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Question 381Question →

An older adult client is 24 hours postoperative following a bowel resection. The practical nurse (PN) is assisting with data collection and bedside care. Which actions indicate that the PN is safely prioritizing the client's physiological adaptation? Select all that apply.

Select all that apply

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Answer: Promptly reporting a heart rate of 112 beats/min and a blood pressure of 98/60 mm Hg to the supervising nurse.; Inspecting the surgical dressing for excessive drainage and monitoring intake and output to assess fluid volume status.; Encouraging the client to perform deep breathing and coughing exercises while splinting the abdominal incision.

Answer

The correct actions include reporting early signs of hemodynamic instability (tachycardia and borderline hypotension), monitoring fluid status via intake/output and dressing checks, and promoting respiratory adaptation through deep breathing and splinting.
The appropriate actions prioritize the client's physiological adaptation by directly addressing and monitoring postoperative risks. Reporting a heart rate of 112 beats/min and blood pressure of 98/60 mm Hg is crucial because these are early compensatory signs of hypovolemic shock. Inspecting the dressing and monitoring intake/output provides direct data collection regarding fluid balance and bleeding risk. Encouraging deep breathing with splinting prevents atelectasis and pneumonia, which are common respiratory complications following abdominal surgery.

Step-by-Step Solution

1
Evaluate the client's physiological status and risk for postoperative complications.
The client is at risk for hypovolemia, respiratory compromise, and infection.
Bowel resection surgery causes fluid shifts, blood loss, and abdominal pain that restricts deep lung expansion.
2
Identify priority findings that require immediate intervention or escalation.
Tachycardia, borderline hypotension, and low urine output are early signs of shock. New-onset confusion indicates poor perfusion or hypoxia.
Addressing Airway, Breathing, and Circulation (ABC) issues takes precedence over routine pain management.
3
Select the nursing actions that demonstrate safe and appropriate care.
Reporting vital sign changes, monitoring fluid balance, and promoting lung expansion are correct. Dismissing confusion, ignoring low urine output, or prioritizing pain over respiratory distress are incorrect.
Safe PN practice requires recognizing acute deterioration and escalating changes appropriately rather than normalizing them.

Key Concept

Postoperative Physiological Adaptation and Complication Recognition
Question 382Question →

A client with a tracheostomy requires suctioning to clear audible, coarse secretions. Arrange the following actions in the correct sequence that the practical nurse (PN) should perform to minimize the risk of hypoxia and mucosal trauma.

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Answer

The correct sequence is: hyperoxygenate the client, advance the catheter without suction, pull the catheter back slightly after meeting resistance, apply intermittent suction while rotating upon withdrawal, and finally reassess the client's status.
Performing tracheostomy suctioning requires a strict sequence to clear secretions safely. Preoxygenation protects against hypoxemia. Advancing without suction and pulling back at the carina prevents mucosal injury. Suctioning only on withdrawal with a twisting motion effectively clears mucus while avoiding tissue damage. Post-procedure assessment evaluates the success of the intervention.

Step-by-Step Solution

1
Hyperoxygenate the client with 100% oxygen.
The client's oxygen reserves are maximized.
Prevents severe hypoxemia when airflow is temporarily compromised by the suction catheter.
2
Advance the sterile suction catheter without applying suction.
The catheter is positioned deep into the trachea.
Applying suction during insertion damages the mucosal lining and unnecessarily depletes oxygen.
3
Pull the catheter back slightly (1 to 2 cm) after meeting resistance.
The catheter tip is positioned just above the carina.
Resting the suction tip directly on the sensitive carina causes severe coughing and tissue trauma.
4
Apply intermittent suction while rotating the catheter upon withdrawal.
Secretions are cleared from the airway.
Rotation prevents the catheter from adhering to one spot, and limiting suction minimizes airway collapse.
5
Reassess the client's oxygen saturation and lung sounds.
The effectiveness of the procedure is confirmed.
Ensures the airway is clear and oxygenation is stable before concluding care.

Key Concept

Airway Management and Complication Prevention
Question 383Question →

While conducting mid-morning rounds, a practical nurse observes that a conscious, alert client with type 1 diabetes mellitus is trembling, pale, and profusely diaphoretic. The client's point-of-care capillary blood glucose reading is 52 mg/dL (2.9 mmol/L). Place the following nursing actions in the correct chronological sequence to safely manage this situation.

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Answer

The correct sequence is to first administer a fast-acting carbohydrate, then recheck the glucose in 15 minutes, followed by providing a complex carbohydrate and protein snack, and finally documenting the event.
For a conscious client experiencing acute hypoglycemia, the priority is to immediately raise the blood glucose level using 15 grams of a simple carbohydrate. After a 15-minute interval, the nurse must recheck the glucose to evaluate if it has risen above 70 mg/dL. If the level is stable, a complex carbohydrate and protein snack is provided to maintain the glucose level over time. Documentation is always completed as the final step after the client is physically stabilized and the immediate risk is resolved.

