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Question 281Question →

A practical nurse (PN) assigned to a medical-surgical unit notices that a registered nurse (RN) colleague exhibits slurred speech, bloodshot eyes, and an unsteady gait. The PN then observes the RN preparing to administer an intravenous medication to a client in an unsafe manner. Arrange the following actions the PN should take in the correct order of priority. (Place the first action at the top and the last action at the bottom.)

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Answer

The correct sequence of actions prioritizes immediate client safety, followed by risk isolation, management notification, and documentation: 1. Intervene to prevent administration, 2. Direct the RN away from the area, 3. Notify the supervisor, 4. Document the incident.
The correct order follows the nursing process and safety prioritization (Maslow's hierarchy). Immediate physiological safety is the highest priority, requiring the nurse to first stop the unsafe administration of medication. Once the immediate act is halted, removing the impaired colleague from the clinical area secures the ongoing safety of the environment. After safety is established, the nurse must fulfill mandatory reporting requirements by notifying the nursing supervisor, who can formally address the impairment. Finally, objective documentation of the event is a legal requirement completed after the situation is secure.

Step-by-Step Solution

1
Apply the prioritization principle of client safety first.
The PN intervenes to stop the RN from giving the medication.
Preventing immediate harm to the client supersedes all other actions, including chain of command reporting.
2
Isolate the source of the risk.
The PN directs the RN out of the client's room.
Removing the impaired colleague prevents any further attempts to provide unsafe care or interact with the client.
3
Follow mandatory reporting protocols for suspected impairment.
The PN notifies the nursing supervisor.
The supervisor has the authority to confront the employee, arrange drug testing, and ensure safe staffing coverage.
4
Fulfill legal and facility documentation requirements.
The PN completes an incident report.
An official, objective record of the event must be created, but only after immediate safety and reporting are handled.

Key Concept

Mandatory Reporting of Impaired Coworkers and Client Advocacy
Question 282Question →

A practical nurse (PN) is preparing to administer a prescribed preoperative sedative to a competent adult client scheduled for an elective surgery. The client suddenly states, "I have changed my mind. I do not want to go through with this surgery anymore." Arrange the following nursing actions in the priority order the PN should perform them. (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 withhold the medication, then affirm the client's right to refuse, explore their concerns, notify the provider, and finally document the event.
When a client refuses treatment, the priority is to immediately stop the intervention to uphold their autonomy and prevent battery. The nurse then acts as an advocate by validating their decision and exploring their concerns to gather necessary data. Following data collection, the nurse reports the situation to the healthcare provider, who is responsible for explaining the medical consequences of the refusal. Finally, the nurse documents the entire event objectively in the medical record to ensure legal compliance and continuity of care.

Step-by-Step Solution

1
Withhold the preoperative sedative and halt further surgical preparation.
Unwanted medical interventions are stopped immediately.
Continuing preparation or administering sedation violates the client's right to refuse and could be considered battery.
2
Affirm the client's right to refuse the procedure to establish a supportive environment.
The client feels heard, respected, and supported in their decision.
Validating the client's autonomy is a core component of nursing advocacy and builds a therapeutic relationship.
3
Explore the client's specific concerns or reasons for refusing the surgery.
The nurse identifies the underlying cause of the refusal.
Data collection helps determine if the refusal stems from a knowledge deficit, fear, or a newly developed complication, which the provider will need to know.
4
Notify the charge nurse and the primary healthcare provider of the client's decision.
The healthcare team is informed of the change in the client's status.
The provider must be notified to discuss the medical consequences of the refusal with the client and to cancel the surgical procedure.
5
Document the client's refusal, withheld medication, and provider notification in the health record.
An accurate, legal record of the event is created.
Objective documentation protects the client and the facility, and it ensures continuity of care.

Key Concept

Client autonomy and the right to refuse treatment
Question 283Question →

A practical nurse (PN) is assigned to care for a client who is scheduled for an elective surgical procedure in 30 minutes. The informed consent has already been signed, and the PN is preparing to administer the prescribed preoperative medications. The client suddenly becomes anxious and states, 'I have changed my mind. I do not want to have this surgery.' Arrange the following nursing actions in the correct order of priority from first to last.

