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While administering medications on a busy progressive care unit, a practical nurse (PN) encounters several situations involving the handling of protected health information (PHI). Which of the following actions demonstrate appropriate adherence to information security and confidentiality protocols? Select all that apply.

Select all that apply

Logging out of the electronic health record (EHR) system before stepping away from the mobile workstation to respond to a nearby bed alarm.

Providing the client's spouse with printed laboratory results after the spouse expresses severe anxiety about the client's current condition.

Providing a client's current vital signs to the respiratory therapist who is preparing to administer a scheduled nebulizer treatment to the client.

Confirming the time of a client's scheduled surgery to a telephone caller who successfully verifies the client's full name and date of birth.

Positioning the mobile workstation screen to face the wall while verifying a complex medication order with the pharmacy over the telephone.

Placing empty intravenous fluid bags containing intact client prescription labels into the regular waste receptacle inside the client's room.

Show answer & explanation

Answer: Logging out of the electronic health record (EHR) system before stepping away from the mobile workstation to respond to a nearby bed alarm.; Providing a client's current vital signs to the respiratory therapist who is preparing to administer a scheduled nebulizer treatment to the client.; Positioning the mobile workstation screen to face the wall while verifying a complex medication order with the pharmacy over the telephone.

Answer

The correct actions are logging out of the EHR system before leaving the workstation, providing vital signs to the respiratory therapist for treatment purposes, and positioning the screen away from public view during phone calls.

Appropriate information security requires safeguarding protected health information (PHI) across all formats. PNs must secure unattended workstations by logging off to prevent unauthorized access, even during emergencies. Sharing PHI with interdisciplinary team members, such as respiratory therapists, is legally permitted because it directly facilitates client treatment. Finally, positioning screens away from public view effectively prevents incidental visual disclosures in busy clinical areas.

Step-by-Step Solution

Analyze each scenario to determine if the disclosure or security practice aligns with HIPAA regulations and the need-to-know principle.

Identified that logging out of the EHR, sharing information with direct care providers, and physically shielding screens are acceptable and required practices.

Information security involves securing electronic devices, ensuring appropriate interdisciplinary communication for treatment, and preventing incidental disclosures.

Evaluate the scenarios involving unauthorized parties or improper disposal.

Identified that sharing PHI with a spouse without consent, confirming medical details over the phone using only basic demographics, and throwing intact prescription labels in regular trash are violations.

Good intentions do not override the legal requirement for explicit client consent, strict telephone verification protocols, and secure destruction of physical PHI.

Key Concept

Under HIPAA, nurses must secure physical, electronic, and verbal PHI. Disclosures are permitted for treatment, payment, and healthcare operations (e.g., to interdisciplinary team members), but require explicit authorization or passcodes for family members and telephone callers.

Question 22Question →

During the morning shift on a cardiac step-down unit, a client recovering from an acute myocardial infarction requires several pharmacological interventions. The client's active electronic health record includes orders for a continuous intravenous heparin infusion, an annual influenza immunization, oral metoprolol, and oral digoxin $0.125\text{ mg}$ (supplied as a liquid concentration of $50\text{ mcg/mL}$ ). Which intervention demonstrates the appropriate application of pharmacological safety and the practical nursing scope of practice?

Evaluating the client's apical pulse for one full minute and confirming two distinct client identifiers before administering the oral metoprolol

Adjusting the rate of the continuous intravenous heparin infusion independently based on the morning activated partial thromboplastin time (aPTT) protocol

Administering the influenza immunization prior to discharge without verifying the client's current temperature or checking for a history of severe allergic reactions

Administering

0.25\text{ mL}

of the oral digoxin solution to deliver the prescribed

0.125\text{ mg}

dose using the supplied

50\text{ mcg/mL}

concentration

Show answer & explanation

Answer: Evaluating the client's apical pulse for one full minute and confirming two distinct client identifiers before administering the oral metoprolol

Answer

The correct action is to evaluate the client's apical pulse for a full minute and confirm two distinct patient identifiers before administering the oral metoprolol.

Evaluating the client's apical pulse for one full minute and verifying two distinct client identifiers before administering metoprolol demonstrates adherence to the 'rights' of medication administration. Furthermore, checking the pulse is a critical pre-administration parameter for beta-blockers, and administering oral medications is well within the practical nurse's scope of practice.

Step-by-Step Solution

Evaluate the scope of practice regarding intravenous infusions.

Determine that titrating continuous IV heparin is strictly a registered nurse (RN) responsibility.

Practical nurses cannot independently adjust high-alert continuous IV drips.

Analyze the requirements for safe vaccine administration.

Identify that screening for acute fever and allergies is mandatory before giving the influenza vaccine.

Failing to check contraindications compromises client safety and violates medication administration protocols.

Calculate the correct volume for the prescribed digoxin dose.

Convert

0.125\text{ mg}

125\text{ mcg}

. Divide by the concentration of

50\text{ mcg/mL}

to get

2.5\text{ mL}

The option suggesting

0.25\text{ mL}

is mathematically incorrect and would result in significant underdosing.

Evaluate the safety checks for oral metoprolol.

Confirm that checking the apical pulse and using two client identifiers is correct.

Beta-blockers affect heart rate, and patient identification is a universal medication safety right within the PN scope.

Key Concept

Safe Medication Administration and PN Scope of Practice

Question 23Question →

A practical nurse (PN) is reviewing the care requirements for a group of assigned clients at the beginning of a shift. Which of the following planned actions demonstrate appropriate application of risk reduction principles within the PN scope of practice? Select all that apply.

Select all that apply

Pausing a continuous enteral tube feeding before placing a client in a supine position for a linen change.

Accepting primary care responsibility for a newly admitted client who requires initiation and titration of a continuous intravenous heparin infusion.