Step-by-Step Solution

1
Administer 15 grams of a fast-acting carbohydrate.
Provides an immediate source of glucose to the bloodstream.
Rapidly reverses the hypoglycemic state, reducing the risk of central nervous system depression or seizures.
2
Reassess the capillary blood glucose level after 15 minutes.
Determines if the initial intervention was successful.
Ensures the blood glucose is rising appropriately, aiming for greater than 70 mg/dL, as dictated by standard hypoglycemia protocols.
3
Provide a complex carbohydrate and protein snack.
Supplies sustained energy over the next several hours.
Fast-acting carbohydrates metabolize quickly; a complex carbohydrate combined with protein prevents a rebound hypoglycemic episode before the next scheduled meal.
4
Document the hypoglycemic episode and interventions.
Creates a permanent record of the acute event.
Fulfills professional obligations by communicating the event to the broader healthcare team only after the client has been safely stabilized.

Key Concept

Reduction of Risk Potential: Emergency Protocol for Hypoglycemia Management
Question 384Question →

Four hours following an uncomplicated laparoscopic appendectomy, a client is transferred to the surgical step-down unit. The client reports feeling unusually anxious, very thirsty, and experiencing moderate abdominal aching. The practical nurse performs an initial assessment and observes that the client's skin is slightly cool and pale. The client's current vital signs reveal a blood pressure of 102/66 mm Hg, a heart rate of 110 beats/min, and a respiratory rate of 22 breaths/min. The preoperative baseline vital signs were blood pressure 130/76 mm Hg, heart rate 74 beats/min, and respiratory rate 16 breaths/min. Based on these findings, which intervention is the priority?

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Answer: Alert the supervising registered nurse to evaluate the client for potential hemorrhage.

Answer

Alert the supervising registered nurse to evaluate the client for potential hemorrhage.
The client is exhibiting the classic compensatory mechanisms of early hypovolemic shock: the heart rate increases to maintain cardiac output, and peripheral blood vessels constrict (causing cool, pale skin) to shunt blood to vital organs. The client's anxiety and thirst are also primary indicators of decreased tissue perfusion. Because identifying and treating shock is a time-sensitive emergency, the PN's highest priority is to alert the RN immediately to prevent further clinical deterioration.

Step-by-Step Solution

1
Analyze the client's postoperative symptoms.
The client has new-onset anxiety, thirst, and cool, pale skin.
Identifying symptom clusters helps distinguish between normal postoperative recovery and acute complications.
2
Compare current vital signs to the preoperative baseline.
Blood pressure has dropped from 130/76 to 102/66, and heart rate has increased significantly from 74 to 110 beats/min.
Trend analysis reveals physiological decompensation that a single set of vital signs might mask.
3
Synthesize the data to determine the underlying physiological issue.
The combination of tachycardia, relative hypotension, anxiety, thirst, and peripheral vasoconstriction indicates early hypovolemic shock.
Recognizing the physiological adaptation to internal bleeding is critical for prioritizing care.
4
Select the safest, most appropriate priority intervention within the PN scope of practice.
Immediate escalation to the RN is required.
Suspected internal hemorrhage is a life-threatening emergency requiring RN-level assessment, provider notification, and potential fluid/blood resuscitation.

Key Concept

Early Recognition of Hypovolemic Shock
Question 385Question →

A practical nurse (PN) is reviewing the electronic health record of an adult client admitted with an exacerbation of heart failure. The client is scheduled to receive a dose of oral furosemide. The morning laboratory results indicate a serum potassium level of 3.1 mEq/L3.1\text{ mEq/L}. The client's most recent vital signs include a blood pressure of 96/58 mm Hg96/58\text{ mm Hg} and a heart rate of 114 beats/min114\text{ beats/min}. Which of the following is the most appropriate action for the PN to take?

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Answer: Withhold the furosemide and immediately notify the registered nurse (RN).

Answer

The most appropriate action is to withhold the furosemide and immediately notify the registered nurse (RN).
The correct action is to withhold the furosemide and notify the registered nurse (RN). Furosemide is a loop diuretic that depletes potassium and fluid volume. The client's serum potassium is critically low (3.1 mEq/L3.1\text{ mEq/L}), placing them at immediate risk for cardiac dysrhythmias. Furthermore, the blood pressure of 96/58 mm Hg96/58\text{ mm Hg} and heart rate of 114 beats/min114\text{ beats/min} indicate potential hypovolemia or compromised perfusion. Giving the medication would dangerously worsen both the electrolyte imbalance and the hemodynamic instability. It is within the practical nurse's scope to withhold a potentially harmful medication and report critical assessment findings to the supervising RN.

