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Question 21Question →

A practical nurse (PN) conducts a routine room check at a residential substance use treatment facility and discovers a client preparing to swallow a handful of unidentified pills. Arrange the following PN actions in the correct order of priority.

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Answer

The correct sequence is to first prevent ingestion, then secure the pills, collect client data, notify the RN, and finally document the event.
In any acute safety crisis involving high-risk behavior, the practical nurse must follow standard safety prioritization frameworks. The absolute first action is to stop immediate harm (preventing ingestion). The second is to secure the environment (removing the pills). Third, the nurse collects data to determine the client's current physiological status. Fourth, this data is reported to the RN or provider for further orders. Finally, the entire incident is documented in the medical record.

Step-by-Step Solution

1
Identify the immediate threat to life or safety.
The client is actively attempting to ingest unidentified pills, posing an immediate risk of harm.
According to the principles of safety and harm reduction, immediate physiological safety takes precedence over all other actions.
2
Determine the sequence of hazard removal and client assessment.
The PN must first intervene and confiscate the pills, then assess the client's vital signs.
The hazard must be secured before assessing the client to ensure the environment is safe and to prevent further ingestion during the assessment process.
3
Establish the order of communication and documentation.
The RN is notified before documentation occurs.
Verbal communication of an acute safety incident to the supervising RN allows for rapid medical intervention, whereas charting is a retrospective record of the event.

Key Concept

Prioritization in acute behavioral and safety incidents requires immediate harm reduction, followed by hazard removal, data collection, reporting, and documentation.
Question 22Question →

A client with a percutaneous endoscopic gastrostomy (PEG) tube is receiving continuous enteral nutrition. The practical nurse (PN) responds to the client's coughing and observes them struggling to breathe, with formula pooling in their mouth. A quick check of the feeding pump reveals it was incorrectly programmed to infuse at 150 mL/hr instead of the prescribed 50 mL/hr. Arrange the following actions in the priority sequence the PN should perform them to manage this error and ensure client safety.

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Answer

The correct priority sequence is to first turn off the enteral feeding pump, then turn the client to a lateral side-lying position, suction the oral cavity, obtain vital signs including oxygen saturation, and finally notify the RN and prescribing provider.
The correct sequence prioritizes the principles of basic life support and error management: mitigate the source of the injury, secure the airway, collect objective data, and then communicate the findings. Stopping the pump instantly halts the hazardous situation. Positioning laterally and suctioning prevent the immediate life-threatening complication of aspiration pneumonia. Finally, obtaining vital signs provides the necessary clinical data to effectively notify the RN and healthcare provider of the client's status.

Step-by-Step Solution

1
Immediately turn off the continuous enteral feeding infusion pump.
The infusion of formula is halted.
Eliminating the source of the error prevents additional volume from entering the stomach and refluxing into the airway.
2
Turn the client to a lateral (side-lying) position.
The airway is physically protected using gravity.
This position facilitates drainage of the regurgitated formula out of the mouth, preventing immediate aspiration into the lungs.
3
Suction the client's oral cavity to remove the visible enteral formula.
The airway is actively cleared of remaining hazards.
Suctioning removes the formula that the client is unable to effectively expectorate, ensuring a patent airway.
4
Obtain the client's oxygen saturation level and a full set of vital signs.
Objective clinical data is gathered.
Assessing vital signs determines the physiological impact of the aspiration event and establishes a baseline for further interventions.
5
Notify the registered nurse (RN) and the prescribing provider of the event and assessment findings.
The healthcare team is activated for advanced care.
Reporting the error along with current vital signs allows the RN and provider to order necessary follow-up care, such as oxygen therapy or a chest radiograph.

Key Concept

Immediate management of a medication/feeding administration error by prioritizing basic airway support and data collection before escalation.
Question 23Question →

A practical nurse (PN) is caring for a client with altered mental status who is repeatedly attempting to pull out their continuous intravenous (IV) catheter. Place the following nursing actions in the correct sequence, beginning with the initial action and progressing from the least restrictive to the most restrictive intervention. (All options must be used).

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Answer

The correct sequence is to first assess for physiological causes, then camouflage the tubing, provide a diversionary activity, arrange for a bedside sitter, and finally request a prescription for restraints as a last resort.
The nursing process requires assessing the client first to identify treatable causes of agitation. Once physiological needs are ruled out, the nurse must exhaust alternatives to restraints, escalating from passive environmental changes (camouflaging tubes) to active behavioral interventions (diversion), then to human supervision (a sitter). Only when all these less restrictive measures fail can the nurse request physical restraints.

Step-by-Step Solution

1
Assess the client's oxygen saturation, pain level, and bladder distention.
Rules out underlying physiological causes of agitation.
Assessment is always the first step in the nursing process to ensure physical needs are met.
2
Camouflage the intravenous tubing by wrapping it loosely in a cohesive bandage and placing it under the client's sleeve.
Removes the visual trigger.
Passive environmental modification is the least restrictive intervention.
3
Provide a safe diversionary activity, such as offering an activity apron or washcloths to fold.
Channels the client's restless energy safely.
Active behavioral redirection is slightly more restrictive but keeps the hands occupied without physical confinement.
4
Collaborate with the nursing supervisor to arrange for a continuous one-to-one bedside sitter.
Provides continuous supervision and verbal redirection.
A sitter restricts privacy but does not physically confine the client.
5
Notify the healthcare provider to request a prescription for bilateral soft wrist restraints.
Secures the medical device physically.
Restraints are the absolute last resort when all other less restrictive alternatives have failed.

