Examkin

All practice questions

636 questions

All types2,933Multiple choice1,506Multiple select653Numeric68Matching70Ordering636
Question 301Question →

A practical nurse has finished providing care to a client placed on contact and droplet precautions. Arrange the steps for removing personal protective equipment (PPE) in the correct sequence to prevent self-contamination before exiting the room.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence for PPE removal (doffing) is: gloves, followed by protective eyewear, then the isolation gown, and finally the surgical mask.
The standard sequence for removing PPE prioritizes removing the most contaminated items first while continually protecting the mucous membranes. Gloves are the most soiled and are removed first. Next, eyewear is removed handling only the clean straps. The gown is then removed and rolled inside-out. The mask is always removed last to ensure the respiratory tract remains protected throughout the entire doffing procedure.

Step-by-Step Solution

1
Remove gloves.
The most heavily contaminated items are safely disposed of.
This prevents the transfer of pathogens from the hands to the face or clean areas of other PPE.
2
Remove protective eyewear.
Eye protection is safely taken off without facial contamination.
With clean hands, the nurse can safely touch the uncontaminated back straps or earpieces.
3
Remove the isolation gown.
The gown is bundled and disposed of safely.
Rolling the gown inside-out contains any infectious material from the front and sleeves.
4
Remove the surgical mask.
The respiratory protection is taken off last.
The mask remains in place to prevent the inhalation of any aerosolized particles that might have been generated while removing the other PPE items.

Key Concept

Proper sequence for removing Personal Protective Equipment (PPE)
Question 302Question →

A client is placed on a stretcher for transport to the surgical suite for an elective procedure. The client has already signed the informed consent document. Suddenly, the client becomes highly anxious, tearful, and states, 'I cannot go through with this. I changed my mind.' The practical nurse (PN) is present in the room. In which order should the PN perform the following actions? (Arrange from first to last)

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first halt the transport, then validate the client's intent, notify the provider and charge nurse, remain at the bedside for support, and finally document the event.
The practical nurse must act immediately as the client's advocate to prevent battery by stopping the transport. Following this, validating the client's statement ensures it is a true revocation rather than transient anxiety. The provider must then be notified, as it is outside the PN's scope to cancel the surgery or discuss alternatives. The PN provides continuous emotional support until the provider arrives, and concludes the process by thoroughly documenting the client's exact words and the actions taken.

Step-by-Step Solution

1
Halt the transport process.
Prevents the client from being taken to the operating room against their newly expressed wishes.
Immediate action is required to uphold the client's right to refuse treatment and prevent battery.
2
Validate the client's statement.
Confirms that the client genuinely wishes to revoke consent rather than merely expressing anxiety.
The PN must clearly differentiate between preoperative fear and a definitive refusal of treatment before escalating the situation.
3
Notify the provider and charge nurse.
Informs the chain of command and the responsible physician of the revoked consent.
The operating provider has the legal responsibility to discuss the consequences of refusal and officially cancel the procedure.
4
Remain with the client to offer support.
Maintains a therapeutic environment while waiting for the provider.
The client is in a vulnerable state; abandoning them to document would compromise psychosocial safety.
5
Document the event in the medical record.
Creates a legal record of the revocation and actions taken.
Accurate, timely documentation of the client's exact words and the provider notification is a strict legal requirement, but it follows active client care.

Key Concept

Client Autonomy and Revocation of Informed Consent
Question 303Question →

A practical nurse (PN) receives the shift assignment on a step-down unit and notes they have been assigned a client who requires continuous titration of an intravenous (IV) vasopressor. Titrating this medication is outside the legal scope of practice for a PN. Arrange the following actions the PN should take to safely resolve this assignment in the correct chronological order.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first identify the scope limitation, immediately notify the charge nurse, collaboratively propose a safe alternative, escalate to the supervisor if the charge nurse refuses to change the assignment, and finally document the entire process.
When faced with an assignment outside their scope of practice, the PN must sequentially: identify the limitation, inform the delegator (charge nurse), collaborate on an alternative, escalate via the chain of command if the issue is unresolved, and document the event. This sequence ensures client safety while maintaining professional and legal standards.

Step-by-Step Solution

1
Identify the scope limitation.
The PN recognizes that titrating IV vasopressors is illegal for their licensure.
Nurses must continually evaluate assignments against their state Nurse Practice Act.
2
Notify the charge nurse.
The charge nurse is made aware that the PN cannot legally or safely care for the client.
The delegator must be informed immediately so they can adjust the assignment before care is delayed.
3
Propose alternatives.
The PN offers solutions, such as swapping clients with an RN.
Collaboration promotes teamwork and ensures the client's needs are met by qualified personnel.
4
Escalate if necessary.
The nursing supervisor is contacted if the charge nurse fails to act safely.
The chain of command must be utilized when lower-level leadership fails to provide a safe practice environment.
5
Document the incident.
An objective record of the situation is created.
Documentation protects the nurse legally and provides a record for quality improvement.