Step-by-Step Solution

1
Analyze the client's laboratory values in relation to the prescribed medication.
The serum potassium level is 3.1 mEq/L3.1\text{ mEq/L}, which indicates hypokalemia. Furosemide is a potassium-wasting loop diuretic that will further lower this critical value.
Administering a loop diuretic to a hypokalemic client can lead to life-threatening cardiac dysrhythmias.
2
Evaluate the client's current vital signs for potential contraindications.
The blood pressure of 96/58 mm Hg96/58\text{ mm Hg} and heart rate of 114 beats/min114\text{ beats/min} suggest hypovolemia or decreased cardiac output.
Diuretics reduce intravascular volume; administering the dose could dangerously worsen the client's hypotension and tachycardia.
3
Determine the appropriate nursing intervention within the practical nurse (PN) scope of practice.
The PN must withhold the scheduled medication and escalate the critical findings to the supervising RN.
The PN acts to maintain client safety and collaborates with the RN when assessment findings require clinical judgment beyond the PN scope.

Key Concept

Safe administration of diuretics requires assessing for and responding to critical fluid volume deficits and electrolyte imbalances, specifically hypokalemia and hypotension.
Question 386Question →

A practical nurse (PN) is monitoring a client admitted with acute pancreatitis who is receiving continuous intravenous (IV) fluids. Which of the following findings or situations require the PN to immediately escalate care to the registered nurse (RN)? Select all that apply.

Select all that apply

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Answer: A blood pressure of 86/54 mm Hg and a heart rate of 118 beats/minute; A positive Chvostek sign with a serum calcium level of 7.2 mg/dL (1.8 mmol/L); A new prescription for intravenous push (IVP) morphine for severe abdominal pain

Answer

The situations requiring immediate RN escalation are the hypotensive and tachycardic vital signs, the positive Chvostek sign with hypocalcemia, and the prescription for intravenous push (IVP) morphine.
The correct selections represent clinical emergencies and scope of practice limitations. Hypotension with tachycardia suggests hypovolemic shock, a major risk in pancreatitis due to third-spacing of fluids. A low serum calcium level (normal 9.0-10.5 mg/dL) with a positive Chvostek sign indicates impending tetany, requiring urgent RN intervention. Finally, the administration of intravenous push (IVP) medications falls outside the standard practical nurse scope of practice, requiring the RN to assume this task.

Step-by-Step Solution

1
Analyze the client's vital signs for indications of systemic complications.
A blood pressure of 86/54 mm Hg with a heart rate of 118 beats/minute indicates potential hypovolemic shock (third-spacing).
Hypovolemic shock is a severe complication of acute pancreatitis requiring immediate RN and provider intervention.
2
Evaluate the laboratory results and physical assessment findings.
A calcium level of 7.2 mg/dL is critically low, and a positive Chvostek sign confirms symptomatic hypocalcemia.
Symptomatic hypocalcemia can lead to tetany and requires immediate RN escalation for IV calcium administration.
3
Review the medication orders against the practical nurse (PN) scope of practice.
The prescription includes intravenous push (IVP) morphine.
IVP medications are outside the standard PN scope of practice; therefore, the RN must be notified to administer the medication.
4
Differentiate between expected disease findings and true emergencies.
An elevated serum amylase, a mild temperature elevation, and a request to leave medications at the bedside do not require RN escalation.
The PN can independently monitor expected diagnostic findings (amylase), benign vitals, and enforce standard medication safety rights.

Key Concept

Reduction of risk potential requires the practical nurse to recognize life-threatening complications (e.g., hypovolemic shock, symptomatic hypocalcemia) and identify tasks outside their scope of practice (e.g., IVP medications) to promptly escalate care to the registered nurse.
Question 387Question →

Two hours following a percutaneous liver biopsy, a client calls the nursing station to report sudden, sharp pain in the right shoulder. Current vital signs reveal a heart rate of 106 beats/minute and a blood pressure of 102/62 mm Hg, compared to a pre-procedure baseline of 78 beats/minute and 126/74 mm Hg. Which action should the practical nurse take first?

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Answer: Alert the registered nurse about the new symptom and vital sign changes

Answer

The practical nurse should prioritize reporting these findings to the registered nurse, as they strongly suggest an internal hemorrhage.
Following a liver biopsy, the development of right shoulder pain can indicate diaphragmatic irritation from an internal hemorrhage (subcapsular hematoma). When this symptom is combined with an increased heart rate and decreased blood pressure, it strongly suggests early hypovolemic shock. The practical nurse must immediately alert the registered nurse so that rapid assessment and medical interventions can be initiated.

Step-by-Step Solution

1
Analyze the client's symptoms and vital sign trends.
The client has developed right shoulder pain, tachycardia, and a dropping blood pressure compared to baseline.
To recognize early signs of a severe post-procedural complication, specifically subcapsular bleeding causing diaphragmatic irritation (referred pain).
2
Determine the appropriate scope of practice for the practical nurse.
The findings represent an acute, unstable change in the client's condition.
Unstable clients or those experiencing acute complications require rapid assessment and intervention beyond the practical nursing scope.
3
Select the priority nursing action.
Alerting the registered nurse is the immediate priority.
To ensure rapid medical escalation and intervention for potential hypovolemic shock.

