correct action is to immediately notify the registered nurse. The client's vital signs show a significant drop in blood pressure and a new onset of tachycardia compared to the baseline. Following an invasive procedure like an EGD with biopsy, these subtle but significant changes are classic early indicators of potential internal hemorrhage or perforation. The practical nurse must recognize this complication and prioritize immediate escalation over routine care.

Step-by-Step Solution

1
Compare the current vital signs to the pre-procedure baseline.
The systolic blood pressure dropped by 38 mm Hg, and the heart rate increased by 36 beats/minute.
Identifying significant deviations from baseline is essential for detecting early postoperative complications.
2
Correlate the vital sign trends with the recent invasive procedure.
The combination of new-onset tachycardia and a significant drop in blood pressure following a gastric biopsy strongly suggests internal bleeding.
An EGD with biopsy carries a specific risk of gastrointestinal hemorrhage or perforation.
3
Determine the priority nursing action within the practical nurse scope of practice.
The PN must immediately report these findings to the registered nurse for urgent assessment.
Critical changes in hemodynamic status require immediate RN intervention and provider notification.

Key Concept

Recognition and escalation of early postoperative hemorrhage indicators
Question 2887Question →

Following a right-sided percutaneous liver biopsy, an adult client is transferred to the medical-surgical floor for ongoing monitoring. Which positioning strategy should the practical nurse implement to minimize the risk of post-procedure complications?

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Answer: Position the client on the right side with a small pillow beneath the lower rib cage.

Answer

Position the client on the right side with a small pillow beneath the lower rib cage.
Following a percutaneous liver biopsy, the most significant immediate risk is bleeding from the highly vascular liver tissue. Positioning the client on the right side (the operative side) allows the client's body weight to apply direct mechanical pressure to the puncture site, promoting hemostasis and preventing hemorrhage.

Step-by-Step Solution

1
Analyze the specific invasive procedure performed on the client.
The client underwent a right-sided percutaneous liver biopsy.
Identifying the anatomical location and nature of the procedure dictates the specific post-operative care and complication risks.
2
Identify the primary physiological risk associated with this specific procedure.
The liver is a highly vascular organ, making severe internal bleeding the primary risk following a needle biopsy.
Anticipating the most life-threatening complication guides the nurse to prioritize preventive interventions.
3
Select the nursing intervention that directly mitigates this risk.
Applying direct mechanical pressure to the right side achieves hemostasis.
Right side-lying uses the client's own body weight against the mattress to compress the puncture site and promote blood clotting.

Key Concept

Post-Procedure Positioning for Hemostasis
Question 2888Question →

A practical nurse is reinforcing infection control instructions with the family members of a client who is placed on droplet precautions for pertussis. Which instruction should the nurse provide to the family?

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Answer: You must put on a standard surgical mask before entering the client's room.

Answer

The nurse should instruct family members to put on a standard surgical mask before entering the room.
Pertussis is transmitted through large respiratory droplets. Droplet precautions require all individuals entering the client's room, including healthcare workers and visitors, to wear a standard surgical mask. This acts as a barrier to protect the mucous membranes of the nose and mouth from infectious droplets.

Step-by-Step Solution

1
Identify the mode of transmission for pertussis (whooping cough).
Pertussis is transmitted via large respiratory droplets generated by coughing or sneezing.
Knowing the transmission route is necessary to determine the correct category of isolation precautions.
2
Determine the personal protective equipment (PPE) requirements for droplet precautions.
A standard surgical mask is required for anyone entering the client's room or coming within 3 to 6 feet of the client.
Large droplets fall to surfaces relatively quickly and do not remain suspended in the air, so a surgical mask provides adequate protection for the mucous membranes.
3
Evaluate the options against standard droplet precaution protocols.
Only the instruction to wear a surgical mask upon entry correctly aligns with droplet precautions.
The other options incorrectly describe airborne precautions, contact precautions, or unsafe distancing practices.

Key Concept

Droplet Precautions
Estimated Time:1m 0s
Question 2889Question →

An adult client with a history of severe inflammatory bowel disease is receiving continuous total parenteral nutrition (TPN) through a peripherally inserted central catheter (PICC). The practical nurse evaluates the morning laboratory results and identifies a serum glucose level of 415 mg/dL (23.0 mmol/L). During the morning assessment, the client appears lethargic, and the vital signs reveal a heart rate of 114 beats/minute and a blood pressure of 94/56 mm Hg. Which action must the practical nurse implement first?