Key Concept

Nurses are legally accountable for accepting only those assignments that fall within their scope of practice and for utilizing the chain of command to resolve unsafe assignments.
Question 304Question →

A practical nurse (PN) receives shift hand-off report for four assigned mother-baby couplets on a postpartum unit. In what order should the PN prioritize evaluating these clients? Arrange the clients from highest priority (first) to lowest priority (last).

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The PN should first evaluate the client with sudden shortness of breath, followed by the client with the boggy fundus, then the client with severe afterpains, and finally the client requiring discharge teaching.
Prioritization requires the nurse to first address life-threatening conditions using the Airway, Breathing, and Circulation (ABC) framework. The client with shortness of breath and impending doom is displaying signs of a pulmonary embolism (Breathing), making them the highest priority. The client with the boggy, deviated fundus is at immediate risk for postpartum hemorrhage (Circulation) and is seen second. Once ABCs are stabilized, acute issues such as severe pain are addressed third. Finally, routine and stable interventions, such as reinforcement of discharge teaching, are completed last.

Step-by-Step Solution

1
Apply the Airway, Breathing, Circulation (ABC) priority framework to identify the most critical client.
The client with sudden shortness of breath and impending doom has a critical breathing compromise (suspected pulmonary embolism).
Airway and breathing emergencies pose the most immediate threat to life and are always the highest priority.
2
Evaluate the remaining clients for circulatory threats or physiological instability.
The client with a boggy, deviated fundus is at high risk for postpartum hemorrhage.
Uterine atony is a circulatory emergency that requires immediate intervention (such as fundal massage and assisting to void) immediately after airway and breathing threats are secured.
3
Assess the remaining stable clients to distinguish between acute symptoms and routine care needs.
The client with severe afterpains requires prompt medication administration.
Acute pain management takes precedence over routine educational tasks or predictable daily care.
4
Assign the lowest priority to routine, predictable, and non-urgent tasks.
The client needing reinforcement of newborn bathing education is evaluated last.
Discharge teaching is a stable, non-urgent task that can be scheduled flexibly around acute care needs.

Key Concept

Client Care Prioritization using ABCs and Maslow's Hierarchy
Question 305Question →

An agency nurse is getting ready to enter the room of a newly admitted pediatric client requiring full personal protective equipment (PPE). Arrange the steps for putting on the required PPE in the correct chronological sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence for donning full PPE is: Gown, Mask, Eyewear or Face shield, and finally Gloves.
According to standardized infection control guidelines from the CDC, the proper sequence for donning (putting on) personal protective equipment is to first apply the gown to cover the torso and arms. Next, the mask is secured to protect the respiratory tract, followed by goggles or a face shield to protect the eyes. Finally, the gloves are applied last so that the cuffs can be pulled securely over the sleeves of the isolation gown, ensuring continuous protection without gaps.

Step-by-Step Solution

1
Don the isolation gown.
The nurse's torso and arms are protected.
Applying the gown first provides the largest area of coverage before securing smaller facial items.
2
Apply the surgical mask.
The respiratory tract is protected.
The mask must be secured before eye protection to ensure a proper fit over the bridge of the nose.
3
Put on protective eyewear or a face shield.
The mucous membranes of the eyes are protected.
Eyewear easily fits over the top edge of the mask.
4
Don clean gloves.
The hands and wrists are protected.
Gloves go on last so they can be pulled tightly over the gown's cuffs to prevent skin exposure.

Key Concept

Standard and Transmission-Based Precautions
Question 306Question →

A client receiving intravenous antibiotics for a severe skin infection unplugs their infusion pump, puts on street clothes, and states, 'I am going home right now.' Arrange the following actions the practical nurse (PN) should take in the correct chronological order.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

First, inquire about the client's reasons. Second, notify the charge nurse and provider. Third, reinforce the provider's explanation of risks. Fourth, witness the AMA signature. Finally, document the event.
The correct sequence prioritizes the nursing process and client advocacy. Gathering data by asking the client why they want to leave comes first. Communication with the healthcare team follows so the provider can address medical risks. The PN then reinforces the provider's teaching. If the client still wishes to leave, witnessing the AMA form ensures legal compliance, followed by comprehensive documentation of the entire event.