Key Concept

Identifying early signs of internal bleeding post-liver biopsy (referred shoulder pain, tachycardia, hypotension) and escalating care appropriately.
Question 388Question →

A charge nurse in an acute care facility is observing a newly licensed practical nurse (PN) provide care to a group of assigned clients. Which of the following actions by the PN require immediate intervention by the charge nurse? Select all that apply.

Select all that apply

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Answer: Filing a laboratory report showing a serum potassium level of 2.8 mEq/L without verbally notifying the registered nurse (RN); Documenting a postoperative client's heart rate of 118 beats/min and blood pressure of 88/54 mm Hg and proceeding to evaluate the next client; Administering a scheduled oral antibiotic after verifying the client's identity using only the room number on the door

Answer

The actions requiring intervention are filing a critically low potassium level without verbal notification, ignoring borderline vital signs indicative of postoperative shock, and verifying a client's identity using only a room number.
The correct selections represent dangerous practice errors that compromise client safety. Failing to verbally escalate a critically low potassium level, ignoring early vital sign trends indicative of postoperative shock, and bypassing proper two-identifier medication verification are all serious violations of risk reduction protocols that require immediate correction by the charge nurse.

Step-by-Step Solution

1
Analyze the role and scope of practice of the practical nurse (PN) in an acute care setting.
The PN is responsible for collecting data, recognizing abnormal findings, escalating critical changes to the RN, and adhering to strict safety protocols.
Understanding the boundaries of the PN scope is necessary to identify when an action is unsafe.
2
Evaluate each action to determine if it violates safety standards or represents a failure to reduce client risk.
Failing to report a potassium of 2.8 mEq/L, ignoring early shock vitals, and using a room number for medication administration are all critical safety violations.
These specific actions place the clients at immediate risk for fatal arrhythmias, unmanaged hemorrhage, and medication errors.
3
Differentiate the unsafe actions from those that are appropriate within the PN scope.
Reinforcing teaching, properly withholding digoxin for bradycardia, and collecting a sterile catheter specimen are all safe, standard PN responsibilities that do not require intervention.
This confirms which specific actions the charge nurse needs to correct immediately.

Key Concept

Risk Reduction and Practical Nurse Scope of Practice
Question 389Question →

A client residing in a long-term care facility requires scheduled medications via a percutaneous endoscopic gastrostomy (PEG) tube. The primary health care provider prescribes liquid levetiracetam 750 mg750 \text{ mg} every 12 hours12 \text{ hours} for seizure management. The supplied medication concentration is 100 mg/mL100 \text{ mg/mL}. According to the facility's enteral medication protocol, the practical nurse must flush the tube with 30 mL30 \text{ mL} of purified water immediately before and 30 mL30 \text{ mL} immediately after administering the medication. Calculate the total fluid volume in milliliters the nurse will administer for a single medication sequence, including the flushes. Record answer to the nearest tenth. Do not include units in answer.

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Answer: 67.5

Answer

67.5
To determine the total volume administered, the nurse must first calculate the medication volume using the standard formula: Dose desired / Dose on hand = Volume to administer. Therefore, 750 mg÷100 mg/mL=7.5 mL750 \text{ mg} \div 100 \text{ mg/mL} = 7.5 \text{ mL}. Next, the nurse must add the flush volumes required before and after the medication to find the total fluid amount for this procedure: 7.5 mL+30 mL+30 mL=67.5 mL7.5 \text{ mL} + 30 \text{ mL} + 30 \text{ mL} = 67.5 \text{ mL}.

Step-by-Step Solution

1
Calculate the volume of the prescribed medication dose.
7.5 mL7.5 \text{ mL}
The required dose (750 mg750 \text{ mg}) must be divided by the concentration available (100 mg/mL100 \text{ mg/mL}) to determine how many milliliters of the liquid medication to draw up.
2
Calculate the total volume of fluid to be administered by adding the medication volume and both flush volumes.
67.5 mL67.5 \text{ mL}
To accurately document the client's fluid intake and ensure proper administration, the nurse must combine the medication volume (7.5 mL7.5 \text{ mL}), the pre-administration flush (30 mL30 \text{ mL}), and the post-administration flush (30 mL30 \text{ mL}).

Key Concept

Enteral Medication Administration and Dosage Calculation
Question 390Question →

A practical nurse is gathering supplies to enter the isolation room of an infant diagnosed with respiratory syncytial virus (RSV). The facility protocol requires full personal protective equipment (PPE) for this assignment. Arrange the following actions for putting on the required PPE in the correct chronological sequence.