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Answer: Notify the registered nurse immediately regarding the critical laboratory value and the current vital signs.

Answer

The correct action is to notify the registered nurse immediately regarding the critical laboratory value and the current vital signs.
The client is exhibiting signs of severe hyperglycemia paired with potential hypovolemia (tachycardia and borderline hypotension), likely resulting from osmotic diuresis. A blood glucose level of 415 mg/dL is a critical value that poses an immediate risk to the client's safety. The priority action for the practical nurse, in accordance with risk reduction principles and their scope of practice, is to urgently communicate these critical findings to the registered nurse. The RN will then complete a comprehensive assessment and coordinate necessary medical interventions with the healthcare provider.

Step-by-Step Solution

1
Analyze the client's laboratory results and vital signs for abnormalities.
The glucose level of 415 mg/dL is critically high. The vital signs (HR 114, BP 94/56) and lethargy indicate physiological instability.
Early recognition of critical values and subtle signs of shock is essential for risk reduction.
2
Determine the appropriate intervention based on the practical nurse's scope of practice.
The practical nurse identifies that independent treatment with high-risk IV medications is outside their scope, and monitoring alone is insufficient.
Actions must legally align with practical nursing guidelines and prioritize client safety.
3
Escalate the findings to the appropriate higher-level clinician.
The registered nurse is notified immediately to perform a comprehensive assessment.
The RN must collaborate with the healthcare provider to initiate urgent interventions such as IV fluid resuscitation or an insulin infusion.

Key Concept

Recognizing and escalating critical laboratory values and signs of physiological instability
Question 2890Question →

A licensed practical nurse (LPN) is providing care for a client who has frequent, watery stools and is diagnosed with *Clostridioides difficile* (*C. diff*) infection. Which infection control interventions should the nurse implement? Select all that apply.

Select all that apply

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Answer: Perform hand hygiene using soap and water after removing personal protective equipment.; Don a clean, single-use gown and clean gloves prior to entering the client's room.; Clean and disinfect reusable medical equipment with a bleach-based (sporicidal) solution.

Answer

The nurse should perform hand hygiene with soap and water, don a gown and gloves before entering the room, and disinfect equipment with a bleach-based solution.
Clostridioides difficile (C. diff) requires strict contact precautions because it is spread through contact with spores in the stool and contaminated environments. The nurse must don a gown and gloves before entering the room to prevent cross-contamination. Because C. diff spores are highly resistant, alcohol-based hand sanitizers are ineffective; the nurse must physically remove the spores from the hands by washing with soap and water after removing PPE. Additionally, any reusable medical equipment must be disinfected with a sporicidal, bleach-based solution to effectively kill the spores.

Step-by-Step Solution

1
Identify the mode of transmission for the specified pathogen.
Clostridioides difficile (C. diff) is an enteric pathogen that forms resistant spores and is transmitted via direct or indirect contact.
Understanding the pathogen's characteristics determines the specific infection control precautions required.
2
Determine the appropriate isolation precautions.
Contact precautions must be implemented, requiring a clean gown and gloves before entering the client's room.
Gowns and gloves prevent the transfer of spores from the client and environment to the nurse's clothing and hands.
3
Evaluate the correct hand hygiene method.
Hand washing with soap and water must be used instead of alcohol-based hand sanitizers.
Alcohol does not eliminate C. diff spores; the mechanical action of washing with soap and water physically removes them from the hands.
4
Determine the proper sequence and location for doffing PPE.
The gown and gloves must be removed inside the client's room prior to exiting.
Removing PPE inside the room prevents the spread of spores into the hallway and other clean areas of the facility.
5
Identify the correct environmental cleaning agent.
A bleach-based (sporicidal) solution must be used for disinfecting reusable medical equipment.
Standard hospital disinfectants are ineffective against C. diff spores; a sporicidal agent is required for proper decontamination.

Key Concept

Contact Precautions and Spore-Forming Pathogen Management
Question 2891Question →

A practical nurse (PN) is caring for a 72-year-old client who was admitted two days ago following a motor vehicle collision that resulted in a fractured pelvis. During the evening shift, the client becomes increasingly restless, begins pulling at the bed linens, and exhibits new-onset confusion regarding the current location. The client's vital signs are blood pressure 104/82 mm Hg, heart rate 114 beats per minute, and respiratory rate 24 breaths per minute. Which action should the PN take first?