Step-by-Step Solution

1
Determine the first action based on the nursing process.
Inquiring about the client's reasons for wanting to leave.
Gathering data is always the initial step. Understanding why the client wants to leave may reveal a problem that the nursing staff can resolve, such as uncontrolled pain or anxiety.
2
Identify the need for collaboration and escalation.
Notifying the charge nurse and healthcare provider.
Leaving against medical advice is a significant safety risk. The healthcare provider must be informed so they can evaluate the client and legally disclose the specific medical consequences of leaving.
3
Determine the practical nurse's role in client education.
Reinforcing the provider's explanation of the health risks.
While the healthcare provider is responsible for the initial disclosure of medical risks, the PN acts as an advocate by reinforcing this information and ensuring the client fully comprehends the consequences.
4
Address the legal requirements if the client refuses to stay.
Witnessing the client's signature on the Against Medical Advice (AMA) form.
If the client remains resolute in their decision to leave, the facility must have legal documentation proving that the client was informed of the risks and chose to leave anyway.
5
Complete the nursing responsibilities for the encounter.
Documenting the entire event in the medical record.
Accurate, factual, and objective documentation of the client's statements, notifications made, education reinforced, and forms signed is legally required.

Key Concept

Client Rights and Advocacy during Refusal of Care
Question 307Question →

A practical nurse (PN) is preparing to administer a scheduled investigational medication to a client participating in a clinical trial. The client refuses the dose, stating, "I changed my mind. I do not want to be in this study anymore, but I am terrified the hospital will stop treating my cancer if I quit." In which order should the PN perform the following actions to advocate for this client's rights? Arrange the actions in the correct chronological sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first withhold the medication, then reassure the client, next notify the healthcare team, and finally document the event.
The nursing process and prioritization frameworks dictate that immediate physical safety (withholding unwanted treatment) comes first. This is followed by immediate psychosocial intervention (reassuring a terrified client). Once the client is stabilized physically and emotionally, the nurse communicates with the team (chain of command) to update the care plan. Finally, the nurse documents the events as a retrospective administrative task.

Step-by-Step Solution

1
Withhold the administration of the investigational medication.
The unwanted treatment is prevented.
Protects the client's immediate right to refuse treatment and withdraw informed consent at any time.
2
Reassure the client that withdrawing from the study will not compromise their standard medical care.
The client's fear of abandonment is alleviated.
Advocacy requires addressing immediate psychological distress and supporting the client's autonomous decisions without coercion.
3
Notify the charge nurse and the healthcare provider of the client's decision.
The interdisciplinary team is made aware of the status change.
Facilitates the prompt transition back to the standard therapeutic regimen.
4
Document the client's exact statements and the refusal in the health record.
A formal legal and medical record is created.
Fulfills professional and legal standards of nursing practice after immediate clinical needs are met.

Key Concept

Client right to refuse treatment and withdraw informed consent without penalty
Question 308Question →

A vocational nurse is assigned to care for a resident in a long-term care facility who has been placed on droplet and contact precautions due to a confirmed adenovirus infection. The nurse is preparing to enter the room to assist with morning hygiene and feeding. Arrange the following steps for donning the required personal protective equipment (PPE) in the correct chronological sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence for donning personal protective equipment is: gown, mask, goggles or face shield, and finally gloves.
According to standardized infection control guidelines, the proper sequence for donning personal protective equipment is to start with the gown, followed by the mask or respirator, then goggles or a face shield, and finally the gloves. This sequence ensures that all clothing and mucous membranes are protected systematically and allows the gloves to form a continuous barrier by overlapping the gown cuffs.

Step-by-Step Solution

1
Put on the isolation gown.
The torso and arms are covered.
The gown is large and bulky, making it the most logical first step before applying facial protection.
2
Apply the surgical mask.
The airway and mucous membranes of the nose and mouth are protected.
The mask is placed before eye protection so the mask edges do not interfere with the placement of goggles or a face shield.
3
Don the eye protection.
The eyes are shielded from potential splashes or respiratory droplets.
Goggles or a face shield are placed over the mask to seal the facial area.
4
Put on clean gloves.
The hands are protected and the gown cuffs are secured.
Gloves are applied last to ensure they can be pulled over the gown sleeves for complete continuous coverage.

Key Concept

Donning sequence for Personal Protective Equipment (PPE)
Question 309Question →

A practical nurse (PN) working in a subacute care facility observes a colleague exhibiting an unsteady gait, slurred speech, and an odor of alcohol while preparing oral medications. The colleague states, 'I just need to finish passing these medications.' Arrange the following actions the PN should take in the correct order of priority.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct priority sequence is to first intervene to prevent the administration of medications, then notify the nursing supervisor, followed by verifying that another nurse has assumed client care, and finally documenting the objective observations in an incident report.
The correct sequence follows standard nursing prioritization frameworks: immediate physiological safety of the client comes first (stopping the medication administration). Once safety is secured, the nurse must utilize the chain of command to manage the impaired staff member. Following this, the unit must ensure safe continuity of care (reassigning clients). Finally, detailed legal documentation is completed once the clinical situation is stabilized.