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Answer

The correct sequence is to first perform hand hygiene, then put on the gown, followed by the mask, then the goggles or face shield, and finally the gloves.
According to standard CDC guidelines for infection control, the proper sequence for donning full personal protective equipment begins with hand hygiene to ensure cleanliness. The isolation gown is applied first to cover the torso and arms. Next, the mask is secured to protect the respiratory mucous membranes. Goggles or a face shield are applied over the mask to protect the eyes. Finally, gloves are donned last so they can be pulled securely over the wrist cuffs of the isolation gown, creating an unbroken barrier between the nurse and the client environment.

Step-by-Step Solution

1
Determine the correct starting point before applying any protective gear.
Hand hygiene must be performed first.
Starting with clean hands prevents the transfer of environmental pathogens onto the clean PPE supplies.
2
Identify the first physical garment to be worn.
The isolation gown is put on next.
The gown provides broad body coverage and serves as the primary base layer of the barrier protocol.
3
Determine the order for facial and respiratory protection.
The mask is applied before the goggles or face shield.
Securing the mask first ensures it fits tightly against the face. Eye protection is then placed over the top edge of the mask.
4
Identify the final step in the sequence.
Gloves are put on last.
Donning gloves at the end allows the nurse to pull the glove openings directly over the gown's long sleeves, creating a continuous seal without exposed skin.

Key Concept

Centers for Disease Control and Prevention (CDC) standardized sequence for donning personal protective equipment (PPE).
Question 391Question →

A healthcare provider prescribes cefazolin 350350 mg intramuscularly (IM) every 88 hours for a client with a respiratory infection. The medication is supplied in a vial containing 500500 mg of cefazolin powder. The reconstitution instructions on the label state: 'Add 2.02.0 mL of sterile water for injection to provide a total reconstituted volume of 2.22.2 mL.' How many milliliters (mL) should the practical nurse (PN) withdraw to administer one dose? Record your answer to the nearest tenth. Do not include units in your answer.

Show answer & explanation

Answer: 1.5

Answer

1.5
To calculate the correct volume for a reconstituted medication, the nurse must use the total volume yielded after the powder is dissolved, not just the volume of the diluent added. The formula is DesiredHave×Volume=350500×2.2=1.54\frac{\text{Desired}}{\text{Have}} \times \text{Volume} = \frac{350}{500} \times 2.2 = 1.54 mL. Rounded to the nearest tenth, the correct amount to administer is 1.51.5 mL.

Step-by-Step Solution

1
Identify the prescribed desired dose.
350350 mg
This is the target amount of medication required for a single administration.
2
Determine the final concentration of the medication on hand.
500500 mg in 2.22.2 mL
When reconstituting a powder, the total resulting volume (2.22.2 mL), not the diluent volume (2.02.0 mL), must be used to calculate concentration because the powder adds displacement volume.
3
Apply the dosage calculation formula: DesiredHave×Volume\frac{\text{Desired}}{\text{Have}} \times \text{Volume}.
350500×2.2\frac{350}{500} \times 2.2
This mathematical relationship ensures the correct proportion of liquid is drawn to deliver the exact milligram amount requested.
4
Calculate the exact volume and round to the nearest tenth.
1.541.54 mL rounds to 1.51.5 mL
Rounding instructions require one decimal place for standard clinical precision.

Key Concept

Reconstituted Medication Dosage Calculation
Question 392Question →

A practical nurse and an assistive personnel (AP) are preparing to move a postoperative client who has limited mobility up in bed using a draw sheet. In what order should the nurse perform the following actions? Arrange the steps in the correct sequence.

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Answer

1. Lower the head of the bed. 2. Place the pillow against the headboard. 3. Have the client fold arms and bend knees. 4. Roll the draw sheet tightly. 5. Slide the client upward on the count of three.
Moving a client up in bed requires careful sequencing to ensure the safety of both the client and the nursing staff. The procedure must begin by minimizing gravitational resistance, which is achieved by laying the bed flat. Next, the client's head must be protected by placing the pillow against the headboard. Preparing the client's body by crossing their arms and bending their knees reduces friction and allows the client to assist in the move. Finally, establishing a firm grip on the draw sheet close to the client's body allows for a safe, coordinated slide on the count of three, preventing shearing injuries and staff back strain.

Step-by-Step Solution

1
Lower the head of the bed to a completely flat position.
The bed is horizontal, removing the incline.
Moving a client up an incline increases the physical strain on staff and the friction on the client's skin. A flat bed uses gravity properly.
2
Remove the pillow from under the client's head and place it against the headboard.
The headboard is padded by the pillow.
This crucial safety step prevents head trauma if the client is pulled too far upward during the maneuver.
3
Ask the client to fold their arms across their chest and bend their knees.
The client is in a compact position.
Crossing arms prevents injury and reduces surface area friction. Bending knees allows the client to use their leg muscles to help push.
4
Roll the edges of the draw sheet tightly against the sides of the client's body.
The draw sheet is prepared for grasping.
Holding the draw sheet close to the client's center of gravity improves biomechanics and reduces the risk of dropping or rolling the client.
5
Coordinate with the AP to shift weight and slide the client upward on the count of three.
The client is repositioned appropriately in the bed.
Coordinated action ensures a smooth transfer, reducing shearing forces on the client's skin and minimizing musculoskeletal strain on the staff.