Administering a scheduled oral dose of potassium chloride to a client whose morning serum potassium level is reported as 6.1 mEq/L.

Checking a client's most recent capillary blood glucose level prior to administering a scheduled dose of rapid-acting insulin.

Verifying a client's identity solely by checking the room number and bed assignment before administering a routine daily medication.

Documenting a subtle decrease in urine output and a heart rate increase from 82 to 108 beats/min as expected findings in a client with an active gastrointestinal bleed.

Show answer & explanation

Answer: Pausing a continuous enteral tube feeding before placing a client in a supine position for a linen change.; Checking a client's most recent capillary blood glucose level prior to administering a scheduled dose of rapid-acting insulin.

Answer

The appropriate actions that demonstrate risk reduction within the PN scope are pausing a continuous enteral tube feeding before placing a client supine, and checking a client's capillary blood glucose level prior to administering rapid-acting insulin.

Risk reduction is successfully achieved when the practical nurse adheres to safety protocols and practices within their defined scope. Pausing enteral feedings before laying a client flat prevents regurgitation and aspiration pneumonia. Checking a blood glucose level before administering rapid-acting insulin is a critical safeguard required to prevent iatrogenic hypoglycemia.

Step-by-Step Solution

Evaluate the risk of aspiration associated with continuous enteral feedings.

Pausing the feeding before laying the client flat is identified as a necessary action to prevent aspiration.

Maintaining the head of the bed elevated during and immediately after feedings uses gravity to keep stomach contents from refluxing.

Assess the PN scope of practice regarding intravenous therapy and patient assignments.

Accepting an assignment for a client requiring titration of continuous IV heparin is identified as an action outside the PN scope.

Titrating high-risk IV medications based on laboratory values requires the comprehensive assessment skills of a registered nurse.

Analyze laboratory values in relation to scheduled medications.

Administering additional potassium to a client with a serum level of 6.1 mEq/L is identified as unsafe.

A potassium level above 5.0 mEq/L is elevated; administering more potassium could cause fatal cardiac dysrhythmias.

Review the protocol for safe administration of high-alert medications like insulin.

Checking the blood glucose level prior to insulin administration is identified as a safe, required practice.

Insulin lowers blood sugar; administering it without knowing the current level risks inducing severe hypoglycemia.

Identify the standard requirements for safe client identification.

Using a room and bed number is identified as an unsafe client identification method.

Two unique, client-specific identifiers (such as name and date of birth) must be used to prevent medication errors.

Evaluate the clinical significance of vital sign trends in a client at risk for hemorrhage.

Dismissing tachycardia and decreased urine output in a bleeding client is identified as a dangerous failure to rescue.

These findings represent early compensatory mechanisms for hypovolemic shock and require immediate escalation rather than routine documentation.

Key Concept

Risk reduction involves practicing strictly within the established scope of practice, properly identifying clients using two unique identifiers, escalating critical laboratory and vital sign abnormalities, and performing procedural safeguards such as verifying blood glucose before insulin and preventing aspiration during enteral feeding.

Question 24Question →

A practical nurse (PN) is preparing to administer a prescribed intramuscular medication that is supplied in a single-dose glass ampule. Arrange the following preparation steps in the correct chronological order to ensure safe medication handling and administration.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence begins with clearing the upper stem of medication, followed by protecting the hands with gauze, snapping the ampule away from the body, attaching a filter needle, withdrawing the medication, and finally replacing the filter needle with an appropriate injection needle.

Safe medication preparation from a glass ampule requires a specific sequence to protect both the nurse and the client. The nurse must first ensure all medication is in the lower chamber (flicking the stem) to prevent dose loss. Next, the nurse protects themselves by wrapping the neck and breaking the glass away from their body. Because breaking the glass can introduce microscopic shards into the liquid, the nurse must attach a filter needle to draw up the medication safely. Once the medication is withdrawn without contaminating the needle on the rim, the filter needle must be discarded and replaced with an injection-appropriate needle, as filter needles are not meant for client administration.

Step-by-Step Solution

Flick the upper stem of the ampule lightly to ensure all medication moves into the lower chamber.

All medication is contained within the base of the ampule.

Prevents loss of the prescribed dose when the ampule is opened.

Wrap a sterile gauze pad or an unopened alcohol swab around the narrow neck of the ampule.

A protective barrier is established around the break point.

Protects the nurse's fingers from glass cuts.

Snap the ampule neck quickly and firmly in a direction pointing away from the body.

The ampule is opened safely.

Directs potential glass shards away from the nurse's face and body.

Attach a filter needle to the sterile syringe.

The syringe is equipped to filter out particulate matter.

Essential to prevent drawing up microscopic glass shards that fell into the medication when the ampule was broken.

Withdraw the prescribed amount of medication while avoiding contact with the outer rim of the ampule.

The correct dose is drawn into the syringe while maintaining sterility.

Touching the unsterile outer rim of the ampule would contaminate the needle.

Remove the filter needle and attach the appropriate size needle for intramuscular injection.

The syringe is ready for safe client administration.

Filter needles are strictly for drawing up medication and are contraindicated for injecting into tissue.

Key Concept

Safe Preparation of Parenteral Medications from an Ampule

Estimated Time:1m 30s

Question 25Question →

An older adult client is admitted to the medical-surgical unit with a sacral pressure injury infected with Vancomycin-resistant *Enterococcus* (VRE). The healthcare provider has prescribed contact precautions. Which actions should the practical nurse implement? Select all that apply.

Select all that apply

Don a clean gown and gloves upon entering the client's room.

Discard the contaminated gown and gloves in a hallway receptacle after exiting the room.

Delegate the evaluation of the wound's drainage to the unlicensed assistive personnel (UAP).