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Answer: Immediately report the change in mental status and vital signs to the registered nurse.

Answer

Immediately report the change in mental status and vital signs to the registered nurse.
Pelvic fractures carry a significant risk for internal hemorrhage. The client's new-onset confusion, restlessness, tachycardia, tachypnea, and narrowing pulse pressure are early clinical indicators of hypovolemic shock resulting from decreased cerebral perfusion. The PN must prioritize client safety by immediately notifying the registered nurse so that rapid medical interventions can be initiated.

Step-by-Step Solution

1
Analyze the client's current presentation and vital signs.
The client has a high-risk injury (pelvic fracture), new-onset confusion, restlessness, tachycardia (114 beats/min), tachypnea (24 breaths/min), and a narrow pulse pressure (104/82 mm Hg).
Identifying acute deviations from baseline is the first step in clinical judgment.
2
Correlate the assessment findings with potential physiological complications.
These systemic findings suggest a lack of oxygenated blood reaching the brain and compensatory mechanisms for blood loss, indicating early hypovolemic shock.
Pelvic fractures are highly vascular and prone to significant, hidden internal hemorrhage.
3
Determine the priority nursing action based on the PN scope of practice.
The PN must immediately escalate the critical findings to the registered nurse.
Recognizing life-threatening complications requires prompt reporting so that rapid medical interventions, such as fluid resuscitation, can be initiated.

Key Concept

Early Recognition of Hypovolemic Shock
Estimated Time:1m 30s
Question 2892Question →

A client is admitted to the surgical nursing unit immediately after a partial thyroidectomy. A practical nurse is contributing to the client's immediate postoperative care plan. Which of the following positioning and comfort measures should the nurse implement? Select all that apply.

Select all that apply

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Answer: Elevate the head of the bed to 30 to 45 degrees.; Support the client's head and neck with pillows to maintain neutral alignment.; Apply an ice collar to the anterior neck as prescribed.

Answer

The nurse should elevate the head of the bed to 30 to 45 degrees, support the head and neck with pillows to maintain neutral alignment, and apply an ice collar as prescribed.
Following neck surgery such as a partial thyroidectomy, basic care prioritizes protecting the airway and the surgical site. A semi-Fowler's position (head elevated 30 to 45 degrees) uses gravity to promote venous return and decrease edema, which protects the airway. Using pillows to support the head and maintain neutral alignment prevents hyperextension, reducing tension on the sutures. Finally, applying an ice collar is an effective comfort measure that induces vasoconstriction, limiting both swelling and bleeding.

Step-by-Step Solution

1
Identify the surgical procedure and the critical postoperative risks associated with it.
The client underwent a partial thyroidectomy. The primary immediate risks include airway obstruction from neck edema, bleeding, and tension on the anterior neck incision.
Recognizing the anatomical location and physiological risks dictates the necessary basic care and comfort interventions.
2
Select interventions that mitigate postoperative risks and promote client comfort.
Elevating the head of the bed and applying an ice collar reduce edema. Supporting the head and neck prevents strain on the suture line.
These specific measures align directly with the physiological requirements for safe recovery following neck surgery.

Key Concept

Postoperative Positioning and Comfort in Neck Surgery
Question 2893Question →

A practical nurse is preparing to administer a scheduled crushed medication via a client's nasogastric (NG) tube. To reduce the risk of complications, arrange the following nursing actions in the correct clinical sequence.

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Answer

The correct sequence is: Elevate the head of the bed, verify tube placement, flush with sterile water, administer the medication, and flush again.
Administering medications via a nasogastric tube requires a strict sequence to prevent life-threatening complications such as aspiration pneumonia and to maintain tube integrity. The client must first be positioned safely (head elevated). Next, tube placement is verified to confirm gastric location. A pre-flush ensures patency and clears the line. The medication is then administered by gravity, followed immediately by a post-flush to deliver the full dose and prevent clogs.