Step-by-Step Solution

1
Assess the immediate risk to clients and intervene directly with the colleague.
The colleague is prevented from interacting with clients or administering potentially fatal incorrect medications.
According to Maslow's hierarchy of needs and basic safety principles, protecting clients from immediate physical harm is always the absolute highest priority.
2
Escalate the situation through the appropriate chain of command.
The nursing supervisor is alerted to the impaired nurse.
Facility management must be involved immediately to formally remove the impaired nurse from the premises and arrange for mandatory drug/alcohol screening.
3
Ensure continuity of care for the affected clients on the unit.
Medication administration and treatments are reassigned to a competent nurse.
Clients cannot be left without care; ensuring a safe handoff prevents legal liability for client abandonment.
4
Complete formal administrative documentation.
An objective, factual incident or variance report is filed.
Legal and ethical guidelines require non-judgmental documentation of the event for internal investigation and potential mandatory reporting to the State Board of Nursing.

Key Concept

Prioritization in Mandatory Reporting of Impaired Practice
Question 310Question →

A practical nurse (PN) is preparing to apply bilateral soft wrist restraints to a client to prevent the removal of essential medical devices. In what order should the PN perform the following actions? Arrange the steps in the correct chronological sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: Verify the prescription, explain the purpose, pad and apply the restraints, secure to the movable bed frame, and assess distal neurovascular status.
The proper application of restraints follows a strict legal and safety protocol. The nurse must first confirm the legal prescription. Next, psychosocial needs are addressed through explanation. Then, the physical application occurs with skin protection (padding). Once on the client, they must be safely anchored to a movable bed frame using a quick-release knot. Finally, the nurse must immediately evaluate for any circulatory or neurological impairment caused by the devices.

Step-by-Step Solution

1
Verify the healthcare provider's prescription.
Legal and facility requirements are met.
Restraints are a prescription intervention and cannot be applied without a valid provider order.
2
Explain the purpose of the restraints.
The client and family are informed.
Communication promotes cooperation and reduces psychosocial distress before physical contact is made.
3
Pad the wrists and apply the restraints.
The restraints are physically placed on the client.
Proper padding is necessary to prevent skin breakdown and friction injuries.
4
Secure the straps to the movable bed frame.
The restraints are safely anchored.
Attaching to the movable frame ensures the restraints move with the client when the bed is adjusted, preventing unintended tightening.
5
Assess distal pulses, skin color, and temperature.
Neurovascular status is confirmed to be intact.
Immediate assessment is required to ensure the restraints are not impeding blood flow or causing nerve damage.

Key Concept

Safe sequence for physical restraint application and monitoring.
Question 311Question →

While completing client rounds in a long-term care facility, a practical nurse (PN) observes an assistive personnel (AP) attempting to increase the flow rate on a client's continuous enteral feeding pump. Arrange the following actions the PN should take in the correct chronological order of priority.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence prioritizes immediate client safety, physiological assessment, equipment correction, staff education, and administrative escalation.
In any clinical situation where an unauthorized or unsafe action is observed, the nursing process dictates a specific priority hierarchy. The nurse must first intervene directly to stop the action and prevent harm. Immediately following, the nurse must perform data collection on the client to identify if any injury has already occurred. Once the client is deemed safe, the therapeutic environment is restored (verifying and resetting the pump). Only after client safety is fully secured does the nurse address the interpersonal and administrative tasks of educating the personnel and reporting the breach to the supervising registered nurse.

Step-by-Step Solution

1
Stop the unsafe action.
The AP ceases altering the enteral feeding pump.
Halting the action immediately prevents further potential harm to the client.
2
Collect client data.
The client's physiological status is determined.
Assessing the client identifies if any adverse effects, such as fluid overload, nausea, or aspiration, have already occurred.
3
Restore prescribed settings.
The enteral feeding continues at the correct rate.
Correcting the equipment ensures the client receives the precise nutritional therapy ordered by the healthcare provider.
4
Educate the assistive personnel.
The AP understands their scope limitations.
Immediate feedback prevents future occurrences and clarifies that regulating tube feedings requires nursing judgment and cannot be delegated.
5
Report the incident.
The supervising RN is informed.
Escalating the issue ensures appropriate facility protocols, documentation, and further disciplinary or educational actions are managed by administration.