Ensure that a dedicated stethoscope and thermometer remain inside the client's room for exclusive use.

Request a transfer to a private negative-pressure isolation room for this client.

Place the client in a room with another client who has an active VRE infection if a private room is unavailable.

Show answer & explanation

Answer: Don a clean gown and gloves upon entering the client's room.; Ensure that a dedicated stethoscope and thermometer remain inside the client's room for exclusive use.; Place the client in a room with another client who has an active VRE infection if a private room is unavailable.

Answer

The nurse should don a clean gown and gloves upon entering the room, ensure dedicated medical equipment remains inside the room, and cohort the client with another VRE-positive client if a private room is unavailable.

Contact precautions require the use of a gown and gloves upon entering the room to prevent transmission of epidemiologically important microorganisms like VRE. Medical equipment must be dedicated to a single client and left in the room to avoid cross-contamination. Furthermore, if a private room is unavailable, cohorting the client with another individual who has the identical active infection is an accepted infection control standard.

Step-by-Step Solution

Identify the mode of transmission for the organism specified in the scenario.

Vancomycin-resistant Enterococcus (VRE) is transmitted via direct or indirect contact.

Determining the transmission route dictates the specific isolation precautions required.

Select interventions that align with contact precautions.

Appropriate interventions include using a gown and gloves upon room entry, dedicating reusable equipment, and cohorting clients with the same infection.

These measures create a physical barrier and limit the spread of the pathogen to the hospital environment and other vulnerable clients.

Eliminate inappropriate actions related to doffing sequence, delegation, and incorrect precaution types.

Discarding PPE in the hallway, delegating assessment to a UAP, and using negative-pressure rooms are incorrect.

PPE must be doffed before exiting the room, UAPs cannot assess, and negative-pressure rooms are strictly for airborne pathogens.

Key Concept

Contact precautions require a private room or cohorting, dedicated equipment, and the use of a gown and gloves upon entry and removed before exiting.

Question 26Question →

A practical nurse (PN) is collecting data on a 78-year-old client who is receiving intravenous antibiotics for a severe urinary tract infection. Which of the following assessment findings should the PN identify as early indicators of systemic decompensation and report to the registered nurse (RN) immediately? Select all that apply.

Select all that apply

A resting heart rate of 114 beats/min and a blood pressure of 96/58 mm Hg

New-onset restlessness and the client stating they are waiting for a train

A respiratory rate of 26 breaths/min with shallow chest expansion

The client reports a pain level of 4 on a 0 to 10 scale localized to the suprapubic area

The client's most recent void yielded 150 mL of cloudy, foul-smelling urine

The client's spouse reports the client has experienced gradual forgetfulness over the past two years

Show answer & explanation

Answer: A resting heart rate of 114 beats/min and a blood pressure of 96/58 mm Hg; New-onset restlessness and the client stating they are waiting for a train; A respiratory rate of 26 breaths/min with shallow chest expansion

Answer

The correct findings are a resting heart rate of 114 beats/min with a blood pressure of 96/58 mm Hg, new-onset restlessness with confusion, and a respiratory rate of 26 breaths/min.

The correct options indicate acute systemic deterioration (sepsis), prioritizing Airway, Breathing, and Circulation (ABC) issues. Tachycardia with borderline hypotension suggests early shock. Tachypnea is a primary respiratory compensatory mechanism during systemic stress. Furthermore, older adults frequently exhibit acute confusion (delirium) as a primary sign of hypoxia or worsening infection.

Step-by-Step Solution

Analyze the client's current diagnosis and primary risk factors.

The older adult client has a severe urinary tract infection, placing them at high risk for the infection spreading systemically (sepsis).

Identifying the primary risk helps distinguish expected localized symptoms from emergent systemic complications.

Evaluate vital signs for Airway, Breathing, and Circulation (ABC) compromise.

A heart rate of 114 beats/min with borderline hypotension (96/58 mm Hg) and a respiratory rate of 26 breaths/min indicate physiological stress.

ABCs are the highest priority in acute care, and these borderline vital signs are classic early indicators of shock and respiratory decompensation.

Assess for acute neurological changes compared to baseline.

New-onset restlessness and confusion (delirium) are critical acute findings, distinguishing them from the chronic gradual forgetfulness reported by the spouse.

In older adults, acute mental status changes are often the first sign of hypoxia or systemic infection.

Compare emergent findings with expected localized symptoms.

Mild suprapubic pain and cloudy urine are localized, expected findings that do not require immediate emergency escalation.

Prioritization requires the nurse to address systemic physiological instability before expected, chronic, or local symptoms.

Key Concept

Physiological Adaptation: Recognizing Early Signs of Systemic Decompensation and Sepsis

Estimated Time:1m 30s

Question 27Question →

A client is 12 hours postoperative following a total thyroidectomy. While inflating the blood pressure cuff to measure the client's vital signs, the practical nurse observes that the client's hand and fingers suddenly curl inward in a spasm. Which action should the nurse take first?

Notify the registered nurse immediately to report the observation.

Massage the client's hand and fingers to relieve the muscle cramping.

Prepare to administer a prescribed dose of intravenous calcium gluconate.

Evaluate the client's most recent serum potassium level to determine the cause.

Show answer & explanation

Answer: Notify the registered nurse immediately to report the observation.

Answer

Notify the registered nurse immediately to report the observation.

The correct answer is to notify the registered nurse immediately. The client is exhibiting Trousseau's sign, which is an early clinical indication of hypocalcemia (low serum calcium). Because the parathyroid glands are located on the posterior surface of the thyroid, they can be inadvertently damaged or removed during a thyroidectomy. Hypocalcemia can quickly escalate to severe tetany and laryngospasm, which compromises the client's airway. Immediate escalation is required for patient safety.