Key Concept

Proper body mechanics and client safety during mobility assistance
Question 393Question →

A practical nurse (PN) is participating in the care of a client who is 24 hours postoperative following an exploratory laparotomy and small bowel resection. Which of the following actions by the PN demonstrate appropriate application of risk reduction principles? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Assisting the client with early ambulation in the hallway to prevent postoperative complications such as atelectasis and venous stasis.; Notifying the registered nurse immediately when the client's nasogastric tube drainage abruptly changes from dark brown to bright frank red.; Instructing the client to firmly splint the abdominal incision with a pillow while performing deep breathing and coughing exercises.

Answer

The correct actions demonstrating risk reduction are assisting with early ambulation, immediately reporting the change in nasogastric drainage to bright red, and teaching the client to splint the incision during coughing.
Appropriate risk reduction in the postoperative period includes proactive interventions that prevent complications and the prompt escalation of abnormal findings. Early ambulation promotes adequate circulation and pulmonary expansion, reducing the risk of deep vein thrombosis and atelectasis. Bright red nasogastric drainage 24 hours postoperatively is an abnormal finding suggesting active hemorrhage and requires immediate escalation to the RN. Furthermore, splinting the abdominal incision during coughing reduces mechanical strain on the suture line, preventing painful wound dehiscence and evisceration.

Step-by-Step Solution

1
Evaluate each option against established standards of care and risk reduction principles for a postoperative client.
Identify actions that prevent complications and recognize those that represent clinical errors or missed signs of deterioration.
Risk reduction involves proactive measures to prevent harm and timely recognition of adverse clinical events.
2
Analyze the vital signs and laboratory data presented in the scenarios.
Recognize that a heart rate of 118 bpm with a blood pressure of 92/60 mm Hg may indicate hypovolemic shock, and a potassium level of 2.8 mEq/L is critically low.
Both findings represent significant physiological instability requiring immediate escalation to the RN or provider, rather than reassurance or delayed reporting.
3
Review procedural standards for medication administration and post-procedure care.
Determine that using a room number for identification is an unsafe practice, while splinting incisions and assisting with early ambulation are evidence-based preventative measures.
Adhering to strict safety protocols (like utilizing two approved patient identifiers) and implementing preventative care interventions directly reduces client risk.

Key Concept

Application of Risk Reduction Principles in Postoperative Care
Question 394Question →

A practical nurse is planning care for a client who is on contact precautions due to a Methicillin-resistant *Staphylococcus aureus* (MRSA) infection. Which instruction is most appropriate for the nurse to give the unlicensed assistive personnel (UAP) assigned to assist this client?

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Answer: Keep the reusable blood pressure cuff and thermometer inside the client's room.

Answer

Instruct the UAP to keep dedicated reusable equipment, such as a blood pressure cuff and thermometer, inside the client's room.
The most appropriate instruction is to use dedicated equipment. Contact precautions require that the client has their own dedicated patient-care equipment (such as thermometers, blood pressure cuffs, and stethoscopes) to prevent the transmission of infectious agents like MRSA to other clients or surfaces. This equipment remains in the room until the client is discharged or the precautions are discontinued.

Step-by-Step Solution

1
Identify the transmission-based precaution requirements for the client's specific pathogen.
MRSA requires contact precautions, which mandate the use of gowns and gloves for all room interactions and the prevention of indirect contact transmission.
Understanding the mode of transmission dictates the necessary environmental and personal protective interventions.
2
Determine the appropriate equipment protocols for contact precautions.
Single-use or dedicated reusable equipment must be utilized and remain in the client's room.
Sharing equipment between clients increases the risk of spreading the pathogen via fomites.
3
Evaluate the appropriateness of the instruction for the UAP's scope of practice.
The instruction to use and maintain dedicated equipment is a safe, routine task parameter suitable for a UAP.
It focuses on environmental safety and basic care rather than clinical assessment or evaluation.

Key Concept

Contact Precautions and Dedicated Equipment
Question 395Question →

An adult client who recently underwent orthopedic surgery is receiving care on a medical-surgical unit. The client reports a pain level of 8 on a 0-to-10 scale and requests their prescribed as-needed (PRN) oral oxycodone. During the pre-administration assessment, the practical nurse (PN) notes that the client is extremely drowsy and has a respiratory rate of 9 breaths per minute. Which of the following actions should the PN take?

Show answer & explanation

Answer: Withhold the oxycodone and immediately report the client's respiratory status to the registered nurse.

Answer

The PN must withhold the oxycodone and immediately report the client's respiratory status to the registered nurse.
The correct action is to withhold the oxycodone and report the findings to the registered nurse. Oxycodone is an opioid analgesic that causes central nervous system depression. A respiratory rate of 9 breaths per minute indicates respiratory depression (normal is 12-20 breaths per minute). The PN must prioritize airway and breathing (ABC framework) over pain management, safely withhold the contraindicated medication, and escalate the critical finding to the RN.