Step-by-Step Solution

1
Elevate the head of the bed to at least 30 to 45 degrees.
The client is placed in a semi-Fowler's position.
This utilizes gravity to reduce the risk of gastroesophageal reflux and aspiration into the lungs.
2
Verify correct tube placement by aspirating gastric contents and assessing pH.
Gastric placement is confirmed.
It is critical to ensure the tube has not become dislodged into the respiratory tract before instilling any fluids.
3
Flush the nasogastric tube with 15 to 30 mL of sterile water.
The tube is cleared of contents and patency is established.
Flushing prevents physical incompatibilities between gastric contents and the medication, while ensuring the tube is not blocked.
4
Instill the diluted medication into the syringe barrel, allowing it to flow by gravity.
The medication is delivered into the stomach.
Gravity instillation reduces the risk of applying too much pressure, which could damage the tube or the gastrointestinal mucosa.
5
Flush the nasogastric tube again with 15 to 30 mL of sterile water.
The tube is cleared of all medication residue.
This final flush ensures the client receives the entire medication dose and prevents the tube from becoming occluded by dried medication.

Key Concept

Safe administration of enteral medications requires sequential risk reduction techniques: aspiration prevention, placement verification, and occlusion prevention.
Question 2894Question →

A practical nurse (PN) is monitoring a client who underwent a percutaneous coronary intervention via the right femoral artery three hours ago. The client states, "I feel really thirsty and a little dizzy." The PN notes the client's heart rate has gradually increased from a baseline of 74 bpm to 108 bpm, and blood pressure has trended from 132/80 mm Hg to 104/62 mm Hg. Which action should the PN perform first?

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Answer: Examine the right femoral access site and palpate the surrounding tissue.

Answer

Examine the right femoral access site and palpate the surrounding tissue.
The correct answer focuses on immediate assessment of the procedural site because the client is demonstrating classic early signs of compensatory shock (tachycardia, narrowing pulse pressure, mild hypotension, thirst, and dizziness). Following a femoral artery puncture, the most immediate life-threatening risk is hemorrhage or retroperitoneal bleeding. Assessing the site directly addresses the 'Circulation' component of the ABC priority framework.

Step-by-Step Solution

1
Analyze the client's clinical presentation and vital sign trends.
The client has developed tachycardia, mild hypotension, dizziness, and thirst compared to baseline.
Recognizing early physiological changes is essential for identifying acute complications like hypovolemia.
2
Connect the symptoms to the recent procedure.
The client had a femoral artery puncture, placing them at high risk for hemorrhage or hematoma formation.
Identifying the most life-threatening complication related to the procedure determines the priority assessment.
3
Prioritize the next nursing action based on the ABCs (Airway, Breathing, Circulation).
The nurse must immediately assess the insertion site for bleeding to evaluate the client's circulatory status.
Intervening to identify and stop potential hemorrhage takes precedence over routine care or symptom management.

Key Concept

Early recognition of hypovolemic shock following an arterial procedure.

Alternative Method

Use the ABC (Airway, Breathing, Circulation) prioritization framework. Since airway and breathing are not compromised in this scenario, the priority shifts to circulation. The vital signs indicate a circulatory problem, leading directly to assessing the site of potential bleeding.
Estimated Time:1m 0s
Question 2895Question →

A practical nurse is caring for an older adult client with a history of atrial fibrillation who is prescribed daily warfarin. During morning rounds, the client appears suddenly confused and restless. The client's most recent International Normalized Ratio (INR) is 5.5. Which of the following actions should the nurse take first?

Show answer & explanation

Answer: Withhold the scheduled warfarin and immediately notify the registered nurse of the client's status.

Answer

The nurse should withhold the scheduled warfarin and immediately notify the registered nurse of the client's status.
An INR of 5.5 is well above the typical therapeutic range of 2.0 to 3.0, indicating a severe risk for bleeding. Furthermore, the client's sudden confusion could be a symptom of an intracranial hemorrhage. The correct action within the practical nurse's scope of practice is to withhold the dose and urgently notify the registered nurse or healthcare provider to ensure patient safety.

Step-by-Step Solution

1
Analyze the client's laboratory data.
The INR of 5.5 is significantly above the therapeutic range of 2.0 to 3.0 for atrial fibrillation.
Identifying abnormal laboratory values is essential to determine if a scheduled medication is safe to administer.
2
Evaluate the client's clinical presentation.
The client is an older adult exhibiting sudden confusion and restlessness.
Acute mental status changes can be a sign of poor perfusion or intracranial bleeding, especially in a client with a high bleeding risk.
3
Determine the appropriate nursing intervention within the practical nurse scope of practice.
The safest and most appropriate action is to withhold the medication and escalate the critical findings to the registered nurse.
The practical nurse cannot safely administer the medication or prescribe antidotes, making prompt reporting the priority.