Step-by-Step Solution

Identify the clinical sign presented in the scenario.

The hand spasm that occurs during blood pressure cuff inflation is known as Trousseau's sign.

Recognizing classic clinical signs is essential for identifying underlying physiological imbalances.

Correlate the clinical sign with the client's surgical history.

The client had a total thyroidectomy. Trousseau's sign indicates hypocalcemia.

The parathyroid glands, which regulate calcium levels, are located adjacent to the thyroid and can be accidentally damaged or removed during a thyroidectomy.

Determine the priority nursing action based on the practical nurse's scope of practice.

The practical nurse must immediately notify the registered nurse.

Hypocalcemia can rapidly progress to severe tetany and life-threatening laryngospasm (airway compromise), requiring immediate RN assessment and collaborative medical intervention.

Key Concept

Recognizing post-thyroidectomy complications (hypocalcemia) and escalating care

Question 28Question →

A practical nurse is assigned to care for an older adult client who has oropharyngeal dysphagia following a cerebrovascular accident (CVA). The client is alert and ready for their afternoon meal. Arrange the following nursing actions in the correct chronological order to safely assist the client with eating and prevent aspiration.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence ensures airway safety by first positioning the client upright, preparing the oral cavity, placing food on the strong side, using the chin-tuck maneuver during the active swallow, and finally checking for retained food.

Safe feeding for a client with dysphagia is a systematic process. Environmental and postural safety must be established first by positioning the client at 90 degrees. The oral cavity is then prepared via hygiene. During the actual feeding, food must be placed where the client has motor control (the unaffected side), and the airway must be actively protected during the swallow using the chin-tuck technique. Finally, a post-swallow assessment ensures no residual hazards remain by checking for pocketing.

Step-by-Step Solution

Elevate the head of the bed to 90 degrees.

The client is placed in a high Fowler's position.

An upright posture enlists gravity to direct the food bolus into the esophagus and reduces the physical risk of tracheal entry.

Provide gentle oral hygiene.

The oral mucosa is moistened and sensory receptors are stimulated.

Moistening the mouth facilitates bolus formation and triggers the swallow reflex more effectively.

Place food on the unaffected side of the mouth.

Food is situated where the client has optimal muscle control.

The strong side has intact musculature to safely manipulate and propel the food backward.

Instruct the client to tuck their chin during the swallow.

The laryngeal opening is physically narrowed.

This specific postural adjustment physically protects the airway while simultaneously widening the esophageal opening.

Inspect the buccal cavities for pocketing.

The mouth is confirmed clear of residual food.

Clients with a CVA may unknowingly retain food in the affected cheek, which could be aspirated later when they lie flat or take a breath.

Key Concept

Aspiration Prevention and Dysphagia Management

Question 29Question →

A practical nurse has completed perineal care for a client with a confirmed *Clostridioides difficile* infection. The nurse is wearing a disposable gown and gloves. Upon completing the care, which sequence is the correct method for removing the personal protective equipment (PPE) before exiting the room?

Remove the gloves first, unfasten the gown, peel it off by touching only the inside surfaces, and wash hands with soap and water.

Unfasten the gown at the neck and waist using the contaminated gloves, remove the gown, remove the gloves, and wash hands with soap and water.

Remove the gloves, unfasten the gown, remove it by grasping the outside front panels, and wash hands with soap and water.

Remove the gloves, unfasten the gown, peel it off by touching only the inside surfaces, and thoroughly cleanse hands using an alcohol-based hand sanitizer.

Show answer & explanation

Answer: Remove the gloves first, unfasten the gown, peel it off by touching only the inside surfaces, and wash hands with soap and water.

Answer

The correct sequence is to remove the gloves first, carefully remove the gown by handling only the inside, and then wash hands with soap and water.

Gloves are the most heavily contaminated PPE and should be removed first. The gown must then be removed by touching only the inside surfaces to avoid contaminating the nurse's bare hands and clothing. Finally, because *C. difficile* spores are resistant to alcohol, hands must be washed with antimicrobial soap and water.

Step-by-Step Solution

Identify the specific pathogen and its required precautions.

*Clostridioides difficile* requires Contact Precautions (enteric), which specifically mandates handwashing with soap and water.

Alcohol-based hand sanitizers are ineffective against the protective spores formed by *C. difficile*.

Determine the safest sequence for removing heavily soiled PPE.

Gloves are removed first because they are the most contaminated item. The gown is then removed by touching only the inside.

Touching the back of the neck with soiled gloves or touching the outside of the gown with bare hands will cross-contaminate the nurse.

Key Concept

Standard and Transmission-Based Precautions: PPE Doffing Sequence and Enteric Spore Precautions

Estimated Time:1m 0s

Question 30Question →

A client with a continuous intravenous (IV) infusion is scheduled for transport to the radiology department. The client appears restless and repeatedly grasps at the IV tubing. Which actions should the practical nurse implement to prevent accidental dislodgement and maintain a safe environment? (Select all that apply.)

Select all that apply

Obscure the IV insertion site by wrapping it loosely with a conforming bandage or stockinette.

Apply bilateral soft wrist restraints to secure the client's hands during the transport process.

Provide a textured item, such as a folded washcloth, for the client to hold in the unaffected hand.

Instruct the transport personnel to silence and adjust the IV pump infusion rate if an occlusion alarm sounds.

Arrange for an unlicensed assistive personnel (UAP) to ride along and sit directly beside the client.

Show answer & explanation

Answer: Obscure the IV insertion site by wrapping it loosely with a conforming bandage or stockinette.; Provide a textured item, such as a folded washcloth, for the client to hold in the unaffected hand.; Arrange for an unlicensed assistive personnel (UAP) to ride along and sit directly beside the client.