Key Concept

The hierarchy of restraint alternatives dictates that nurses must first assess for physiological causes of agitation, then systematically implement interventions progressing from least restrictive (environmental and diversionary) to most restrictive (physical restraints).
Question 24Question →

A practical nurse (PN) enters a client's room and discovers an electrical outlet sparking, which has ignited a nearby privacy curtain. The client is bedbound and receiving continuous oxygen therapy. Arrange the following actions in the priority order the PN should perform them.

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Answer

The correct priority sequence is: 1) Transfer the client out of the room, 2) Activate the fire alarm, 3) Close the door and shut off oxygen, 4) Retrieve the extinguisher and pull the pin, 5) Aim at the base of the fire and squeeze the handle.
Emergency fire response in a healthcare setting is governed by the RACE acronym: Rescue, Alarm, Contain, Extinguish. The PN must first Rescue the bedbound client by moving them to a safe area. Second, the PN must activate the Alarm to summon help. Third, the PN must Contain the fire by closing the door and shutting off the oxygen valve. Finally, the PN can attempt to Extinguish the fire using the PASS technique: Pull the pin, Aim at the base, Squeeze the handle, and Sweep from side to side.

Step-by-Step Solution

1
Rescue the client from immediate danger.
The client is moved to a safe area away from the fire.
Life safety is always the primary focus; a bedbound client cannot evacuate themselves.
2
Activate the fire alarm.
Facility emergency response protocols are initiated.
Alerting other staff and the fire department ensures appropriate resources arrive to assist.
3
Contain the fire.
The room door is closed and the oxygen supply is disabled.
Closing the door limits oxygen feeding the fire and blocks smoke spread; turning off oxygen removes a highly combustible gas.
4
Prepare the fire extinguisher.
The safety pin is pulled on a Class C extinguisher.
Class C is appropriate for electrical fires. Pulling the pin unlocks the operating lever.
5
Extinguish the fire.
The extinguishing agent is discharged at the base of the flames.
Aiming at the base attacks the fuel source directly, and squeezing the handle releases the agent to smother the fire.

Key Concept

Emergency Fire Response (RACE and PASS protocols)
Question 25Question →

A practical nurse has completed wound care for a client placed on airborne and contact precautions due to disseminated varicella-zoster. The nurse is currently wearing a disposable isolation gown, an N95 respirator, a face shield, and gloves. Arrange the following steps for removing the personal protective equipment (PPE) in the correct chronological order to prevent environmental contamination and self-exposure.

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Answer

The correct sequence for doffing PPE is to first remove the gloves, then the face shield, followed by the gown. The nurse must then exit the room and close the door before removing the N95 respirator, finishing the process with hand hygiene.
According to standardized infection control guidelines, the most contaminated items must be removed first to prevent self-contamination. Gloves are removed first, immediately followed by the face shield. The gown is then unfastened and rolled inside-out. Crucially for airborne precautions, the nurse must completely exit the negative pressure room and close the door before removing the N95 respirator to prevent inhalation of infectious particles. Finally, hand hygiene is always performed as the last step to ensure no pathogens remain on the hands.

Step-by-Step Solution

1
Remove gloves.
Hands are freed from the most contaminated PPE.
Prevents the transfer of highly concentrated pathogens to the head and neck area during the removal of other PPE.
2
Remove face shield.
Eye protection is safely taken off without contaminating the face.
Must be removed by the clean ear pieces or headband before the gown to avoid reaching behind the neck while wearing a contaminated gown.
3
Remove isolation gown.
Gown is rolled inside-out and discarded in the designated receptacle.
The front and sleeves are heavily contaminated; removing it by folding it inward prevents environmental and uniform contamination.
4
Exit the isolation room.
Nurse leaves the patient environment and ensures the door is sealed.
Airborne precautions require the respirator to remain securely on until the nurse is outside the negative pressure environment.
5
Remove N95 respirator.
Respirator is discarded safely outside the patient room.
Protects the nurse from inhaling airborne particles (varicella-zoster) that are still circulating inside the patient's room.
6
Perform hand hygiene.
Hands are completely decontaminated.
Removes any pathogens potentially transferred to the bare hands during the entire PPE doffing process.

Key Concept

Standard Sequence for Removing (Doffing) Personal Protective Equipment
Question 26Question →

A practical nurse is preparing to transfer a client who has left-sided weakness from the edge of the bed to a wheelchair. In what order should the nurse perform the following actions?