Step-by-Step Solution

1
Assess the client's pre-administration vital signs and level of consciousness.
The respiratory rate is 9 breaths per minute, which indicates significant bradypnea and respiratory depression.
Opioid analgesics like oxycodone depress the central nervous system, and a safe respiratory baseline (typically 12 or more breaths per minute) is required before administration.
2
Evaluate findings against the ABC (Airway, Breathing, Circulation) prioritization framework.
Breathing is compromised, making it a higher priority than the client's severe pain.
Airway and breathing must always take precedence over pain management in emergent or unstable clinical scenarios.
3
Determine the appropriate action based on the practical nurse (PN) scope of practice.
The medication is withheld and the abnormal finding is escalated to the supervising registered nurse (RN).
The PN must safeguard the client by withholding contraindicated medications and reporting critical deviations to the RN for further medical evaluation.

Key Concept

Opioid administration safety, ABC prioritization, and the practical nurse scope of practice regarding critical assessment findings.
Question 396Question →

A practical nurse is assisting a client with right-sided weakness and a history of dysphagia to eat their prescribed pureed meal. During the meal, the client begins to cough continuously and their voice sounds noticeably wet and gurgly. Which of the following is the priority action for the nurse to take?

Show answer & explanation

Answer: Stop the feeding immediately and ensure the client remains in a high upright position.

Answer

Stop the feeding immediately and ensure the client remains in a high upright position.
A continuous cough and a wet, gurgly voice during a meal are critical indicators of potential aspiration. The immediate priority is to stop the intake of food to protect the airway and keep the client upright to prevent further aspiration.

Step-by-Step Solution

1
Identify the clinical signs presented in the scenario.
The client has a continuous cough and a wet, gurgly voice while eating.
Recognizing these symptoms is essential to identify active aspiration in a client with known dysphagia.
2
Apply the principles of airway, breathing, and circulation (ABC) prioritization.
The airway is currently compromised by the food intake.
In any emergency or potential emergency, protecting the airway is the absolute first priority.
3
Determine the most appropriate immediate nursing intervention.
The nurse must immediately halt the feeding process and maintain the client in a safe, upright position.
Stopping the meal removes the source of the aspiration, and an upright position uses gravity to help prevent further material from entering the trachea.

Key Concept

Aspiration Precautions and Airway Prioritization in Dysphagia
Question 397Question →

A practical nurse (PN) is preparing to administer scheduled morning doses of oral digoxin and furosemide to a client diagnosed with heart failure. Which actions must the PN take to ensure safe medication administration? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Auscultate the client's apical pulse for one full minute.; Review the client's most recent serum potassium laboratory results.; Ask the client to state their name and verify their date of birth on the identification band.

Answer

The practical nurse must auscultate the apical pulse for one full minute, review the most recent serum potassium results, and verify the client's identity using their name and date of birth.
Safe administration of this specific medication combination requires evaluating the apical pulse because digoxin slows the heart rate, and reviewing serum potassium because furosemide can cause hypokalemia, which in turn increases the risk of digoxin toxicity. Furthermore, standard medication safety mandates using two proper client identifiers, such as the client's name and date of birth.

Step-by-Step Solution

1
Analyze the prescribed medications and their physiological implications.
The client is receiving digoxin, which affects the heart rate, and furosemide, which promotes fluid and potassium loss.
Understanding the pharmacokinetics and adverse effects of these medications dictates the necessary pre-administration clinical assessments.
2
Determine the specific safety parameters for these medications.
An apical pulse check is mandatory for digoxin. A serum potassium level check is required because furosemide-induced hypokalemia precipitates digoxin toxicity.
These targeted assessments ensure the medications are safe to administer at the current time and prevent life-threatening complications.
3
Apply general medication administration rights and scope of practice limitations.
The PN must use two acceptable client identifiers (name and date of birth). Adjusting doses or ignoring critical lab values is unsafe and outside the PN scope of practice.
Strict adherence to the rights of medication administration and professional boundaries prevents medication errors and client harm.

Key Concept

Safe administration of concurrent digoxin and furosemide requires assessing the apical pulse, monitoring serum potassium to prevent toxicity, and strictly adhering to the rights of medication administration within the practical nurse scope of practice.
Question 398Question →

A practical nurse (PN) is caring for a client who had an uncomplicated vaginal delivery 4 hours ago. The client reports feeling dizzy. The PN observes that the client's perineal pad, which was changed 30 minutes ago, is now completely saturated with dark red blood. Current vital signs are blood pressure 96/58 mm Hg and heart rate 115 beats/min. Which of the following actions should the PN take first?

Show answer & explanation

Answer: Massage the client's uterine fundus and immediately alert the registered nurse (RN).