Answer

The correct interventions are obscuring the IV site, providing a sensory diversion item, and assigning a UAP to accompany the client.

The correct actions focus on prioritizing client safety using least-restrictive methods and appropriate delegation. Obscuring the IV site removes the visual trigger, providing a washcloth offers a safe sensory distraction for restless hands, and having a UAP accompany the client ensures immediate supervision and redirection.

Step-by-Step Solution

Analyze the client's behavior and the risk presented.

The client is restless and grasping at the IV tubing, creating a high risk for accidental dislodgement and subsequent injury or bleeding.

Identifying the specific safety hazard dictates the necessary interventions.

Evaluate the proposed interventions against the principle of least restrictive restraints.

Applying wrist restraints is a restrictive measure and a last resort. Hiding the site, providing a distraction, and using a sitter are least-restrictive alternatives.

Nursing standards require attempting and documenting least-restrictive alternatives before utilizing physical restraints.

Evaluate the delegation and assignment aspects of the interventions.

Assigning a UAP to sit with the client is an appropriate delegation of a routine safety task. However, delegating the adjustment of an IV pump to transport personnel is outside their scope of practice.

The practical nurse must only delegate tasks that fall within the receiver's scope of practice and training to ensure client safety.

Key Concept

Implementing least restrictive alternatives and appropriate delegation to maintain client safety.

Question 31Question →

A client is admitted to the nursing unit directly after undergoing a percutaneous liver biopsy. To reduce the risk of internal bleeding and ensure safety, what is the most appropriate position for the practical nurse to place this client?

Resting on the right side with a small towel roll under the puncture site

Resting on the left side with a supportive pillow placed behind the back

Lying flat on the back with the lower extremities elevated on pillows

Sitting upright in bed at a 60-degree angle with the knees slightly bent

Show answer & explanation

Answer: Resting on the right side with a small towel roll under the puncture site

Answer

Resting on the right side with a small towel roll under the puncture site

Positioning the client on the right side (where the liver is located) applies direct, continuous pressure to the liver capsule and the biopsy puncture site. This use of body weight, often augmented by a rolled towel, acts as a tamponade to promote hemostasis and minimize the risk of severe internal hemorrhage.

Step-by-Step Solution

Analyze the client's recent diagnostic procedure.

The client had a percutaneous liver biopsy, which involves puncturing a highly vascular organ.

Understanding the nature of the procedure highlights the primary complication to prevent, which is severe bleeding.

Identify the goal of immediate post-procedure positioning.

The primary goal is to apply direct, continuous pressure to the puncture site to promote clotting (hemostasis).

External pressure acts as a mechanical barrier against bleeding from the internal wound.

Determine the optimal anatomical position to achieve this goal.

Placing the client on the right side compresses the liver against the chest wall. Adding a towel roll directly under the right costal margin maximizes this pressure.

The liver is located on the right side of the abdomen; therefore, right lateral positioning uses the client's own body weight to tamponade the bleeding.

Key Concept

Post-Procedure Positioning and Hemorrhage Prevention

Question 32Question →

A client is transferred back to the medical-surgical unit after undergoing a percutaneous liver biopsy. To promote hemostasis and prevent complications, which of the following positions is most appropriate for this client?

Right side-lying position with a folded towel under the puncture site

Left side-lying position with the right knee drawn up toward the chest

Semi-Fowler's position with the head of the bed elevated 45 degrees

Supine position with the lower extremities elevated on pillows

Show answer & explanation

Answer: Right side-lying position with a folded towel under the puncture site

Answer

Right side-lying position with a folded towel under the puncture site

The liver is a highly vascular organ located in the right upper quadrant of the abdomen, making bleeding the most significant risk following a biopsy. Positioning the client on their right side (often with a small towel or pillow tucked under the puncture site) utilizes the client's own body weight to apply continuous, direct pressure to the liver capsule. This splinting action is a fundamental care intervention that promotes hemostasis and prevents severe internal hemorrhage.

Step-by-Step Solution

Identify the anatomical location of the procedure.

The liver is located in the right upper quadrant of the abdomen.

Knowing the organ's precise location dictates where external pressure must be applied.

Determine the primary physiological risk following the procedure.

Because the liver is a highly vascular organ, hemorrhage is the most significant immediate complication after a biopsy.

Identifying the primary risk guides the nurse in selecting the most critical basic care intervention.

Select the position that best mitigates the identified risk.

The right side-lying position is chosen.

This position uses the client's body weight against the mattress (often enhanced by a folded towel) to compress the liver, promoting clot formation and hemostasis.

Key Concept

Post-procedure positioning to prevent hemorrhage

Estimated Time:1m 0s

Question 33Question →

A practical nurse (PN) is reviewing the medication administration record (MAR) and morning laboratory results for assigned clients. Identify the actions that represent safe and appropriate practice for the PN. Select all that apply.

Select all that apply

Withhold scheduled subcutaneous enoxaparin for a client with a morning platelet count of

75,000\text{/mm}^3

and notify the registered nurse.

Accept a delegated task from the registered nurse to administer an initial intravenous (IV) push dose of hydromorphone for a client experiencing severe pain.

Reinforce teaching for a client starting oral rifampin that their urine, sweat, and tears may turn a harmless red-orange color.

Administer a scheduled dose of oral metoprolol to a client who has an asymptomatic resting heart rate of

54\text{ beats/min}

Administer a prescribed oral potassium chloride supplement to a client with a morning serum potassium level of

3.2\text{ mEq/L}

Bypass the barcode medication administration scanner during a temporary system outage and identify the client using only their room number.

Show answer & explanation

Answer: Withhold scheduled subcutaneous enoxaparin for a client with a morning platelet count of $75,000\text{/mm}^3$ and notify the registered nurse.; Reinforce teaching for a client starting oral rifampin that their urine, sweat, and tears may turn a harmless red-orange color.; Administer a prescribed oral potassium chloride supplement to a client with a morning serum potassium level of $3.2\text{ mEq/L}$ .