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Answer

The nurse must first secure the environment by placing the wheelchair on the client's strong side and locking all brakes. Next, the nurse prepares the client with non-slip footwear and a transfer belt. Finally, the nurse executes the transfer by bracing the weak leg, assisting the client to stand, pivoting on the strong leg, and having the client reach for the armrests before sitting.
Safe transfer mechanics require setting up the environment first (wheelchair placement on the unaffected side with brakes locked), followed by client preparation (non-slip footwear and a transfer belt). During execution, the nurse must brace the weak side while the client bears weight and pivots on the strong side. Finally, the client secures their balance by reaching for the armrests before lowering into the seat.

Step-by-Step Solution

1
Position the wheelchair on the client's right side and lock all brakes.
The environment is safe and ready for the transfer.
Setting up the destination on the strong side prevents the client from having to cross over their weak side.
2
Apply non-slip footwear and check foot placement.
The client has a stable base of support.
Prevents slipping when weight-bearing begins.
3
Fasten the transfer belt around the waist.
A secure gripping point is established.
Ensures the nurse can lift safely without pulling on the client's arms or shoulders.
4
Brace the left knee and foot, then assist to stand.
The client achieves a standing position without collapsing.
The left side is weak and prone to buckling under body weight; bracing it provides necessary artificial support.
5
Pivot the client on their right leg.
The client is aligned squarely with the wheelchair.
Turning on the strong leg provides the necessary biomechanical stability.
6
Instruct the client to reach back for the armrests before sitting.
The client lowers safely into the chair.
Provides sensory feedback regarding the chair's location and allows for a controlled lowering motion.

Key Concept

Safe Client Transfer and Mobility
Question 27Question →

A practical nurse (PN) is caring for a client with a T4 spinal cord injury. The client suddenly reports a severe, pounding headache. The PN observes profuse diaphoresis above the level of the injury and records a blood pressure of 210/110 mm Hg. In which order should the PN perform the following actions? Arrange the actions from first to last.

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Answer

The correct sequence is: 1) Elevate the head of the bed, 2) Examine the urinary catheter, 3) Contact the registered nurse (RN), and 4) Document the findings.
Autonomic dysreflexia is a medical emergency characterized by severe hypertension and a pounding headache in clients with spinal cord injuries above T6. The first action is always to elevate the head of the bed to use orthostatic pressure changes to lower the blood pressure. Next, the PN must search for and resolve the trigger, which is most often a distended bladder caused by a kinked catheter. After taking these immediate independent bedside actions, the PN must notify the RN. Finally, the event and interventions should be documented once the client is safe.

Step-by-Step Solution

1
Elevate the head of the bed to a high-Fowler's position.
The client's upper body is raised, promoting orthostatic changes.
This immediately helps to lower the dangerously high blood pressure and decreases the risk of cerebral hemorrhage before any other action is taken.
2
Examine the indwelling urinary catheter system for kinks or obstructions.
The source of the autonomic dysreflexia trigger is identified and potentially resolved.
Bladder distention is the most common noxious stimulus causing autonomic dysreflexia; removing the stimulus halts the sympathetic nervous system surge.
3
Contact the registered nurse (RN) to report the abnormal findings.
The supervising nurse is informed of the acute change in status.
The RN or healthcare provider must be notified to evaluate the client, adjust the plan of care, or administer prescribed antihypertensive medications if the blood pressure does not resolve.
4
Document the client's vital signs and the sequence of events.
A legal and clinical record of the emergency and interventions is created.
Documentation is completed after the client is stabilized and the healthcare team is notified.

Key Concept

Prioritization of care for a client experiencing autonomic dysreflexia
Question 28Question →

A practical nurse is monitoring a client who began receiving a packed red blood cell transfusion 15 minutes ago. The client suddenly reports severe lower back pain, feeling chilled, and shortness of breath. Arrange the following nursing actions in the correct priority order.

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Answer

The correct priority sequence is: stop the transfusion, replace the tubing with a new set primed with normal saline, obtain vital signs, notify the charge nurse and provider, and finally return the blood products to the blood bank.
In an acute hemolytic transfusion reaction, the immediate priority is to stop the offending agent. Maintaining IV access is the next critical step for emergency fluid resuscitation, but it must be done with new tubing to prevent flushing residual blood into the client. Once the line is secure, the nurse assesses vital signs to determine the severity of the shock, which is then reported to the healthcare provider. Finally, once the client is stable and orders are executed, the blood products are returned to the laboratory for investigation.

Step-by-Step Solution

1
Recognize the clinical signs of a transfusion reaction.
Identify that lower back pain, chills, and shortness of breath indicate an acute hemolytic reaction.
Immediate recognition is required to halt the physiological insult.
2
Stop the transfusion immediately.
The instillation of incompatible red blood cells is halted.
This is the primary action to prevent further hemolysis and potential acute kidney injury.
3
Maintain IV access with new tubing and 0.9% sodium chloride.
Venous access is secured without administering residual blood.
Intravenous access is necessary for emergency resuscitation. A new tubing set prevents pushing the remaining incompatible blood into the client's circulation.
4
Gather objective clinical data.
Current vital signs and respiratory status are obtained.
The nurse needs a complete clinical picture to report to the provider.
5
Notify the charge nurse and healthcare provider.
The emergency is communicated using the SBAR framework.
The provider will use the vital signs and symptoms to prescribe emergency interventions such as vasopressors or diuretics.
6
Return the blood products to the blood bank.
The bag, tubing, and labels are sent for analysis.
This administrative task is done only after the client is stabilized to determine the exact cause of the reaction.