Key Concept

Prioritization of Care and Delegation Boundaries
Question 312Question →

A practical nurse (PN) accidentally drops a glass collection bottle containing a client's pleural fluid, which shatters and creates a biohazardous spill in a high-traffic unit hallway. Arrange the following actions in the correct priority order to safely manage this hazard.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first isolate the area, then don personal protective equipment (PPE), use a mechanical device to collect the broken glass, deposit the glass into a sharps container, and finally cover the remaining fluid with absorbent pads and disinfectant.
Managing a complex biohazardous spill involving broken glass requires a systematic, prioritized approach to safety. The immediate action is always to isolate the area to prevent injury or cross-contamination by others. Next, the nurse must protect themselves by donning appropriate PPE. Once protected, the physical sharps hazard (glass) must be removed using mechanical means (never by hand) to prevent percutaneous injury. The glass is immediately placed in a sharps container. Finally, once the sharps are cleared, the remaining liquid is absorbed and the area is chemically decontaminated.

Step-by-Step Solution

1
Isolate the immediate area and instruct clients and staff to avoid the spill location.
The spill perimeter is secured.
The absolute first priority in any acute hazard management scenario is securing the environment. This prevents other individuals from walking through the spill, which could result in falls, percutaneous injuries from unseen glass, or the tracking of bloodborne pathogens throughout the facility.
2
Don appropriate personal protective equipment (PPE), including gloves, a fluid-resistant gown, and a face shield.
The nurse is fully protected from biohazardous exposure.
Before physically interacting with the spill, the nurse must ensure their own safety by applying PPE to prevent mucosal or contact exposure to pleural fluid, which is a potentially infectious body fluid.
3
Use a mechanical device such as tongs or a disposable scoop to safely collect the shattered glass pieces.
The physical sharps hazard is safely collected without direct hand contact.
Occupational Safety and Health Administration (OSHA) standards explicitly dictate that contaminated broken glass must never be picked up by hand, even when wearing heavy-duty gloves. Mechanical devices are mandatory to prevent percutaneous exposure.
4
Deposit the collected glass fragments directly into a rigid, puncture-resistant sharps container.
The sharps hazard is permanently contained.
Broken glass must be placed immediately into a rigid, puncture-proof container to prevent downstream injuries to the nurse, other clients, or environmental services personnel.
5
Cover the remaining fluid with absorbent pads and saturate the area with an EPA-registered disinfectant.
The biohazardous fluid is absorbed and the floor is successfully decontaminated.
Only after the physical sharps hazard is fully removed should the nurse address the remaining biological liquid hazard by neutralizing it with absorbent materials and appropriate chemical disinfectants.

Key Concept

Biohazardous Spill and Sharps Management
Question 313Question →

A practical nurse (PN) at a community pediatric clinic is collecting data on a toddler who presents with multiple bruises in various stages of healing. The caregiver's explanation of the injuries is inconsistent with the physical findings. Arrange the following actions in the order the PN should perform them to comply with legal and ethical standards.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence prioritizes immediate client safety, followed by objective data collection, utilization of the chain of command, fulfilling mandated reporting laws, and finally, comprehensive legal documentation.
In any scenario involving suspected abuse, the PN must first apply the nursing process and safety principles. Ensuring client safety is paramount (Step 1). Once safe, the PN collects objective data (Step 2) to have factual information. The PN then follows the chain of command (Step 3) before fulfilling the legal obligation of being a mandated reporter to the state (Step 4). Finally, documentation of all findings and actions completes the legal and ethical requirements (Step 5).

Step-by-Step Solution

1
Prioritize immediate client safety.
The child is placed in a secure environment within the clinic.
Client safety is the foundational step in any suspected abuse or emergency scenario.
2
Gather objective clinical data.
The PN accurately measures and describes the bruises.
Accurate physical details are required for an effective report and must be collected while the client is present.
3
Utilize the chain of command.
The supervising healthcare provider is informed of the situation.
Facility protocols require informing supervisors of critical safety or legal concerns immediately.
4
Fulfill legal mandated reporting obligations.
A report is filed with state child protective services.
Practical nurses are mandated by law to report suspected child abuse to authorities; this duty cannot be ignored.
5
Complete legal documentation in the electronic health record.
All physical findings and the agency report reference number are documented.
The medical record must legally reflect the objective evidence and the steps taken to protect the client.

Key Concept

Mandatory Reporting and Prioritization in Suspected Abuse
Question 314Question →

A practical nurse (PN) working in a skilled nursing facility has just received the morning hand-off report for a group of assigned clients. Arrange the following clients in the order the PN should prioritize their care, from highest priority (first) to lowest priority (last).