Answer

The correct actions are withholding enoxaparin for thrombocytopenia, reinforcing teaching about expected side effects of rifampin, and administering potassium chloride for hypokalemia.

Safe pharmacological practice for the practical nurse involves withholding enoxaparin when the platelet count is critically low to prevent hemorrhage, educating clients on harmless but startling medication side effects (like rifampin causing red-orange secretions), and appropriately treating documented electrolyte deficits (such as administering potassium for hypokalemia).

Step-by-Step Solution

Evaluate the clinical data and prescribed medication for each client scenario.

Identify therapeutic indications, potential contraindications, and required monitoring for the specific drug classes (anticoagulants, antimicrobials, electrolytes, beta-blockers, opioids).

To ensure clinical safety and prevent adverse pharmacological events.

Analyze each proposed nursing action against the established LPN/PN scope of practice.

Differentiate between tasks that are safe to perform (administering oral/subcutaneous medications, reinforcing teaching) and tasks that must be refused or escalated (IV push medications, ignoring critical safety parameters).

To maintain legal practice boundaries and ensure the highest level of client safety.

Key Concept

The practical nurse must integrate pharmacological knowledge with strict adherence to scope of practice, ensuring safe medication administration, accurate monitoring of laboratory values, and appropriate client teaching reinforcement.

Question 34Question →

A practical nurse (PN) is assigned to a team of clients on an adult medical unit. The PN must collaborate with a registered nurse (RN) and an assistive personnel (AP) to provide safe care. Which of the following decisions by the PN demonstrates correct application of delegation principles and professional scope of practice?

Directing the AP to feed a client who experiences bilateral hand tremors but maintains an intact and functional swallowing reflex.

Accepting a directive from the unit charge nurse to formulate the initial nursing care plan for a client admitted directly from the emergency department.

Recording a client's morning serum potassium level of 2.7 mEq/L (2.7 mmol/L) in the chart, with the intention to notify the provider during afternoon rounds.

Proceeding to apply bilateral soft wrist restraints to a confused client who repeatedly touches their surgical dressing, prior to attempting less restrictive interventions.

Show answer & explanation

Answer: Directing the AP to feed a client who experiences bilateral hand tremors but maintains an intact and functional swallowing reflex.

Answer

The correct decision is directing the AP to feed a client who experiences bilateral hand tremors but maintains an intact and functional swallowing reflex.

The correct decision represents safe and effective delegation. While feeding a client with a high risk of aspiration (such as following an acute stroke with dysphagia) requires a licensed nurse, feeding a client who merely has motor difficulties (like tremors) but a fully intact swallowing reflex is a routine activity of daily living (ADL) that can be safely delegated to an assistive personnel (AP).

Step-by-Step Solution

Evaluate the appropriateness of delegating the feeding task to the AP.

Determine that because the client has an intact swallowing reflex (no dysphagia), feeding is a routine, low-risk task that safely falls within the AP's scope.

The 'right task' and 'right circumstance' of delegation are met when a client is stable and the task does not require nursing judgment.

Analyze the acceptance of formulating an initial care plan.

Identify that the initial comprehensive assessment and care plan formulation are strictly within the RN's scope of practice.

PNs cannot accept delegated tasks that require independent, complex nursing judgment, even if instructed by a charge nurse.

Assess the management of the critical laboratory value.

Recognize that a potassium level of 2.7 mEq/L is a critical panic value requiring immediate intervention.

Safe collaborative practice mandates immediate escalation of critical diagnostic findings to prevent adverse client outcomes, such as arrhythmias.

Review the protocol for applying physical restraints.

Conclude that applying restraints before trying alternatives violates safety protocols and legal guidelines.

Least restrictive measures must always be exhausted and documented before utilizing physical restraints to protect client autonomy and prevent injury.

Key Concept

Delegation, Scope of Practice, and Interprofessional Collaboration

Question 35Question →

A practical nurse observes an unlicensed assistive personnel (UAP) preparing to enter the room of a client on Contact Precautions for a *Clostridioides difficile* infection. The UAP washes their hands with soap and water, dons a pair of clean gloves, and then picks up a disposable isolation gown to put on over their uniform. What is the most appropriate action for the practical nurse to take?

Stop the UAP and explain that the isolation gown must be put on before the gloves.

Advise the UAP to secure the sleeves of the isolation gown tightly over the cuffs of the gloves.

Instruct the UAP to apply a standard surgical mask before tying the gown at the waist.

Take over the client's care, as UAPs are not permitted to enter rooms under Contact Precautions.

Show answer & explanation

Answer: Stop the UAP and explain that the isolation gown must be put on before the gloves.

Answer

The nurse must stop the UAP and correct the donning sequence, ensuring the isolation gown is put on before the gloves.

According to standard infection control protocols, the isolation gown must always be donned before the gloves. This specific sequence is critical because the gloves must be pulled securely over the cuffs of the isolation gown to create a continuous barrier. If the gown is put on after the gloves, the wrists may be exposed to infectious agents, compromising safety.

Step-by-Step Solution

Analyze the UAP's sequence of donning personal protective equipment (PPE).

The UAP is attempting to put on gloves before the isolation gown.

Identifying the error in real-time is the first step in preventing an infection control breach.

Recall the standard CDC guidelines for donning PPE.

The correct sequence is: 1. Gown, 2. Mask/Respirator, 3. Goggles/Face Shield, 4. Gloves.

This standardized sequence ensures that all exposed skin and clothing are adequately covered.

Evaluate the clinical consequence of the UAP's error.