Key Concept

Prioritization of emergency nursing actions during an acute hemolytic transfusion reaction.
Question 29Question →

A practical nurse (PN) is collecting data on a client who has a complete spinal cord injury at the T4 level. The client suddenly reports a severe, throbbing headache and blurred vision. The PN observes profound diaphoresis on the client's face and neck, and the blood pressure is 215/115 mm Hg. Arrange the following nursing actions in the priority order the PN should perform them. (Place the first action at the top and the last action at the bottom.)

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Answer

The correct priority order is: 1) Elevate the head of the bed to a high Fowler's position, 2) Loosen any constrictive clothing or restrictive devices, 3) Inspect the indwelling urinary catheter tubing for kinks, 4) Reassess the client's blood pressure and heart rate, and 5) Notify the registered nurse (RN) and health care provider (HCP).
Autonomic dysreflexia is a life-threatening neurologic emergency characterized by a massive sympathetic surge in clients with spinal cord injuries at or above T6. The immediate priority is to lower the blood pressure to prevent a hemorrhagic stroke. Elevating the head of the bed accomplishes this rapidly through orthostatic hypotension. Once the client is upright, the nurse sequentially addresses external and internal noxious stimuli by loosening clothing and checking for bladder distention (the most frequent trigger). After removing potential triggers, the nurse reassesses the vital signs to evaluate the effectiveness of the interventions. Finally, the RN and HCP must be notified, especially if pharmacological management is required for persistent hypertension.

Step-by-Step Solution

1
Elevate the head of the bed to a high Fowler's position.
The client is placed in an upright, seated position.
This immediately induces orthostatic hypotension, using gravity to rapidly decrease the dangerously high blood pressure and prevent a stroke.
2
Loosen any constrictive clothing, abdominal binders, or anti-embolism stockings.
External restrictions and pressure points are removed.
Removing external physical irritants eliminates superficial noxious stimuli that can trigger or sustain the massive sympathetic response.
3
Inspect the indwelling urinary catheter tubing for kinks, obstruction, or dependent loops.
The urinary drainage system is assessed and restored to patency if blocked.
Bladder distention is the most common internal trigger for autonomic dysreflexia; resolving the blockage eliminates the primary noxious stimulus.
4
Reassess the client's blood pressure and heart rate.
Vital signs are evaluated following initial interventions.
Reassessment determines if the independent nursing interventions successfully lowered the blood pressure and resolved the sympathetic surge.
5
Notify the registered nurse (RN) and health care provider (HCP) of the client's condition.
The healthcare team is alerted to the client's status.
If conservative measures fail to resolve the hypertensive crisis, medical intervention (such as administering rapid-acting antihypertensive medications) is urgently required.

Key Concept

Prioritization of care for a client experiencing autonomic dysreflexia, focusing on immediate mechanical reduction of blood pressure followed by the sequential removal of external and internal noxious stimuli.
Estimated Time:2m 0s
Question 30Question →

A practical nurse (PN) is monitoring a client who is receiving a packed red blood cell (PRBC) transfusion. The client suddenly becomes restless and reports severe lower back pain, chills, and shortness of breath. In what order should the PN perform the following actions? Arrange the actions in the correct sequence from first to last.

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Answer

The correct sequence is to first stop the blood transfusion immediately, then replace the IV tubing and initiate an infusion of 0.9% sodium chloride. Next, the PN must notify the registered nurse (RN) and the healthcare provider, followed by obtaining a complete set of vital signs. Finally, the blood bag and attached tubing should be returned to the blood bank.
When a client exhibits signs of an acute hemolytic transfusion reaction (such as severe lower back pain, chills, and dyspnea), the absolute first priority is to stop the transfusion to prevent further exposure to the incompatible blood. Next, the nurse must maintain a patent intravenous line with 0.9% sodium chloride using completely new tubing. Using the old tubing would inadvertently push the remaining reactive blood into the client. After securing IV access, the nurse immediately notifies the RN and healthcare provider to initiate emergency medical interventions. Once help is notified, the nurse assesses vital signs to monitor hemodynamic stability. Finally, after the client is stable, the blood bag, tubing, and associated labels are returned to the blood bank for diagnostic investigation.