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct priority sequence is: 1) The client with hypoglycemia, 2) The post-operative client in pain, 3) The client needing a tube feeding residual check, 4) The client awaiting discharge instructions.
Prioritization relies on addressing unstable, acute, or life-threatening physiological needs first. The client with symptomatic hypoglycemia requires immediate intervention to prevent severe complications. Once stabilized, the nurse addresses time-sensitive moderate needs, such as administering pain medication to the post-operative client before physical therapy. Routine physiological care, such as checking gastric residuals, follows. Finally, stable clients with psychosocial or educational needs, such as discharge teaching reinforcement, are seen last.

Step-by-Step Solution

1
Identify any life-threatening or acute physiological conditions using the ABCs (Airway, Breathing, Circulation) or safety frameworks.
The client with a blood glucose of 65 mg/dL and tremors is identified as the highest priority.
Symptomatic hypoglycemia is a metabolic emergency that can rapidly deteriorate if not treated immediately.
2
Evaluate the remaining clients for time-sensitive, moderate physiological needs.
The post-operative client requiring pain medication prior to physical therapy is identified as the second priority.
Pain management before a scheduled intervention (physical therapy) is crucial for participation and recovery.
3
Assess the remaining clients for routine physiological maintenance or assessment needs.
The client requiring a routine enteral feeding residual check is identified as the third priority.
Routine assessments are necessary for ongoing care but can safely wait until acute and time-sensitive needs are addressed.
4
Identify stable clients whose needs are primarily psychosocial, educational, or long-term.
The client needing reinforcement of discharge instructions is identified as the final priority.
Educational reinforcement for a stable client preparing for discharge is not time-critical and should be addressed last.

Key Concept

Prioritization of care based on acuity, physiological instability, and time sensitivity.
Question 315Question →

An LPN/LVN is preparing to leave the negative-pressure isolation room after bathing a client who has disseminated varicella zoster. The nurse is wearing full transmission-based personal protective equipment, including an N95 respirator, isolation gown, and gloves. Sequence the following actions to demonstrate the safest method for doffing the protective gear.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The safest doffing sequence is to first remove the gloves, followed by the gown inside the room. Next, exit the room and close the door. Then, remove the N95 respirator outside the room, and finally perform thorough hand hygiene.
The Centers for Disease Control and Prevention (CDC) guidelines require that PPE be removed in a manner that prevents self-contamination. For a client on Airborne and Contact precautions, all contact-related PPE (gloves and gown) must be removed inside the isolation room. The nurse must then exit the room and close the door to maintain the negative-pressure environment before removing the N95 respirator, which protects against airborne particles. Hand hygiene is always performed as the final step.

Step-by-Step Solution

1
Remove and discard the contaminated gloves inside the isolation room.
The most contaminated PPE is safely disposed of.
Removing gloves first prevents the highly contaminated hands from touching the nurse's body or clean areas of the gown during subsequent doffing steps.
2
Unfasten the isolation gown, pull it away from the shoulders, and roll it inside out for disposal.
The gown is safely removed without contaminating the nurse's uniform.
Contact precautions require the gown to be removed inside the room so that pathogens are not carried into the hallway.
3
Exit the negative-pressure room and ensure the door is fully closed.
The nurse transitions from the contaminated environment to a clean environment.
Airborne pathogens can escape if the door is left open, and the nurse must be in a clean environment before removing respiratory protection.
4
Take off the N95 respirator by lifting the bottom strap, then the top strap, without touching the front.
The respiratory protection is safely removed without self-contamination.
The front of the respirator is heavily contaminated with airborne particles; touching only the straps behind the head prevents transfer of infectious material.
5
Perform thorough hand hygiene using an alcohol-based hand rub or soap and water.
Any remaining pathogens on the nurse's hands are destroyed or washed away.
Hand hygiene is the mandatory final step of any PPE doffing procedure to ensure the nurse does not serve as a vector for infection.

Key Concept

Safe sequence for doffing personal protective equipment (PPE) for combined Airborne and Contact precautions.
Estimated Time:1m 30s
Question 316Question →

A practical nurse (PN) responds to a continuous bed alarm. Upon entering the room, the PN discovers a client experiencing acute delirium who has firmly grasped their pleural chest tube and is actively trying to remove it. The client is highly combative and cannot be verbally de-escalated. Arrange the following nursing interventions in the correct order of execution from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct priority sequence is to first physically protect the life-sustaining device, activate the call system for staff assistance, apply the emergency restraints with help, notify the healthcare provider for a clinical evaluation and formal prescription, and finally document the incident.
In life-threatening emergencies where a client is actively attempting to remove a critical medical device, the nurse's immediate priority is physiological safety. Physical interventions and restraints may be applied emergently without a prior prescription to prevent severe harm, provided the nurse obtains immediate assistance and the healthcare provider is notified directly afterward for a formal evaluation and order.