If gloves are put on first, the wrists may remain exposed because the gloves cannot properly seal over the gown's cuffs.

Exposed wrists increase the risk of transmitting spores from the environment to the UAP.

Determine the appropriate nursing intervention.

The practical nurse must immediately intervene, halt the UAP, and correct the PPE sequence.

Nurses are responsible for monitoring infection control practices and guiding assistive personnel in maintaining a safe care environment.

Key Concept

PPE Donning Sequence and Infection Control Intervention

Question 36Question →

A practical nurse is preparing to administer an oral suspension to a client who weighs $154\text{ lb}$ . The healthcare provider has prescribed $15\text{ mg/kg/day}$ to be administered in two equally divided doses. The pharmacy dispenses the medication with a concentration of $0.25\text{ g/5 mL}$ . How many $\text{mL}$ should the practical nurse administer for each dose? Record your answer to the nearest tenth. Do not include units in your answer.

Show answer & explanation

Answer: 10.5

Answer

10.5

To arrive at the correct answer of

10.5

, the practical nurse must systematically process multiple conversions. First, the client's weight is converted to kilograms (

154 \div 2.2 = 70\text{ kg}

). Next, the total daily dose is calculated (

70 \times 15 = 1050\text{ mg/day}

). Because the medication is divided into two equal doses, the single dose requirement is

525\text{ mg}

. Before calculating the volume, the dispensed concentration of

0.25\text{ g/5 mL}

must be converted to milligrams (

0.25 \times 1000 = 250\text{ mg/5 mL}

). Finally, using the desired over have formula:

(525\text{ mg} \div 250\text{ mg}) \times 5\text{ mL}

equals exactly

10.5\text{ mL}

Step-by-Step Solution

Convert the client's weight from pounds to kilograms.

154\text{ lb} \div 2.2\text{ lb/kg} = 70\text{ kg}

Weight-based dosing requires the client's weight in kilograms.

Calculate the total daily dose in milligrams.

70\text{ kg} \times 15\text{ mg/kg/day} = 1050\text{ mg/day}

This establishes the total amount of medication the client needs over a 24-hour period.

Determine the amount required for a single dose.

1050\text{ mg/day} \div 2\text{ doses} = 525\text{ mg/dose}

The prescription specifies two equally divided doses per day.

Convert the supplied medication concentration from grams to milligrams.

0.25\text{ g} \times 1000\text{ mg/g} = 250\text{ mg}

. The available concentration is

250\text{ mg}

per

5\text{ mL}

Units of measurement must match between the desired dose (mg) and the available medication supply (g) before calculating volume.

Calculate the volume to administer for a single dose.

(525\text{ mg} \div 250\text{ mg}) \times 5\text{ mL} = 2.1 \times 5\text{ mL} = 10.5\text{ mL}

Applying the standard dimensional analysis or 'Desired over Have times Volume' formula yields the exact volume to administer.

Key Concept

Multi-step dosage calculation involving weight conversion, frequency division, and unit conversion.

Question 37Question →

A healthcare facility's compliance officer is reviewing recent electronic health record (EHR) access logs and information disclosures. Match each scenario of data access or disclosure with the correct determination regarding client confidentiality and permissible use.

Click a left item, then click its matching right item

Show answer & explanation

Answer

The interpreter and the transferring practical nurse have permissible access based on direct care provision and transition operations. The nursing student and the intensive care unit nurse have impermissible access due to lacking a current clinical 'need to know.'

Each scenario is correctly matched based on the HIPAA privacy rule and the 'need to know' principle. Access is permissible when directly related to current treatment, care coordination, or authorized healthcare operations. Access is impermissible when driven by curiosity, academic research on unassigned clients, or personal follow-up on former clients.

Step-by-Step Solution

Analyze the interpreter scenario.

The interpreter is an authorized member of the care team needing data for direct treatment communication.

Determines that this access falls under permissible healthcare operations.

Analyze the nursing student scenario.

The student is accessing an unassigned client's chart to gather data for a presentation.

Identifies that accessing the chart without a direct clinical assignment is an impermissible privacy violation, regardless of an intent to de-identify the data.

Analyze the transferring practical nurse scenario.

The nurse is sending required medical information to a receiving facility for continuity of care.

Confirms this is a permissible disclosure for the purpose of ongoing treatment.

Analyze the intensive care unit nurse scenario.

The nurse is checking on a former client out of personal concern, without current clinical responsibilities.

Recognizes that past therapeutic relationships do not justify current access, making it impermissible.

Key Concept

HIPAA Need to Know Principle and Permissible Disclosures

Question 38Question →

A practical nurse is caring for a client who returned 3 hours ago following a percutaneous coronary intervention (PCI) via the right femoral artery approach. The client reports a new, deep aching pain in the right lower back. The right groin dressing is dry and intact, and bilateral pedal pulses are palpable. Current vital signs are: blood pressure 104/64 mm Hg (baseline 132/80 mm Hg), heart rate 102 bpm (baseline 74 bpm), and respiratory rate 18 breaths/min. Which of the following actions should the practical nurse take first?

Notify the supervising registered nurse immediately of the assessment findings.

Administer the prescribed as-needed acetaminophen to relieve the reported back pain.

Document the expected procedural discomfort and continue scheduled vital sign checks.

Assist the client to turn onto the left side to relieve pressure on the lower back.

Show answer & explanation

Answer: Notify the supervising registered nurse immediately of the assessment findings.

Answer

The correct action is to notify the supervising registered nurse immediately of the assessment findings.

The client is exhibiting classic signs of a retroperitoneal hemorrhage, a severe complication of femoral artery catheterization. The combination of new lower back pain and subtle signs of hemodynamic compromise (mild tachycardia and decreased blood pressure from baseline) despite a dry insertion site requires immediate escalation to the registered nurse for rapid medical intervention.