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Answer

The correct priority is to first withhold preoperative medications, then confirm the client's intent, notify the surgeon and RN, support the client while the surgeon explains the risks, and finally document the event.
When a client revokes informed consent, the immediate priority is to halt any interventions related to the procedure, such as giving preoperative medications. Next, the nurse clarifies the client's intent to ensure the refusal is definitive. Because it is outside the Practical Nurse's scope of practice to counsel the client on the medical risks of refusing surgery, the surgeon and supervising RN must be notified immediately. The Practical Nurse then remains to support the client while the surgeon provides the required medical explanations. Finally, detailed legal documentation is completed once the immediate situation is safely managed.

Step-by-Step Solution

1
Withhold preoperative medications.
Halts the surgical preparation.
Ensures client safety and strictly respects the client's immediate autonomy to refuse treatment.
2
Confirm the client's intent.
Clarifies the client's wishes.
Verifies that the client's statement is a definitive revocation of consent rather than just an expression of acute anxiety.
3
Notify the surgeon and RN.
Escalates the situation to appropriate providers.
Only the healthcare provider can legally discuss the medical risks of procedure cancellation.
4
Support the client during the provider's explanation.
Maintains a therapeutic and safe environment.
The PN advocates for the client while adhering to strict scope of practice boundaries.
5
Document the event.
Creates a legal record of the revocation.
Fulfills legal and ethical requirements for the medical record after acute actions are resolved.

Key Concept

When a client revokes informed consent, the Practical Nurse's priority is to immediately halt preparations, confirm the decision, and notify the provider, as explaining the medical risks of refusal is strictly within the provider's scope of practice.
Question 284Question →

A nurse is preparing to enter an isolation room that requires full personal protective equipment. Arrange the items in the correct sequence for donning (putting on) this equipment according to standard infection control guidelines.

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Answer

The correct sequence for donning full personal protective equipment is: Gown, Mask or Respirator, Goggles or Face Shield, and finally Gloves.
According to the Centers for Disease Control and Prevention (CDC) guidelines, the proper sequence for putting on (donning) personal protective equipment is: gown first, followed by the mask or respirator, then goggles or face shield, and finally gloves. This specific sequence is designed to maximize protection by securing the largest piece of equipment first and ensuring that the gloves can correctly overlap the gown cuffs to maintain an unbroken protective barrier over the wrists.

Step-by-Step Solution

1
Put on the isolation gown.
The torso and clothing are protected.
The gown is the largest foundational piece of equipment and is put on first to secure it properly at the neck and waist.
2
Apply the mask or respirator.
The respiratory tract is protected.
Securing the mask before eye protection ensures a proper fit directly on the face and around the nose.
3
Put on eye protection.
The eyes are shielded from splashes or sprays.
Eye protection sits over the top edge of the mask, preventing gaps where droplets could enter.
4
Don clean gloves.
The hands are protected and the gown cuffs are sealed.
Gloves must be put on last so they can be pulled entirely over the wrists of the isolation gown, leaving no skin exposed.

Key Concept

CDC Standard Sequence for Donning Personal Protective Equipment (PPE)
Question 285Question →

A practical nurse (PN) is assisting with the admission of a client who is scheduled for an elective surgery. The healthcare provider has already explained the procedure, risks, and alternatives. Arrange the following actions the PN should take to facilitate the informed consent process in the correct chronological order.

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Answer

The correct sequence is to first verify the client has not received sedatives, then check for any remaining questions, observe the client sign the document, and finally sign the document as a witness.
The practical nurse's role in informed consent is strictly limited to advocating for the client and witnessing the signature. The PN must first establish that the client is competent (has not received sedatives) and ready (has no remaining questions for the provider). Once readiness is established, the PN observes the voluntary signature and then immediately signs as the official witness.

Step-by-Step Solution

1
Assess client competence.
Verify no sedatives were given.
A client cannot give legal consent if under the influence of central nervous system depressants.
2
Assess client readiness.
Ask if there are remaining questions.
The PN verifies understanding but does not explain the procedure; if questions exist, the provider must be called to explain further.
3
Witness the signature.
Watch the client physically sign the form.
The core of the PN's legal role in informed consent is observing the voluntary signature.
4
Document the witnessing.
Sign the form as a witness.
The PN completes the legal requirement by adding their own signature immediately after seeing the client sign.

Key Concept

Practical Nurse Role in Informed Consent
Estimated Time:1m 0s
Question 286Question →

A practical nurse (PN) is providing a complete bed bath for a bedridden client. Arrange the following body parts in the correct order in which they should be washed, proceeding from the cleanest area to the dirtiest area.