Step-by-Step Solution

1
Physically hold the client's hands.
Prevents the immediate removal of the chest tube.
Immediate physical safety and airway/breathing maintenance takes precedence over administrative requirements during a life-threatening emergency.
2
Activate the room's emergency call system.
Summons additional nursing staff to the room.
The PN cannot safely manage a combative client or apply restraints without assistance, which minimizes injury risk for both staff and the client.
3
Apply temporary bilateral soft wrist restraints.
Secures the client's extremities.
Restraints are applied as a last resort emergency measure to protect the client from self-harm when least restrictive measures (verbal de-escalation) have failed.
4
Contact the healthcare provider.
Initiates the legal prescription process.
Emergency restraints require an immediate provider evaluation and formal order (typically within 1 hour) to comply with legal and facility protocols.
5
Document the event and assessments.
Creates a legal and clinical medical record.
Thorough documentation of the precipitating behavior, lack of success with alternatives, and baseline neurovascular status is required after the client is safe.

Key Concept

Emergency Application of Physical Restraints
Question 317Question →

Before entering the room of a resident requiring contact and droplet precautions, a nurse gathers the necessary personal protective equipment (PPE). Arrange the following steps for putting on the PPE in the correct sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence for donning personal protective equipment is: Gown, Mask, Goggles, and finally Gloves.
According to standard infection control guidelines, the proper sequence for donning (putting on) PPE begins with the gown to cover the torso and clothing. Next, the mask is secured to protect the respiratory tract, followed by goggles or a face shield for eye protection. Finally, clean gloves are applied last, extending over the cuffs of the isolation gown to ensure a continuous protective barrier before touching the client or environment.

Step-by-Step Solution

1
Put on the isolation gown.
The nurse's torso, arms, and clothing are covered.
The gown is the bulkiest item and forms the base layer of protection.
2
Secure the surgical mask.
The nurse's nose and mouth are protected.
Securing the mask before applying eye protection ensures a proper fit and minimizes adjustment.
3
Place goggles over the eyes.
The nurse's eyes are protected from splashes or sprays.
Eye protection should be placed after the mask so it rests comfortably and does not interfere with the mask's seal.
4
Don clean gloves.
The nurse's hands are protected and the gown cuffs are sealed.
Applying gloves last prevents cross-contamination from touching the hair, face, or other PPE items while dressing.

Key Concept

Donning Personal Protective Equipment (PPE) Sequence
Estimated Time:45s
Question 318Question →

A client arrives at an outpatient clinic triage desk reporting a four-week history of a persistent cough, blood-tinged sputum, and severe night sweats. The waiting room is crowded with other clients. In what sequence should the practical nurse (PN) perform the following actions to ensure safety and infection control?

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct priority sequence is to first establish source control by masking the client, second to physically isolate the client in a negative-pressure room, third to don appropriate personal protective equipment (N95 respirator) for self-protection, fourth to safely assess the client, and finally to report the clinical findings to the healthcare provider.
In any scenario involving a highly contagious airborne pathogen in a public space, the absolute first priority is source control (placing a surgical mask on the client). Once the immediate threat to the environment is mitigated, the client must be isolated (moved to an AIIR). Only after the client is isolated should the nurse don specialized protective equipment (N95 respirator) to safely enter the room, conduct the required nursing assessment, and subsequently report the findings to the provider.

Step-by-Step Solution

1
Provide a standard surgical mask to the client.
Immediate source control is established in the public area.
This prevents the aerosolization of infectious particles into the crowded waiting area, providing immediate protection to bystanders while further actions are organized.
2
Escort the client to an airborne infection isolation room (AIIR).
The client is physically separated from the general public.
Containing the client in a negative-pressure environment effectively stops the spread of airborne pathogens to the rest of the facility.
3
Don a fit-tested N95 respirator.
The nurse is fully protected from airborne transmission.
Healthcare workers must wear an N95 respirator prior to entering an enclosed AIIR with a client who is suspected of having active tuberculosis.
4
Collect a respiratory history and vital signs.
Essential baseline clinical data is gathered safely.
Nursing assessment can only be performed after the environment is secured and the nurse is properly protected.
5
Report findings to the healthcare provider.
Medical interventions and diagnostics can be officially initiated.
The provider requires the collected baseline data to write orders for diagnostics, such as sputum cultures for acid-fast bacilli (AFB) and a chest x-ray.