Key Concept

Pharmacological Therapies and Scope of Practice
Question 2896Question →

During a shift on an infectious disease unit, a client with disseminated varicella-zoster virus requires routine morning care. The client is appropriately housed in an airborne infection isolation room. Which action should the practical nurse take to maintain safety and standard protocols?

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Answer: Take off the contaminated gloves and gown inside the isolation room before crossing the threshold into the hallway.

Answer

Take off the contaminated gloves and gown inside the isolation room before crossing the threshold into the hallway.
Disseminated varicella-zoster virus requires both airborne and contact precautions. According to standard infection control protocols, the nurse must remove the most contaminated equipment (gloves and gown) inside the client's room prior to exiting. This contains the pathogen within the isolated environment. The N95 respirator is then removed only after leaving the room and closing the door.

Step-by-Step Solution

1
Identify the transmission-based precautions required for disseminated varicella-zoster virus.
The client requires both airborne and contact precautions.
Disseminated varicella spreads through direct contact with fluid from lesions as well as via airborne respiratory droplets.
2
Determine the correct doffing sequence and location for the required personal protective equipment (PPE).
Gloves and gown must be removed inside the isolation room, while the N95 respirator must be removed outside the room.
Removing contact PPE inside prevents spreading pathogens to the hallway, while keeping the respirator on until outside protects the nurse from airborne particles.
3
Evaluate the remaining options against the LPN/LVN scope of practice.
Administering intravenous push (IVP) medications is identified as an out-of-scope action.
IVP medications require rapid clinical judgment and advanced RN-level assessment during administration.

Key Concept

Transmission-Based Precautions and Practical Nurse Scope of Practice
Question 2897Question →

A practical nurse is providing basic care for an older adult client who is weak and on prescribed bed rest following a right-sided thoracentesis. The client is receiving continuous oxygen therapy via nasal cannula. Which actions should the nurse include in the plan of care? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Assist with a partial bed bath while ensuring the posterior chest dressing remains dry and intact.; Provide a warmed blanket and dim the overhead room lights to promote relaxation.; Perform oral hygiene using moistened sponge swabs to alleviate mucous membrane dryness.

Answer

The correct actions are to assist with a partial bed bath while protecting the dressing, provide a warmed blanket with dimmed lights, and perform oral hygiene using moistened swabs.
Providing a partial bed bath while keeping the dressing intact maintains hygiene without risking infection at the puncture site. Dimming lights and providing a warmed blanket are effective nonpharmacological comfort measures that promote rest. Using moistened swabs for oral care safely relieves the mucous membrane dryness often caused by continuous oxygen therapy.

Step-by-Step Solution

1
Analyze the client's clinical status and recent procedure.
The client is weak, post-thoracentesis, on bed rest, and requires continuous oxygen therapy.
Understanding the clinical context is essential to determine safe basic care interventions.
2
Evaluate each care intervention for safety and appropriateness.
Bathing with dressing protection, environmental comfort measures, and oral care are safe and indicated.
These actions promote hygiene and comfort without compromising respiratory status or violating safety protocols.
3
Identify contraindicated actions that compromise safety.
Flat positioning, removing the oxygen cannula, and raising all four side rails are identified as unsafe.
These actions increase the risk of respiratory distress, hypoxia, and constitute unauthorized restraint use.

Key Concept

Safe Implementation of Basic Care and Comfort Interventions
Question 2898Question →

An adolescent is brought to the emergency department exhibiting a high fever, severe headache, and nuchal rigidity. The healthcare provider suspects meningococcal meningitis. What is the most appropriate infection control measure for the practical nurse to take when initiating direct care for this client?

Show answer & explanation

Answer: Secure a standard procedural mask over the nose and mouth before entering the room.

Answer

The correct action is to secure a standard procedural mask over the nose and mouth before entering the room, as this aligns with droplet precautions.
Meningococcal meningitis is a highly contagious bacterial infection spread through large respiratory droplets. Standard infection control guidelines mandate the immediate implementation of Droplet Precautions upon suspicion of the disease. This requires healthcare personnel to wear a procedural or surgical mask upon entering the client's room to protect their own mucous membranes from exposure.