Step-by-Step Solution

1
Recognize the clinical manifestations of an acute hemolytic transfusion reaction.
Identifies the life-threatening emergency based on the client's symptoms.
Lower back pain, chills, and dyspnea are hallmark signs of a severe immune response that require immediate intervention.
2
Stop the blood transfusion immediately.
Halts the delivery of the incompatible blood product.
This is the absolute highest priority to prevent further physiological harm and limit the amount of reactive antigen entering the bloodstream.
3
Replace the IV tubing and initiate an infusion of 0.9% sodium chloride.
Maintains a patent IV access route with a compatible isotonic solution.
A patent IV is required for emergency fluid resuscitation and medications. New tubing is essential to avoid pushing the remaining reactive blood in the old tubing into the client.
4
Notify the registered nurse (RN) and the healthcare provider.
Escalates the clinical emergency to the appropriate personnel.
The RN and provider must rapidly evaluate the client and prescribe emergency pharmacological interventions.
5
Obtain a complete set of vital signs.
Establishes an objective clinical baseline of the client's hemodynamic status.
Vital signs help determine the severity of systemic shock and guide ongoing resuscitation efforts.
6
Return the blood bag and attached tubing to the blood bank.
Preserves the physical evidence of the transfusion.
The blood bank must analyze the remaining product and tubing to confirm the cause of the reaction (e.g., ABO incompatibility).

Key Concept

Prioritization of emergency interventions for an acute hemolytic transfusion reaction
Question 31Question →

A practical nurse (PN) is assisting with the care of a client who is 48 hours postoperative following an abdominal bowel resection. The client experiences a severe bout of coughing, followed by a sudden report of "my stomach tearing open." The PN inspects the surgical site and observes an active wound evisceration. Arrange the following nursing actions in the correct order of priority from first to last.

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Answer

The correct sequence of interventions is to first secure assistance while staying with the client, then properly position the client to reduce abdominal tension, cover the eviscerated bowel with sterile moistened dressings, obtain vital signs, and finally ensure the client remains NPO.
When an abdominal evisceration occurs, it is a life-threatening surgical emergency requiring a highly specific sequence of actions. The absolute highest priority is to ensure the client is not left alone while simultaneously mobilizing help and necessary sterile supplies via the call light. Because gathering supplies takes time, the immediate next step is to mechanically limit the evisceration by placing the client in a low Fowler's position with flexed knees to reduce intra-abdominal pressure. Once supplies are handed to the nurse, covering the bowel with sterile, saline-soaked gauze is critical to preserve tissue viability. Only after the exposed organs are physically protected should the nurse transition to systemic monitoring (vital signs) to assess for shock, followed by final preoperative preparations such as reinforcing NPO status.

Step-by-Step Solution

1
Ensure immediate safety by activating the call light.
Additional staff are alerted to bring sterile supplies and notify the healthcare provider.
The practical nurse cannot leave the unstable client to fetch supplies or make phone calls during a surgical emergency.
2
Position the client in low Fowler's with knees bent.
Tension on the abdominal musculature is immediately relieved.
Lowering intra-abdominal pressure mechanically stops further bowel loops from eviscerating while waiting for supplies to be brought to the bedside.
3
Cover the evisceration with moist, sterile dressings.
The protruding bowel is protected from the external environment.
Exposed viscera rapidly dry out and become necrotic; sterile saline preserves tissue viability and minimizes infection risk.
4
Assess the client's vital signs.
Baseline systemic hemodynamic data is collected.
Monitoring is crucial for detecting early signs of hemorrhagic shock, which follows the immediate stabilization of the wound itself.
5
Ensure the client remains strictly NPO.
The client is prepared for safe anesthesia administration.
Evisceration requires an emergency surgical repair; confirming NPO status prevents dangerous aspiration during the upcoming surgery.

Key Concept

Wound Evisceration Prioritization
Question 32Question →

A practical nurse is preparing to perform open tracheostomy suctioning for an adult client who has coarse crackles and a weak cough. To reduce the risk of hypoxia and mucosal trauma, arrange the following procedural steps in the correct chronological order.

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Answer

The correct sequence is to first verify suction pressure, then hyperoxygenate the client, advance the catheter without suction, withdraw slightly upon meeting resistance, and finally apply intermittent suction while rotating and withdrawing.
The correct sequence ensures the procedure is performed safely and minimizes severe physiological risks. First, the suction pressure is verified to prevent excessive vacuum trauma. Second, the client is hyperoxygenated to provide an oxygen reserve, as suctioning removes air alongside secretions. Third, the catheter is advanced without suction to avoid damaging the mucosal lining on the way down. Fourth, the catheter is withdrawn slightly after meeting resistance at the carina to prevent suctioning directly on sensitive bifurcated tissue. Finally, intermittent suction is applied while rotating and withdrawing to safely clear the airway.

Step-by-Step Solution

1
Verify the wall suction pressure is set to between 80 and 120 mm Hg.
Equipment is safely calibrated.
Prevents tracheal trauma from excessive negative pressure.
2
Hyperoxygenate the client using a manual resuscitation bag connected to 100% oxygen.
Client's oxygen reserves are maximized.
Prevents severe hypoxemia during the suctioning process, as suctioning removes both oxygen and secretions.
3
Advance the sterile catheter into the artificial airway without applying suction.
Catheter is positioned near the pooled secretions.
Applying suction during insertion strips the mucosal lining and depletes oxygen before reaching the target area.
4
Withdraw the catheter 0.5 to 1 cm (0.2 to 0.4 in) after meeting resistance.
Catheter tip is moved away from the sensitive carina.
The carina is highly sensitive and prone to bleeding or inducing severe bronchospasm if direct suction is applied to it.
5
Apply intermittent suction while rotating the catheter during withdrawal.
Secretions are effectively cleared with minimal trauma.
Rotating prevents the catheter from adhering to one spot on the tracheal wall, and limiting suction to withdrawal prevents prolonged hypoxia.