Key Concept

Prioritization of Infection Control: Source Control and Airborne Precautions
Question 319Question →

A practical nurse is performing scheduled two-hour care for a client who is currently in bilateral soft wrist restraints. Arrange the following steps of restraint care in the correct chronological order.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct chronological sequence is to first remove the restraints, assess the skin and circulation, perform range-of-motion exercises, address basic physiological needs like hydration and toileting, and finally reapply the restraints and document the care.
Providing scheduled restraint care follows a logical sequence prioritizing physiological safety and basic human needs. The nurse must first remove the restrictive device to gain access to the extremity. The immediate priority is assessing for injury (skin breakdown, poor circulation). Once safety is established, the nurse performs range-of-motion to prevent immobility complications. Next, basic needs such as hydration, nutrition, and toileting are provided while the client is unrestrained. Finally, the restraints are correctly reapplied to maintain safety, and the entire intervention is documented per facility policy.

Step-by-Step Solution

1
Untie the quick-release knots and temporarily remove both restraints.
The client's extremities are freed from immobilization.
Restraints must be removed at least every two hours to allow for necessary physical assessment and nursing care.
2
Assess the skin integrity, peripheral pulses, and temperature of both wrists.
The neurovascular status of the affected extremities is verified.
Direct visualization and palpation immediately reveal any signs of skin breakdown, cyanosis, or decreased perfusion caused by the restraints.
3
Perform active or passive range-of-motion exercises on the client's arms.
The joints are mobilized and blood flow is stimulated.
Immobility from restraints increases the risk of joint stiffness and venous stasis; range-of-motion exercises counteract these complications.
4
Offer the client fluids, a snack, and the opportunity to use the bedpan.
The client's basic physiological needs for hydration, nutrition, and elimination are met.
Clients in restraints rely entirely on nursing staff to provide opportunities for eating, drinking, and toileting while their hands are free.
5
Reapply the restraints securely and document the assessment findings.
The client is secured safely, and the care provided is legally recorded.
Reapplication ensures ongoing client safety, while timely documentation proves that mandatory two-hour restraint care protocols were followed.

Key Concept

Standard protocol requires that physical restraints be removed at least every 2 hours to conduct thorough neurovascular and skin assessments, perform range-of-motion exercises, and meet the client's basic needs for food, fluids, and elimination.
Estimated Time:1m 0s
Question 320Question →

A practical nurse (PN) is conducting a home visit for a hospice client who has a Physician Orders for Life-Sustaining Treatment (POLST) form specifying 'Do Not Resuscitate' (DNR). The client is currently disoriented and lacks capacity. The client's spouse suddenly states, 'I cannot just let them die. I want you to do CPR if they stop breathing.' In which order should the PN perform the following actions? Arrange the actions from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first verify the spouse's legal proxy status, then confirm their explicit intent to revoke the DNR, followed by removing the physical POLST form from the home. After securing the physical environment, the PN contacts the provider, and finally documents the event.
When a proxy requests to revoke a DNR for a client lacking capacity, the first step is to verify their legal authority (Durable Power of Attorney for Healthcare). Once verified, the PN must confirm their explicit intent to ensure it is not merely an expression of grief. After confirming intent, the immediate priority is client safety: the PN must remove the physical POLST form (often kept on a refrigerator) to prevent emergency medical services (EMS) from mistakenly withholding CPR if the client suddenly arrests. After securing the physical environment, the PN notifies the healthcare provider to officially cancel the written medical order. Finally, after the situation is safely managed and communicated, the PN documents the proxy's exact words and the actions taken in the legal health record.

Step-by-Step Solution

1
Verify the spouse's legal proxy status.
The spouse's authority to make medical decisions is confirmed.
The nurse must ensure the individual requesting the change has legal authority before altering a life-sustaining treatment plan.
2
Confirm the spouse's intent.
The request to revoke the DNR is clearly established.
The PN must differentiate between an expression of grief and a formal legal request to revoke the DNR.
3
Remove the physical POLST form.
The risk of EMS inappropriately following the voided DNR is eliminated.
The physical document dictates the actions of emergency responders and must be removed immediately to ensure client safety.
4
Contact the healthcare provider.
The provider is informed of the proxy's decision.
The provider must officially update the client's code status in the hospice agency's records.
5
Document the event.
A legal record of the revocation is created.
Documentation should be completed only after all acute legal, safety, and communication steps are handled.

Key Concept

A legally designated healthcare proxy can revoke a DNR on behalf of a client who lacks capacity. The nurse must verify proxy status, confirm intent, prioritize immediate safety by removing physical DNR identifiers, and then coordinate with the provider.
PreviousPage 16 / 32Next
All practice questions — NCLEX-PN | Examkin