Step-by-Step Solution

1
Analyze the client's clinical presentation and the provider's suspected diagnosis.
The client has symptoms of meningitis, and meningococcal meningitis is suspected.
Identifying the specific suspected pathogen determines the necessary mode of transmission-based precautions.
2
Determine the transmission route for Neisseria meningitidis (meningococcal meningitis).
The pathogen is transmitted through large respiratory droplets generated by coughing, sneezing, or talking.
Matching the pathogen to its transmission route prevents cross-contamination and healthcare-associated infections.
3
Select the appropriate personal protective equipment (PPE) for droplet precautions.
A standard procedural or surgical mask must be worn upon entering the room or coming within three feet of the client.
Procedural masks effectively block large respiratory droplets from reaching the nurse's mucous membranes.

Key Concept

Empiric implementation of Droplet Precautions for suspected meningococcal meningitis
Question 2899Question →

A practical nurse is preparing to administer a mixed dose of intermediate-acting (NPH) and short-acting (Regular) insulin to a client with diabetes mellitus. Arrange the following steps in the correct chronological order for mixing these insulins in a single syringe.

Drag items to arrange them in the correct order

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Answer

The correct sequence for mixing insulins is: clean both vials, inject air into the NPH vial, inject air into the Regular vial, draw up the Regular insulin, and finally draw up the NPH insulin.
When mixing short-acting (Regular) and intermediate-acting (NPH) insulin, the correct sequence ensures that the fast-acting insulin is not contaminated with the longer-acting insulin. The standard mnemonic is 'clear before cloudy.' After cleaning the vials, air is injected into the NPH vial first, followed by air into the Regular vial. The Regular (clear) insulin is drawn up first while the needle is already in the vial. Finally, the NPH (cloudy) insulin is drawn up to complete the exact total dose.

Step-by-Step Solution

1
Clean the rubber stoppers of both insulin vials with alcohol swabs.
The stoppers are disinfected.
Maintains aseptic technique before inserting needles into the vials.
2
Inject an amount of air equal to the prescribed dose into the NPH insulin vial.
Pressure is equalized in the NPH vial.
Prevents a vacuum, making it easier to withdraw medication later. This is done first because the needle has not touched any insulin yet.
3
Inject an amount of air equal to the prescribed dose into the Regular insulin vial.
Pressure is equalized in the Regular vial.
Prepares the vial for immediate withdrawal of insulin.
4
Invert the Regular insulin vial and withdraw the prescribed dose into the syringe.
The short-acting insulin is drawn into the syringe.
Clear (Regular) insulin is drawn up first so that the vial is not contaminated with cloudy (NPH) insulin, which could alter the rapid action of future doses drawn from the Regular vial.
5
Insert the needle into the NPH insulin vial and withdraw the prescribed dose.
The total mixed dose is gathered in the syringe.
Cloudy (NPH) insulin is drawn up last. Care must be taken not to inject any Regular insulin into the NPH vial.

Key Concept

Safe Medication Administration: Mixing Insulins (Clear before Cloudy)
Question 2900Question →

An older adult client in a long-term care facility is receiving a continuous enteral feeding via a nasogastric tube. The practical nurse is preparing to perform a complete bed bath and change the client's bed linens, which requires lowering the head of the bed. Which action is essential for the nurse to take?

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Answer: Stop the enteral feeding pump before lowering the head of the bed to a flat position.

Answer

The nurse must stop the enteral feeding pump before lowering the head of the bed to a flat position.
Clients receiving continuous enteral feedings are at a high risk for aspiration if they are laid flat, as the formula can easily reflux from the stomach into the esophagus and airway. To safely perform a bed bath or linen change that requires a flat bed position, the practical nurse must first stop the feeding pump. The feeding should only be resumed once the procedure is finished and the head of the bed is returned to an elevation of at least 30 to 45 degrees.

Step-by-Step Solution

1
Identify the client's current treatment and the physical requirements of the planned basic care procedure.
The client is receiving a continuous enteral feeding, and a complete bed bath requires the bed to be temporarily lowered to a flat position.
Understanding the intersection of prescribed therapies and basic care activities is necessary to identify potential safety hazards.
2
Recognize the primary safety risk associated with enteral feedings and patient positioning.
Administering enteral feedings while the client is supine creates a high risk for regurgitation and pulmonary aspiration.
Gravity is required to help keep the nutritional formula in the stomach and prevent reflux into the esophagus and airway.
3
Determine the necessary nursing intervention to mitigate this risk during the procedure.
The continuous feeding must be temporarily paused before the head of the bed is lowered.
Stopping the introduction of new formula into the stomach before laying the client flat prioritizes airway protection and physiological safety.

Key Concept

Aspiration Precautions during Enteral Nutrition and Basic Care
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