Key Concept

Tracheostomy Suctioning Safety Sequence
Estimated Time:1m 30s
Question 33Question →

A practical nurse (PN) on an orthopedic surgical unit is planning to delegate the ambulation of a client who is 2 days post-operative following a total hip arthroplasty to an assistive personnel (AP). Arrange the steps of the delegation process in the correct chronological order from first to last.

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Answer

The correct sequence follows the NCSBN Five Rights of Delegation: assess the client's condition, confirm the AP's competency, provide specific instructions, supervise the initial performance, and finally evaluate the client's response.
The delegation process must follow a structured, chronological path to ensure client safety and legal compliance. The PN must first assess the client's stability to establish the Right Circumstance. Only after establishing clinical stability should the PN verify the AP's specific competency for the task, ensuring the Right Person. Once competency is confirmed, the PN communicates clear parameters to provide the Right Direction. During the execution of the task, the PN provides necessary oversight for the Right Supervision. Finally, the PN reviews the outcome and documentation to complete the Right Evaluation.

Step-by-Step Solution

1
Assess the client's stability.
The PN determines the client is physiologically ready for the task.
Delegation cannot occur safely until the 'Right Circumstance' is established through nursing assessment.
2
Verify AP competency.
The PN ensures the AP knows how to maintain total hip precautions.
The PN must ensure the 'Right Person' is performing the task to prevent client injury (e.g., hip dislocation).
3
Provide clear directions.
The AP receives exact parameters for the ambulation.
The 'Right Direction/Communication' ensures the AP knows exactly what is expected and what to report.
4
Supervise the transfer.
The PN directly observes the highest-risk portion of the task.
The 'Right Supervision' allows the PN to correct any unsafe practices immediately during the initial transfer.
5
Evaluate the outcome.
The PN gathers feedback on how the client tolerated the activity.
The 'Right Evaluation' closes the delegation loop and allows the PN to update the plan of care.

Key Concept

NCSBN Five Rights of Delegation Sequence
Question 34Question →

A practical nurse is providing care for a client who is 3 days postoperative following an exploratory laparotomy. The client coughs forcefully, and the nurse observes a sudden separation of the surgical incision with loops of bowel protruding. In what order should the nurse perform the following actions? (Arrange the steps from first to last.)

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Answer

The correct sequence is to first call for assistance while staying with the client, then position the client to reduce abdominal tension, next cover the exposed organs with moist sterile dressings, and finally obtain vital signs.
When a client experiences wound evisceration, it is a life-threatening complication that requires immediate risk reduction. The priority is always client safety, which begins by calling for help while staying at the bedside. The next immediate physical need is to stop further evisceration by placing the client in a low Fowler's position with flexed knees to reduce abdominal tension. Once the tension is reduced, the nurse must protect the exposed tissue from necrosis by covering it with sterile, saline-soaked dressings. Finally, after the immediate physical threat is stabilized, the nurse assesses vital signs to monitor for shock while waiting for the surgical team.

Step-by-Step Solution

1
Initiate the emergency response.
Call for immediate assistance while remaining at the bedside.
Wound evisceration is a surgical emergency. The nurse must immediately secure help without leaving the unstable client alone.
2
Minimize further organ protrusion.
Place the client in a low Fowler's position with the knees flexed.
This specific position significantly reduces tension on the abdominal muscles, preventing more bowel from protruding through the incision.
3
Protect the exposed tissues.
Cover the bowel with sterile dressings soaked in sterile normal saline.
Exposed bowel can quickly dry out and become necrotic. A moist, sterile environment preserves the tissue until surgical intervention occurs.
4
Monitor for systemic deterioration.
Obtain and record the client's vital signs.
Evisceration can lead to rapid fluid shifts and hypovolemic or neurogenic shock, requiring close hemodynamic monitoring.

Key Concept

Management of Wound Evisceration
Question 35Question →

A practical nurse is monitoring a client who is receiving a packed red blood cell (PRBC) transfusion. Fifteen minutes into the infusion, the client suddenly reports severe lower back pain and chills. In what order should the practical nurse perform the following actions? Arrange the steps from first to last.

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Answer

The correct sequence is: Stop the blood transfusion, initiate 0.9% sodium chloride with new tubing, obtain vital signs, notify the registered nurse and healthcare provider, and finally send the remaining blood and tubing to the blood bank.
When a client exhibits signs of a severe transfusion reaction, such as lower back pain and chills, the absolute first priority is to stop the infusion. Once the source of harm is stopped, the nurse must maintain IV access using normal saline and new tubing to prepare for emergency medication administration. After securing the line, the nurse obtains vital signs to report a complete clinical picture to the RN and healthcare provider. Finally, the blood and tubing are sent to the blood bank per facility protocol for diagnostic analysis.