Answer

Massage the client's uterine fundus and immediately alert the registered nurse (RN).
The client is displaying explicit signs of postpartum hemorrhage (saturating a pad in less than 1 hour) and early hypovolemic shock (dizziness, tachycardia, and hypotension). The priority action within the practical nurse's scope is to palpate and massage the uterine fundus to stimulate contraction and control the bleeding, while simultaneously notifying the registered nurse (RN) for immediate collaborative intervention.

Step-by-Step Solution

1
Analyze the client's symptoms and vital signs.
The client has dizziness, tachycardia (115 beats/min), and hypotension (96/58 mm Hg), which are all indicators of compromised circulation.
Identifying abnormal vital signs is essential for recognizing early stages of hypovolemic shock.
2
Evaluate the volume and rate of perineal blood loss.
Saturating a pad in 30 minutes is excessive bleeding, confirming an active postpartum hemorrhage.
Normal lochia does not completely saturate a pad in under an hour; rapid saturation requires emergency intervention.
3
Determine the priority nursing intervention within the PN scope of practice.
The immediate physical intervention is fundal massage, combined with rapid escalation to the RN.
Fundal massage helps an atonic uterus contract to stop the bleeding, while RN notification ensures emergency medical protocols can be initiated.

Key Concept

Recognizing and Managing Postpartum Hemorrhage and Hypovolemic Shock
Question 399Question →

A practical nurse (PN) is assigned to a team of clients on a step-down unit. Which medication administration action demonstrates appropriate clinical judgment and adherence to the PN scope of practice?

Show answer & explanation

Answer: Withholding a prescribed dose of oral atenolol and alerting the registered nurse after auscultating an apical pulse of 52 beats per minute.

Answer

The correct action is withholding the prescribed dose of oral atenolol and alerting the registered nurse after auscultating an apical pulse of 52 beats per minute.
Atenolol is a beta-adrenergic blocking agent that reduces myocardial workload and heart rate. Prior to administering any beta-blocker, the nurse must assess the client's apical pulse. If the heart rate is less than 60 beats per minute in an adult, the safe and appropriate action within the PN scope of practice is to withhold the medication and promptly notify the registered nurse or healthcare provider to prevent severe bradycardia and decreased cardiac output.

Step-by-Step Solution

1
Evaluate each action against the established practical nurse (PN) scope of practice.
IV push medications are identified as an RN responsibility, eliminating the hydromorphone option.
Maintaining practice boundaries ensures client safety during high-risk medication administration.
2
Analyze the remaining options for pharmacological contraindications.
Live vaccines are contraindicated in immunosuppressed clients, eliminating the varicella vaccine option.
Systemic corticosteroids suppress the immune system, making live vaccines dangerous.
3
Review the options for adherence to fundamental medication safety protocols.
Visual recognition is not an acceptable identifier, eliminating the pantoprazole option.
Two unique identifiers are universally required prior to any medication administration.
4
Assess the final option for correct pre-administration parameters.
Withholding a beta-blocker for a heart rate below 60 beats per minute and reporting it to the RN is the correct, safe action.
Beta-blockers lower heart rate; administering them to a bradycardic client can cause severe hemodynamic compromise.

Key Concept

The practical nurse must integrate pharmacology knowledge (drug effects and contraindications), safety protocols (medication rights), and scope of practice (withholding vs. administering IV push) to ensure safe client care.
Question 400Question →

A practical nurse is reviewing the plan of care for a newly admitted client who has a confirmed diagnosis of seasonal influenza. Which of the following transmission-based precautions should the nurse implement? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Place the client in a private room.; Wear a standard surgical mask when entering the client's room.; Apply a standard surgical mask to the client if transport outside the room is necessary.

Answer

The nurse should implement droplet precautions, which include placing the client in a private room, wearing a standard surgical mask when entering the room, and having the client wear a surgical mask during transport.
Seasonal influenza is transmitted via large respiratory droplets. Appropriate droplet precautions require placing the client in a private room to prevent exposure to other clients. Healthcare personnel must wear a standard surgical mask when entering the room to protect their own mucous membranes from infectious droplets. If the client must leave the room for diagnostic tests or procedures, a standard surgical mask should be placed on the client to contain their respiratory secretions.

Step-by-Step Solution

1
Identify the mode of transmission for the specified pathogen.
Seasonal influenza is transmitted via large respiratory droplets generated by coughing, sneezing, or talking.
Determining the transmission route is the first step in selecting the correct isolation precautions.
2
Select the appropriate transmission-based precautions category based on the pathogen.
Droplet precautions are required for influenza, in addition to routine standard precautions.
Droplet precautions are specifically designed to prevent the spread of pathogens that travel short distances through the air.
3
Determine the specific nursing interventions associated with droplet precautions.
Appropriate interventions include assigning a private room, the nurse wearing a surgical mask, and the client wearing a surgical mask if transported outside the room.
These specific actions contain the respiratory droplets at the source and protect the nurse's mucous membranes from exposure.

Key Concept

Droplet Precautions
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