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Answer

The correct sequence for a bed bath is from the cleanest area to the dirtiest area: Face and neck, followed by the chest and abdomen, then the legs and feet, and finally the perineal area.
Bathing must always progress from the cleanest areas to the dirtiest areas to prevent the spread of pathogens. The correct sequence starts at the head (face and neck), moves down the trunk (chest and abdomen), continues to the extremities (legs and feet), and ends with the most contaminated region (the perineal area).

Step-by-Step Solution

1
Identify the core principle of bathing a client.
The principle is to wash from the cleanest area to the dirtiest area.
This prevents the transfer of microorganisms from highly contaminated areas to cleaner areas.
2
Determine the cleanest area among the choices.
The face and neck are washed first.
The face (especially the eyes) is highly susceptible to infection and is considered the cleanest part of the body.
3
Sequence the remaining body parts descending toward the lower body.
The chest and abdomen are washed next, followed by the legs and feet.
The trunk is cleaner than the lower extremities and feet.
4
Identify the dirtiest area to be washed last.
The perineal area is placed last in the sequence.
The perineum harbors the most microorganisms and washing it last prevents contaminating the bath water and spreading bacteria to the rest of the body.

Key Concept

The fundamental principle of personal hygiene and bathing is to clean from the cleanest area to the dirtiest area to prevent cross-contamination.
Question 287Question →

Prior to entering a negative-pressure isolation room to perform routine care and oral suctioning for a client with a highly contagious respiratory pathogen, a practical nurse gathers the required supplies. The client requires strict Airborne and Contact precautions. Arrange the following actions for donning personal protective equipment (PPE) in the correct chronological sequence.

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Answer

The correct sequence for donning full personal protective equipment is: Hand hygiene, followed by the isolation gown, the N95 respirator, the face shield, and finally, the gloves.
According to standard infection control guidelines, PPE must be donned in an order that ensures maximum protection and structural integrity of the gear. Hand hygiene always precedes PPE contact. The gown is applied first due to its bulk. The respirator follows so it can be fitted tightly to the face. Eye protection rests over the respirator, and gloves are applied last to seal the gown cuffs.

Step-by-Step Solution

1
Perform hand hygiene.
Hands are decontaminated.
Prevents transferring pathogens to clean PPE during the application process.
2
Don the isolation gown.
The torso and clothing are covered.
Applied first as it covers the most area and requires the most movement to tie behind the neck and back.
3
Apply the N95 respirator.
The respiratory tract is protected.
Must be applied directly to the face for a proper seal, before eye protection obstructs the bridge of the nose.
4
Don the face shield.
The mucous membranes of the eyes are protected.
Applied over the respirator to accommodate the respirator's shape and straps.
5
Put on gloves.
Hands and wrists are fully covered.
Gloves go on last so they can stretch over the gown's cuffs, ensuring a seamless protective barrier.

Key Concept

Donning Sequence for Personal Protective Equipment (PPE)
Question 288Question →

A practical nurse is preparing to leave the room after completing care for a client in an airborne infection isolation room (AIIR). The client is diagnosed with active pulmonary tuberculosis and a vancomycin-resistant enterococci (VRE) infection of a lower extremity wound. The nurse is currently wearing an isolation gown, an N95 respirator, and clean gloves. Arrange the following steps for safely doffing the personal protective equipment (PPE) and exiting the area in the correct sequence.

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Answer

The correct sequence for doffing the required PPE is to first remove the gloves, followed by the isolation gown. The nurse must then exit the isolation room and close the door before removing the N95 respirator. Finally, the nurse performs thorough hand hygiene.
The Centers for Disease Control and Prevention (CDC) sequence for doffing PPE is carefully designed to prevent self-contamination. The most contaminated items, the gloves, are removed first. The gown is removed next, taking care to roll it inside out so the clean side is exposed. Because the client is on airborne precautions, it is critical that the N95 respirator remains in place until the nurse has fully exited the negative-pressure room and the door is closed. Once safely outside, the respirator is removed by the straps without touching the contaminated front surface. Finally, hand hygiene is performed to eliminate any microscopic pathogens transferred to the hands during the doffing process.