Step-by-Step Solution

1
Identify the immediate life threat and intervene.
The transfusion is stopped immediately.
Lower back pain and chills are classic signs of a hemolytic transfusion reaction. The source of the reaction must be halted immediately to minimize harm.
2
Maintain vascular access without worsening the reaction.
0.9% sodium chloride is infused through completely new tubing.
If the existing tubing is flushed, the remaining blood in the line will be pushed into the client. New tubing ensures only normal saline enters the vein, keeping the line open for emergency drugs.
3
Assess the client's physiological status.
A full set of vital signs is obtained.
The nurse needs current baseline data (blood pressure, heart rate, temperature, oxygen saturation) to understand the physiological impact of the reaction.
4
Escalate the situation to higher-level providers.
The RN and healthcare provider are notified.
The provider needs the assessment data to order appropriate interventions, such as antihistamines, corticosteroids, or vasopressors.
5
Preserve evidence for institutional analysis.
The blood bag and tubing are sent to the blood bank.
The blood bank must analyze the remaining product to identify cross-matching errors or bacterial contamination.

Key Concept

Reduction of Risk Potential: Emergency Management of Transfusion Reactions
Question 36Question →

A practical nurse is assisting a client with right-sided hemiplegia who is sitting on the edge of the bed to transfer into a wheelchair. In what order should the nurse perform the following actions? Arrange the steps from first to last.

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Answer

The correct sequence prioritizes environmental safety and leading with the strong side: Position the wheelchair on the left side, lock the wheels, apply a transfer belt, brace the right knee during the stand, and instruct the client to reach with their left hand.
Safe transfer of a client with hemiplegia requires moving toward the strong side. The environment is secured first (chair positioned on the strong left side, brakes locked). Next, the client is secured with a gait belt. During the pivot, the nurse protects the weak side by bracing the right knee, allowing the client to use their strong left arm and leg to guide the transfer safely.

Step-by-Step Solution

1
Analyze the client's deficit and prepare the environment.
The nurse identifies the left side as the strong side, positions the wheelchair on the left at a 45-degree angle, and locks all wheels.
Transfers must always be directed toward the unaffected side to maximize client participation and safety. Securing the environment prevents equipment from shifting during weight transfer.
2
Secure the client for physical movement.
The nurse applies a transfer (gait) belt around the client's waist.
The belt provides a secure grip for the nurse to control the client's descent if they begin to fall, avoiding pulling on the client's arms or shoulders.
3
Provide support to the compromised extremity during the lift.
The nurse braces the client's right knee with their own knee/foot while assisting the client to stand.
Right-sided hemiplegia means the right leg lacks motor control and strength; bracing it prevents the knee from buckling under the client's weight.
4
Utilize the strong side to complete the pivot and transfer.
The client reaches for the wheelchair armrest with their functional left hand before sitting.
Reaching with the strong arm maintains spatial orientation and provides a final point of stability as the client lowers into the chair.

Key Concept

Safe mobility and transfer techniques for clients with hemiplegia
Question 37Question →

A practical nurse (PN) and an assistive personnel (AP) are preparing to move a client up in bed using a draw sheet. The client has limited mobility but can follow commands. In what order should the PN perform the following actions to ensure safety and proper body mechanics? Arrange the steps in the correct chronological sequence.

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Answer

First, place the bed in a flat position at waist height. Second, remove the pillow and place it against the headboard. Third, instruct the client to cross their arms and bend their knees. Fourth, roll the draw sheet close to the client's sides. Fifth, shift weight from the back foot to the front foot to complete the move.
The correct sequence ensures maximum safety for both the client and the caregivers. Preparing the environment (bed height and positioning the pillow) must occur first to prevent strain and head injury. Next, preparing the client's body posture reduces friction and allows the client to assist. Finally, establishing a firm grip and utilizing leg muscles for the weight shift ensures the move is executed with proper ergonomics.

Step-by-Step Solution

1
Place the bed in a flat position and elevate it to the caregivers' waist height.
The environment is ergonomically optimized for the caregivers.
This establishes a safe center of gravity and prevents the nurses from fighting against the incline of the bed.
2
Remove the pillow from under the client's head and position it upright against the headboard.
The hard surface of the headboard is padded.
This vital safety step prevents accidental head trauma if the client is pulled upward too quickly.
3
Ask the client to cross their arms over their chest and bend their knees.
The client is positioned to minimize friction and assist with the move.
Having the client fold their arms prevents them from dragging on the bed, and bent knees allow the client to push off the mattress, reducing the physical load on the nurses.
4
Roll the draw sheet closely alongside the client's body and grasp it firmly.
The caregivers secure a strong, controlled grip.
Holding the sheet as close to the client as possible maintains the load near the nurses' center of gravity, which is a key principle of body mechanics.
5
Stand with a wide base of support and shift weight from the back foot to the front foot while moving the client.
The client is safely shifted toward the head of the bed.
Relying on the large muscles of the legs (shifting weight) rather than the smaller muscles of the lower back prevents musculoskeletal injuries.