Step-by-Step Solution

Analyze the client's symptoms in the context of the recent invasive procedure.

The client has new deep lower back pain 3 hours after a right femoral artery catheterization.

Back or flank pain after a femoral procedure is a cardinal sign of retroperitoneal hemorrhage, even if the external insertion site appears dry.

Compare the current vital signs against the client's baseline data.

The heart rate has increased from 74 to 102 bpm, and the blood pressure has decreased from 132/80 to 104/64 mm Hg.

Identifying subtle shifts in vital signs helps differentiate benign back pain from early hypovolemic shock caused by internal bleeding.

Synthesize the clinical data to determine the risk level.

The combination of back pain and borderline hypovolemic vital signs indicates a high risk for a life-threatening retroperitoneal hemorrhage.

Recognizing severe complications is necessary for safe risk reduction and prioritization.

Select the appropriate nursing intervention within the practical nurse scope of practice.

The practical nurse must immediately escalate the findings to the registered nurse or provider.

Life-threatening complications require immediate advanced assessment and intervention beyond the practical nurse scope.

Key Concept

Recognizing Retroperitoneal Hemorrhage

Question 39Question →

A practical nurse (PN) is preparing to administer the measles, mumps, and rubella (MMR) live vaccine to an adult female client in a community health clinic. Which of the following actions should the PN take to ensure safe practice? Select all that apply.

Select all that apply

Inquire if the client is currently pregnant or plans to become pregnant within the next four weeks.

Withhold the vaccine and notify the registered nurse if the client is currently receiving immunosuppressive therapy.

Proceed with the immunization without assessing for gelatin or neomycin allergies if the client has received previous vaccines.

Bypass the barcode scanning process because the vaccine is administered as a standard, prepackaged dose.

Calculate the required medication volume to administer by converting the client's current weight from pounds to kilograms.

Accept a delegated task to administer a newly prescribed intravenous (IV) push antibiotic to the client during the same visit.

Show answer & explanation

Answer: Inquire if the client is currently pregnant or plans to become pregnant within the next four weeks.; Withhold the vaccine and notify the registered nurse if the client is currently receiving immunosuppressive therapy.

Answer

The correct actions are to inquire if the client is pregnant or plans to become pregnant, and to withhold the vaccine if the client is receiving immunosuppressive therapy.

The MMR vaccine is a live attenuated virus. It is strictly contraindicated during pregnancy due to the risk of fetal harm, and clients should be advised to avoid pregnancy for at least four weeks after vaccination. Additionally, live vaccines are contraindicated in clients who are severely immunocompromised (such as those receiving immunosuppressive therapy), as they can cause severe or fatal infections. Therefore, the practical nurse must actively screen for these conditions before administration.

Step-by-Step Solution

Identify the medication classification and properties.

The MMR vaccine is a live attenuated viral vaccine.

Understanding that the vaccine contains live viruses helps identify absolute contraindications related to immune function and fetal safety.

Evaluate the client's current health status against known contraindications.

Pregnancy and severe immunosuppression are absolute contraindications for live vaccines.

Live vaccines can cross the placenta or cause severe systemic infection in clients lacking an adequate immune response.

Review the practical nurse (PN) scope of practice and medication safety standards.

The PN must perform all medication rights verification, recognize that adult MMR doses are standardized rather than weight-based, and refuse tasks outside their scope, such as IV push administration.

Adhering to strict safety standards and scope of practice prevents patient harm and professional liability.

Key Concept

Safe administration of live attenuated vaccines and adherence to the practical nurse scope of practice.

Question 40Question →

During the night shift, a nurse is evaluating an 82-year-old client who had a partial gastrectomy 48 hours ago. The client, who was previously resting quietly, is now agitated, confused, and trying to pull off the surgical dressing. Clinical findings include a heart rate of 118 beats/min, a respiratory rate of 26 breaths/min, and a blood pressure of 100/62 mm Hg. The client is rubbing their abdomen and groaning. Which action should the nurse prioritize?

Assess the client's oxygen saturation level and apply prescribed supplemental oxygen.

Administer the prescribed breakthrough analgesic to alleviate the client's abdominal discomfort.

Reorient the client to the hospital environment and dim the room lights to encourage sleep.

Document the current findings and resume hourly monitoring, as the vital signs remain within acceptable post-surgical parameters.

Show answer & explanation

Answer: Assess the client's oxygen saturation level and apply prescribed supplemental oxygen.

Answer

The priority action is to assess the client's oxygen saturation level and apply prescribed supplemental oxygen.

The client is exhibiting early signs of hypoxia and potential shock, indicated by new-onset agitation, tachycardia, tachypnea, and borderline hypotension. In the physiological adaptation phase following surgery, acute changes in mental status combined with these vital signs prioritize the need for immediate respiratory support and oxygenation assessment based on the ABCs.

Step-by-Step Solution

Analyze the client's change in mental status and vital signs.

The client exhibits sudden onset agitation, tachycardia (118 beats/min), tachypnea (26 breaths/min), and borderline hypotension (100/62 mm Hg).

Recognizing acute changes is essential for identifying potential life-threatening complications such as shock or hypoxia in the post-operative period.

Apply the Airway, Breathing, Circulation (ABC) prioritization framework.

The client's symptoms strongly suggest impaired oxygenation, which takes clinical precedence over pain management or environmental modifications.

The ABC framework guides nurses to address the most critical and immediate threats to life first.

Determine the initial nursing intervention.

Assessing oxygenation status and providing prescribed respiratory support directly addresses the most critical physiological need.

Restoring adequate oxygenation is the immediate priority before treating pain or attempting to reorient a confused client.

Key Concept

Recognizing early signs of physiological decompensation and applying ABC prioritization.

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