Step-by-Step Solution

1
Remove and discard gloves.
The nurse's hands are freed from the most contaminated protective barrier.
Gloves touch the client and the environment directly; removing them first minimizes the risk of contaminating other surfaces during the doffing process.
2
Remove and discard the isolation gown.
The gown is rolled inside out and safely placed in the infectious waste receptacle.
The front and sleeves of the gown are contaminated. Pulling it away by touching only the inside prevents pathogens from transferring to the uniform.
3
Exit the airborne infection isolation room.
The nurse is now in a clean environment, such as a hallway or anteroom.
The N95 respirator must remain on until the nurse has completely left the contaminated airborne environment to prevent inhalation of infectious droplet nuclei.
4
Remove the N95 respirator.
The respirator is removed and discarded without the nurse touching the front filter.
Handling only the elastic straps prevents contamination of the nurse's hands from the outer surface of the mask.
5
Perform hand hygiene.
The nurse's hands are cleansed of any residual pathogens.
Hand hygiene is the essential final step to ensure safety before continuing client care or documentation.

Key Concept

Proper PPE Doffing Sequence for Airborne and Contact Precautions
Question 289Question →

A practical nurse is preparing to apply prescribed thigh-high anti-embolism stockings for a client who has been sitting in a bedside chair for the past three hours. In what order should the nurse perform the following actions? (Arrange the steps from first to last)

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Answer

First assist the client to a supine position, then elevate the legs for 15 to 30 minutes to reduce edema. Next, measure the leg for accurate sizing, invert the stocking down to the heel, and finally apply it smoothly up the leg.
The precise sequencing of anti-embolism stocking application is critical for clients who have been in a dependent position (sitting or standing). Gravity causes venous pooling and dependent edema. If the stockings are measured or applied immediately, they will be incorrectly sized and will trap the fluid. Therefore, the nurse must first assist the client to bed and elevate the legs for 15 to 30 minutes to promote venous return. Only after the edema has resolved should the nurse measure the leg, prepare the stocking by turning it inside out to the heel, and smoothly roll it on to ensure safe, effective compression.

Step-by-Step Solution

1
Assist the client to a supine position.
The client is safely positioned in bed.
A supine position is the mandatory prerequisite for initiating the venous return process and applying the stockings.
2
Elevate the legs for 15 to 30 minutes.
Dependent edema resolves and venous pooling decreases.
Applying stockings over edematous legs traps fluid in the interstitial spaces; elevating the legs first reverses gravity-induced pooling from sitting.
3
Measure the leg dimensions.
The correct stocking size is identified.
Measurements must reflect the true baseline size of the leg, which can only be obtained after dependent swelling has subsided.
4
Invert the stocking down to the heel.
The stocking is prepared for the foot.
This specific technique allows the nurse to securely position the heel before applying the tighter remainder of the stocking.
5
Roll the stocking up the leg smoothly.
The stocking applies graduated compression without wrinkles.
Wrinkles or bunched fabric can create a tourniquet effect, completely obstructing venous return and causing tissue ischemia.

Key Concept

Application of anti-embolism stockings and management of dependent edema
Estimated Time:1m 30s
Question 290Question →

A practical nurse accidentally drops a glass medication ampule on the floor, causing it to shatter. To prevent injury and manage the hazard safely, arrange the following actions in the correct chronological sequence.

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Answer

The correct sequence is to first secure the immediate area, then put on protective gloves, use a broom and dustpan to sweep up the glass, and finally dispose of the fragments in a rigid sharps container.
Safe hazard management dictates a specific order of operations: protect the public, protect oneself, mitigate the hazard safely, and dispose of it properly. Securing the area ensures no immediate harm comes to others. Donning gloves provides essential personal protection. Using a dustpan avoids hand-to-glass contact, and using a sharps container ensures the hazard does not injure waste disposal personnel.

Step-by-Step Solution

1
Secure the area.
Prevents immediate accidental injury to bystanders.
Restricting access is the first step in hazard management to stop anyone from unknowingly interacting with the danger.
2
Don utility gloves.
Protects the nurse's hands.
Personal protective equipment must be worn before retrieving cleaning tools or getting close to the hazardous material.
3
Sweep up fragments with a broom and dustpan.
Safely gathers the broken glass without direct contact.
Mechanical means must always be used to collect broken glass to eliminate the risk of accidental cuts.
4
Dispose of glass in a sharps container.
Eliminates the hazard entirely.
Puncture-resistant containers contain the sharp objects safely, preventing subsequent injuries during waste management.