Key Concept

Proper body mechanics and sequence of steps during patient positioning.
Question 38Question →

A practical nurse is initiating a 24-hour urine collection for a client on the medical-surgical unit to evaluate kidney function. In what chronological order should the nurse implement the steps for this diagnostic procedure? (Arrange from first to last)

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Answer

The correct sequence is to first discard the initial void, document the start time, collect all subsequent urine on ice for 24 hours, obtain a final void at the exactly 24-hour mark, and then transport the labeled container to the laboratory.
A 24-hour urine collection must measure only the urine produced within a strict 24-hour window. Therefore, the procedure begins by starting with an empty bladder (discarding the first void) and documenting that exact time. Over the next 24 hours, all subsequent urine must be collected and kept cold to preserve the specimen. At exactly 24 hours from the start time, the client voids one last time to empty the bladder of any urine produced during the final moments of the period. Finally, the complete and correctly labeled specimen is transported to the laboratory for analysis.

Step-by-Step Solution

1
Discard the initial void.
The bladder is emptied of urine formed prior to the testing period.
Including prior urine would falsely elevate the 24-hour analyte values.
2
Document the precise start time.
The 24-hour clock officially begins.
A precise start time is required to ensure the collection window lasts exactly 24 hours.
3
Collect all subsequent urine and keep it cold.
All urine produced during the testing window is preserved.
Missing any urine invalidates the test; refrigeration prevents chemical breakdown.
4
Obtain one last void at exactly 24 hours.
The 24-hour collection period is officially concluded.
This captures the very last amount of urine produced within the exact 24-hour timeframe.
5
Label and send the container to the laboratory.
The specimen is securely handed off for diagnostic processing.
Timely transport maintains specimen integrity.

Key Concept

24-Hour Urine Specimen Collection Protocol
Question 39Question →

Prior to entering the room of a client diagnosed with varicella, a nurse gathers the necessary personal protective equipment (PPE). Arrange the following donning steps in the correct sequence according to standard guidelines.

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Answer

The correct sequence for donning full PPE is to first secure the isolation gown, followed by applying the N95 respirator, then positioning the eye protection, and finally extending the gloves over the gown cuffs.
According to standardized infection control guidelines, the proper sequence for donning full PPE begins with the gown to protect clothing, followed by the mask or respirator to protect the airway. Eye protection is added next, and gloves are donned last to ensure they cover the gown's cuffs, maintaining a continuous protective barrier.

Step-by-Step Solution

1
Don the isolation gown.
The torso and clothing are covered.
The gown is the largest item and provides the foundational barrier for the body. It must be secured first.
2
Don the N95 respirator.
The respiratory tract is protected.
Applying the respirator before eye protection ensures the straps rest smoothly on the head and do not interfere with the goggles or face shield.
3
Don eye protection.
The eyes and face are protected from potential splashes or sprays.
Eye protection is placed over the mask or respirator, completing the facial barrier.
4
Don clean gloves.
The hands are covered, and the wrists are sealed.
Gloves must go on last so they can be extended over the gown cuffs, preventing any exposed skin at the wrists.

Key Concept

Centers for Disease Control and Prevention (CDC) sequence for donning personal protective equipment (PPE).
Estimated Time:1m 0s
Question 40Question →

A practical nurse (PN) is preparing to collect an aerobic wound culture from a client's stage 3 pressure injury. To ensure accurate laboratory results and reduce the risk of specimen contamination, arrange the following actions in the correct chronological sequence.

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Answer

The correct chronological sequence is: 1) Remove the soiled dressing, 2) Cleanse the wound bed with sterile normal saline, 3) Rotate a sterile swab over granulation tissue, 4) Place the swab into the sterile transport tube, and 5) Label the specimen container at the bedside.
The correct sequence ensures the culture reflects the true infectious organism rather than surface flora. Removing the dressing allows for assessment. Cleansing the wound prior to swabbing is a critical risk-reduction step to eliminate surface exudate. The swab is then applied to healthy granulation tissue, immediately placed in a transport medium to protect the sample, and labeled at the bedside to prevent identification errors.

Step-by-Step Solution

1
Remove the soiled dressing and assess the wound bed.
The wound is exposed for evaluation.
Allows the nurse to observe the wound's status before initiating the collection procedure.
2
Cleanse the wound bed with sterile normal saline.
Surface exudate and normal flora are washed away.
Prevents the culture from growing surface contaminants that do not represent the actual tissue infection.
3
Rotate a sterile swab over an area of healthy granulation tissue.
A sample of the infecting microorganism is obtained.
Pathogens actively causing infection are most concentrated in viable, granulating tissue.
4
Place the culture swab securely into the sterile transport tube.
The specimen is sealed in a supportive medium.
Protects the aerobic bacteria from dying or being contaminated by the external environment.
5
Label the specimen container in the presence of the client.
The specimen is correctly identified with the client's information.
Bedside labeling is a standard safety practice to eliminate the risk of sample mix-ups.

Key Concept

Proper specimen collection techniques for aerobic wound cultures to reduce the risk of inaccurate laboratory data.
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