Key Concept

Hazard Management and Sharp Object Safety
Question 291Question →

A practical nurse (PN) is managing the care of a client with right-sided hemiparesis who is preparing for transfer to an inpatient rehabilitation facility. Arrange the PN's collaborative, delegatory, and care coordination actions in the most appropriate chronological order.

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Answer

The correct sequence begins with data collection, followed by interprofessional communication, RN collaboration for care plan modification, AP delegation, and concludes with documentation of the client's response.
The correct chronological order strictly adheres to the clinical nursing process and respects the legal boundaries of the PN/VN scope of practice. The PN must first collect independent data before presenting it to the interprofessional team. Once the team provides recommendations, the PN must collaborate with the RN to update the formal care plan, because independent care plan modification is outside the PN scope. Only after the care plan is updated can the PN safely and legally delegate the specific, approved transfer techniques to the Assistive Personnel (AP). Finally, the PN evaluates and documents the outcome of these delegated actions.

Step-by-Step Solution

1
Perform focused data collection.
Current baseline functional mobility is established.
Accurate, current data is required before any care coordination or interprofessional reporting can occur.
2
Report findings to the interprofessional team.
The team receives the necessary data to formulate rehabilitation recommendations.
Effective transition of care relies on shared, up-to-date client information.
3
Collaborate with the RN.
The nursing care plan is legally and safely updated.
The PN contributes to the care plan, but formal modifications require RN collaboration and oversight.
4
Delegate to the AP.
The AP receives clear instructions on new transfer techniques.
Safe delegation under NCSBN guidelines requires an established, updated care plan outlining the authorized interventions.
5
Document the client's response.
The effectiveness of the interventions is recorded in the electronic health record.
Documentation represents the evaluation phase, completing the cycle of care coordination.

Key Concept

The practical nurse's role in care coordination emphasizes sequential data collection, interprofessional communication, adherence to scope of practice regarding care plan modification, and safe delegation based on established plans.
Question 292Question →

A practical nurse is preparing to safely transfer a client with left-sided hemiparesis (weakness) from the bed to a wheelchair. To prevent injury to both the client and the nurse, arrange the following steps in the correct chronological order. (Place the first action at the top and the final action at the bottom).

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Answer

The correct sequence requires prioritizing environmental safety first, preparing the client physiologically, applying safety equipment, prompting the client to stand using their strong side, and finally pivoting safely into the chair.
Safe transfer protocols dictate that the wheelchair must be placed on the client's unaffected (strong) side so the client can lead with their strength. Environmental safety, such as locking the wheels, must always precede physical movement. The client is then brought to a seated position to stabilize blood pressure and equipped with non-skid footwear and a gait belt. During the physical transfer, the client pushes up using their own strength to minimize the lifting strain on the nurse, followed by a controlled pivot to safely lower into the seat.

Step-by-Step Solution

1
Prepare the environment.
The wheelchair is locked and positioned on the client's strong side.
Ensures the destination is secure before attempting to move the client.
2
Position the client and apply footwear.
The client is dangling at the bedside wearing non-skid socks or shoes.
Prevents orthostatic hypotension and ensures traction to prevent falls.
3
Apply the gait belt.
A transfer belt is secured around the client's waist.
Provides a designated, secure hold for the nurse to safely control the transfer.
4
Assist to stand.
The client pushes up and bears weight on the unaffected right leg.
Promotes client independence and prevents back injury to the nurse.
5
Pivot and sit.
The client is safely seated in the wheelchair.
Completes the transfer smoothly without unsafe twisting motions.

Key Concept

Safe Client Transfer and Fall Prevention
Question 293Question →

A practical nurse enters a client's room and discovers a small fire in the bedside wastebasket. The client is in bed and receiving supplemental oxygen. In what order should the nurse perform the following actions? Arrange the actions from first to last.

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Answer

The correct sequence follows the RACE acronym: Rescue the client, Alarm the facility, Confine the fire, and Extinguish the fire.
The RACE acronym (Rescue, Alarm, Confine, Extinguish) dictates the exact sequence of mandatory actions during a fire. Client safety (Rescue) is always the first priority. Only after the client is out of immediate danger should the nurse alert others (Alarm), contain the hazard (Confine), and attempt to fight the fire (Extinguish).

Step-by-Step Solution

1
Rescue the client
The client is removed from immediate danger.
Life safety is always the highest priority during a fire emergency, particularly when oxygen is in use in the immediate vicinity.
2
Alarm the facility
Emergency responders and other facility staff are notified.
Activating the alarm ensures that help is on the way to manage the emergency and initiate facility-wide protocols.
3
Confine the fire
The fire and smoke are contained to the room of origin.
Closing doors and windows minimizes airflow, reducing the fire's oxygen supply and protecting the rest of the facility from smoke inhalation hazards.
4
Extinguish the fire
The small fire is put out if it is safe to do so.
Once people are safe, the alarm is sounding, and the area is secured, a fire extinguisher can be used on small, manageable fires.

Key Concept

Emergency Fire Response (RACE Protocol)
Question 294Question →

A practical nurse (PN) is caring for an adult client who expresses deep dissatisfaction with the care provided by a nursing assistant on the previous shift. The client states, "I am very upset and I want to file a formal complaint." Arrange the actions the PN should take in the correct chronological order to advocate for the client's rights. (Place the first action at the top and the last action at the bottom.)

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Answer

The correct sequence is to first listen to the client's concerns, then explain the grievance process and provide forms, followed by notifying the nursing supervisor, and finally documenting the event.
Advocating for a client who wishes to file a grievance follows the nursing process: first assess and listen, then implement interventions (informing and assisting), report to the appropriate authority, and finally document the entire sequence of events.

Step-by-Step Solution

1
Prioritize therapeutic communication.
The PN actively listens to the client.
Validating the client's concerns builds trust and clarifies the issue.
2
Empower the client.
The PN explains the grievance process and provides forms.
Clients have the right to file complaints without retaliation; the PN facilitates this right.
3
Report through the chain of command.
The PN notifies the nursing supervisor.
Management must be aware of client dissatisfaction to investigate and intervene appropriately.
4
Complete documentation.
The PN records the event in the client's chart.
Accurate, timely documentation serves as a legal record of the client's status and nursing actions.

Key Concept

Client Rights: Grievance Process and Advocacy
Question 295Question →

While floating to an isolation unit, a nurse gathers supplies to administer medications to a client diagnosed with disseminated herpes zoster. Arrange the following steps for donning personal protective equipment (PPE) in the correct chronological order.

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Answer

The correct chronological sequence for donning PPE is: hand hygiene, isolation gown, N95 respirator, goggles or face shield, and finally clean gloves.
Following the standardized Centers for Disease Control and Prevention (CDC) sequence for donning personal protective equipment is essential to ensure a continuous barrier and prevent contamination. Hand hygiene must always occur first. The gown covers the largest surface area and goes on next. The N95 respirator follows to establish an airtight seal against the face. Eye protection is then applied to cover remaining facial exposure without disrupting the mask. Gloves are applied last to seal the wrists by overlapping the gown cuffs.

Step-by-Step Solution

1
Perform hand hygiene
Hands are decontaminated.
Prevents the transfer of existing microorganisms onto the clean PPE.
2
Apply the isolation gown
The nurse's torso and clothing are fully covered.
Establishes the primary body barrier first.
3
Apply the N95 respirator
The airway is protected from airborne particles.
Must be secured directly to the face for a proper fit test and seal.
4
Apply goggles or a face shield
The mucous membranes of the eyes are protected.
Fits safely over the top of the respirator without compromising its seal.
5
Apply clean gloves
Hands and wrists are fully protected.
Done last so the glove openings can be stretched over the gown cuffs, leaving no exposed skin.

Key Concept

Standard CDC Sequence for Donning Personal Protective Equipment
Question 296Question →

During a scheduled home health visit, a practical nurse (PN) observes a family caregiver aggressively grab an older adult client by the arms and shout threats at them. The client appears frightened and is trembling. Arrange the following actions the PN should take in the correct priority order. (Place the highest priority action first.)

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Answer

The PN must first intervene to ensure safety, then assess the client, notify the clinical supervisor, report to protective services, and finally document the event.
In any scenario involving active abuse or an immediate threat, the nurse must prioritize actions based on Maslow's hierarchy of needs and the nursing process. The absolute first priority is to secure the client's safety by stopping the active abuse. Second, the nurse must assess the client for injuries (Assessment). Third, the nurse informs the chain of command (Implementation/Communication) to ensure agency protocols are initiated. Fourth, the nurse fulfills the legal duty of being a mandated reporter by contacting adult protective services. Finally, the nurse documents the entire event objectively in the medical record, which is always the final step in managing an acute incident.

Step-by-Step Solution

1
Intervene immediately to separate the caregiver from the client.
The active physical and emotional threat to the client is stopped.
Immediate physical safety is the highest priority when active abuse is witnessed, superseding all other actions.
2
Perform a physical assessment to check the client for acute injuries.
Objective clinical data regarding the client's physical status is collected.
The nursing process requires assessing the client for injuries immediately after securing their environment to determine if emergency medical care is needed.
3
Notify the home health agency clinical supervisor about the incident.
The chain of command is activated to support the nurse and client.
Agency leadership must be aware of critical safety incidents to ensure proper protocols are followed and alternate caregivers or immediate discharge planning is arranged.
4
Submit a formal report to the state adult protective services agency.
Legal obligations for mandatory reporting are fulfilled.
Nurses are mandated reporters and are legally required to report suspected or observed elder abuse to state protective authorities in a timely manner.
5
Document the objective observations and reporting actions in the clinical record.
A permanent, legal account of the incident and nursing interventions is created.
Thorough documentation is essential for legal and continuity of care purposes, but it always follows direct client care and urgent reporting tasks.

Key Concept

Mandatory reporting and clinical prioritization of client safety in cases of active abuse.
Question 297Question →

A practical nurse (PN) is preparing to delegate a routine daily care task to an assistive personnel (AP). In what order should the PN perform the following steps to ensure safe delegation? Arrange the actions in the correct chronological sequence.

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Answer

Determine appropriateness, communicate instructions, verify comprehension, and evaluate the outcome.
Safe delegation follows a specific sequence. First, the nurse determines if the task is appropriate (Right Task/Circumstance). Second, the nurse provides clear directions (Right Communication). Third, the nurse verifies the AP's understanding of those directions. Finally, after the task is completed, the nurse evaluates the outcome (Right Supervision/Evaluation).

Step-by-Step Solution

1
Identify the correct sequence for delegation based on the NCSBN Five Rights of Delegation.
The first step is determining if the task is right for the AP.
Client safety requires confirming the task is within the AP's scope and the client is stable.
2
Determine the next action after task appropriateness is established.
The PN must give clear instructions.
Proper communication ensures the AP knows exactly what is expected.
3
Identify the action that immediately follows giving instructions.
The PN verifies the AP's understanding.
Confirming comprehension prevents misunderstandings and potential harm.
4
Identify the final step in the delegation process.
The PN evaluates the task completion.
The PN remains accountable for the task and must ensure it was completed appropriately.

Key Concept

The delegation process requires sequential adherence to the Five Rights of Delegation: identifying the right task and circumstance, providing right direction/communication, and ensuring right supervision/evaluation.
Question 298Question →

A practical nurse (PN) enters a client's room on a rehabilitation unit and witnesses an unlicensed assistive personnel (UAP) holding a client firmly by the wrists. The UAP states, "If you do not get up for a shower right now, you will not get any breakfast." The client is visibly distressed and attempting to pull away. In what order should the PN perform the following actions? Arrange them from highest priority (first) to lowest priority (last).

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Answer

The correct sequence is to first instruct the UAP to release the client, direct the UAP to leave the room, evaluate the client for injuries, notify the charge nurse, and finally document the objective observations.
In situations involving suspected abuse or immediate threats to client safety, the nurse's first action must always be to intervene and stop the harm. Next, securing the environment by removing the offending staff member ensures ongoing safety. Only after the environment is safe can the nurse accurately and effectively assess the client for injuries. Once the client's medical and emotional needs are addressed, the nurse fulfills mandated reporting obligations by notifying leadership. Finally, objective documentation of the event is completed to create a legal record.

Step-by-Step Solution

1
Intervene immediately to stop the abuse.
The physical hold is broken, addressing the most immediate threat.
Client safety is the immediate priority. Active harm or rights violations must be halted instantly.
2
Remove the perpetrator from the environment.
The UAP leaves the room, securing the immediate area.
The client cannot be properly assessed or feel safe while the abuser is still present in the room.
3
Assess the client.
The client's physical and emotional status are evaluated.
Once safety is established, the PN must determine if medical intervention is needed for physical injuries.
4
Report the incident.
The charge nurse and supervisor are informed.
Nurses are mandated reporters. Leadership must be involved to initiate an investigation and protect other clients.
5
Document the incident.
An objective record of the event is created.
Accurate, factual documentation is legally required but must occur only after the client is safe and leadership is aware.

Key Concept

Prioritization in suspected abuse and client rights violations emphasizes immediate physical safety, removal of the threat, patient assessment, and subsequent administrative reporting.
Question 299Question →

An assistive personnel (AP) has recently joined the staff on a long-term care unit. The assigned practical nurse (PN) must delegate several daily hygiene and mobility procedures to the AP. Arrange the following actions by the PN in the proper chronological order to safely execute the delegation process.

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Answer

The correct sequence follows the Five Rights of Delegation: 1) Gather data on client stability, 2) Verify AP competency, 3) Communicate expectations and parameters, 4) Monitor task performance, and 5) Evaluate outcomes and data.
The delegation process must follow a logical, step-by-step sequence based on the National Council of State Boards of Nursing (NCSBN) Five Rights of Delegation. The PN must first determine if the task is appropriate for the client's current condition (Right Task/Circumstance). Next, the PN verifies that the specific AP is competent to perform the task (Right Person). Once the right task and person are established, the PN provides clear, direct instructions (Right Direction). While the task is underway, the PN monitors the AP to ensure safety (Right Supervision). Finally, the PN evaluates the client's response and reviews the completed task (Right Evaluation).

Step-by-Step Solution

1
Determine the initial requirement for safe delegation.
Assess the client's current health stability.
The 'Right Task' and 'Right Circumstance' mandate that the client must be stable and the task must not require independent nursing judgment before any delegation can occur.
2
Identify who is appropriate to perform the tasks.
Confirm the AP's training and competence.
The 'Right Person' principle requires the PN to verify that the individual has the legal authority and documented skills to perform the specific procedures safely.
3
Relay the assignment details to the selected team member.
Provide specific instructions, expectations, and reporting parameters to the AP.
The 'Right Direction and Communication' principle ensures the AP knows exactly how to complete the task and when to notify the PN of any clinical changes.
4
Ensure the tasks are executed properly during the shift.
Observe and supervise the AP's ongoing performance.
The 'Right Supervision' principle maintains the PN's accountability by requiring ongoing monitoring to guarantee client safety during care delivery.
5
Conclude the delegation process.
Review the AP's documentation and evaluate the client's response.
The 'Right Evaluation' principle dictates that the PN must assess the overall outcomes of the delegated tasks to inform future care planning.

Key Concept

The Five Rights of Delegation: Right Task, Right Circumstance, Right Person, Right Direction/Communication, and Right Supervision/Evaluation.
Question 300Question →

A practical nurse (PN) completes care for a client placed on droplet and contact precautions. The PN is preparing to exit the client's room. Arrange the following steps for removing (doffing) the required personal protective equipment (PPE) in the correct chronological sequence.

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Answer

The correct chronological sequence for doffing PPE is: removing gloves, removing the face shield, removing the gown, removing the surgical mask, and finally performing hand hygiene.
The standardized CDC doffing sequence is systematically designed to remove the most heavily contaminated items first while maintaining critical protection for the mucous membranes until the very end. Gloves are removed first, followed by eye protection, the gown, and finally the mask, concluding with immediate hand hygiene.

Step-by-Step Solution

1
Remove gloves.
The most contaminated items are safely discarded.
Prevents the transfer of pathogens to other surfaces or the face during subsequent doffing steps.
2
Remove face shield.
Eye protection is removed without touching the contaminated front.
The front of the shield may harbor infectious droplets; handling only the clean back straps ensures safety.
3
Remove gown.
The gown is bundled inside out and safely discarded.
Rolling the gown inside out traps infectious material within the bundle, preventing contamination of the underlying uniform.
4
Remove surgical mask.
The mask is removed by the elastic ties only.
Retaining the mask until the end protects the respiratory tract from potential aerosols generated while removing the gown or gloves.
5
Perform hand hygiene.
Hands are thoroughly sanitized.
This crucial final step eliminates any pathogens that may have contacted the skin during the removal procedure.

Key Concept

Standard Sequence for Removing (Doffing) Personal Protective Equipment
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