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Question 421Question →

A practical nurse is assigned to care for a client who has bacterial conjunctivitis and a history of open-angle glaucoma. The provider has prescribed timolol maleate ophthalmic solution (drops) and erythromycin ophthalmic ointment for the right eye. In which order should the nurse perform the following actions to safely administer these medications? Arrange the steps in the correct chronological sequence.

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Answer

The correct sequence is to first cleanse the eye, then instill the drops, apply nasolacrimal pressure, wait five minutes, apply the ointment, and finally instruct the client to gently close and roll their eyes.
The correct sequence ensures that the eye is properly prepared, the aqueous medication (timolol) is absorbed without causing dangerous systemic side effects, and the lipid-based medication (erythromycin) does not block the absorption of the drops.

Step-by-Step Solution

1
Cleanse the eye from the inner to the outer canthus.
Debris and infectious crusts are safely removed.
Prevents the introduction of bacteria into the eye and tear duct, and avoids cross-contamination to the opposite eye.
2
Administer the timolol drops.
The aqueous medication is delivered to the conjunctival sac.
Aqueous drops cannot penetrate the lipid barrier created by ointments, so they must be administered first.
3
Perform nasolacrimal occlusion.
The tear duct is temporarily blocked.
Prevents systemic absorption of the beta-blocker, reducing the risk of severe side effects like bradycardia and hypotension.
4
Wait 3 to 5 minutes.
The timolol drops are fully absorbed.
Ensures the subsequent ointment does not physically wash the drops out of the conjunctival sac before they take effect.
5
Administer the erythromycin ointment.
Antibiotic ointment is applied.
Ointments are applied last because their thick, lipid-based structure blocks other topical medications from reaching the eye tissue.
6
Instruct the client to gently close their eyes.
Medication is dispersed.
Distributes the ointment evenly without expelling it from the eye via forceful blinking or squeezing.

Key Concept

Administration Sequence for Multiple Ophthalmic Medications
Question 422Question →

A practical nurse (PN) enters the room of a client with macular degeneration who is acutely agitated. The client is pointing at moving shapes cast by the window blinds and screaming, "Keep those snakes away from my bed!" The environment is chaotic due to multiple loud alarms sounding from the roommate's medical equipment. Arrange the following nursing actions in the priority order the PN should implement them.

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Answer

The correct priority sequence is to first establish a safe verbal presence, then use therapeutic communication to present reality, followed by eliminating the specific visual trigger, reducing overall sensory overload, and finally reporting the event.
In acute sensory crises involving illusions, the nursing priority sequence follows safety and Maslow's hierarchy. The nurse must first ensure safety by not startling a visually impaired client (announce presence). Next, psychological safety is established by validating fear and presenting reality. Then, the nurse addresses the specific trigger (shadows), followed by the contributing factors (loud alarms). Finally, the nurse reports the incident for continuity of care.

Step-by-Step Solution

1
Announce presence and use a calm tone.
Prevents startling the visually impaired client.
Immediate safety and establishment of a non-threatening environment.
2
Acknowledge fear and present reality.
Helps ground the client emotionally and cognitively.
Therapeutic communication directly addresses the acute distress caused by the illusion.
3
Adjust lights and blinds.
Removes the source of the visual illusion.
Direct environmental modification to stop the perceptual alteration.
4
Address the roommate's equipment alarms.
Lowers ambient sensory overload.
General environmental control prevents further agitation and confusion.
5
Document and report to the RN.
Ensures continuity of care and further assessment.
Collaboration and legal documentation follow immediate client stabilization.

Key Concept

Prioritization of nursing interventions for acute sensory alterations and illusions
Question 423Question →

A practical nurse (PN) is caring for a client with a spinal cord injury at the T4 level. The client suddenly reports a severe, pounding headache and blurred vision. The PN measures the client's blood pressure at 218/114 mm Hg and notes profuse diaphoresis above the level of the injury. Arrange the following nursing actions in the priority order the PN should perform them to minimize the risk of a cerebrovascular complication.

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Answer

The correct sequence is to first elevate the head of the bed, then loosen restrictive clothing, followed by assessing the urinary catheter, notifying the RN, and finally documenting the event.
In autonomic dysreflexia (a medical emergency in clients with spinal cord injuries at T6 or above), noxious stimuli below the injury cause an uninhibited sympathetic response, leading to severe hypertension. The absolute first priority is to place the client in a high-Fowler's or sitting position to induce orthostatic hypotension and rapidly lower the blood pressure, reducing the risk of a stroke. Next, the nurse should quickly remove any restrictive clothing that might act as a cutaneous stimulus. The third step is to check for the most common cause of the syndrome: bladder distension (e.g., checking for a kinked catheter). Once initial independent steps are taken, the PN must escalate care by notifying the RN or provider, especially if the blood pressure remains elevated and requires medication. Documentation is always the final step in the sequence.

Step-by-Step Solution

1
Elevate the head of the bed to a high-Fowler's or sitting position.
Takes advantage of orthostatic hypotension to lower the blood pressure.
The client is experiencing autonomic dysreflexia, a life-threatening hypertensive crisis. The most immediate risk is a cerebrovascular accident (stroke), so mechanically lowering the blood pressure via gravity is the absolute highest priority.
2
Loosen any tight clothing, restrictive binders, or anti-embolism stockings.
Removes immediate cutaneous stimuli.
Any painful or restrictive stimulus below the level of the spinal cord injury can trigger or worsen the sympathetic nervous system surge.
3
Assess the urinary catheter tubing for kinks or dependent loops.
Identifies and potentially resolves the most common noxious stimulus.
A distended bladder is the leading cause of autonomic dysreflexia. Unkinking a catheter can immediately relieve the distension and resolve the crisis.
4
Notify the registered nurse (RN) or healthcare provider.
Escalates the clinical situation for further medical management.
If removing immediate stimuli does not lower the blood pressure, the RN or provider must be involved to administer short-acting antihypertensive medications or perform advanced assessments.
5
Document the clinical findings, interventions performed, and client response.
Maintains an accurate legal and medical record.
Documentation is always performed after life-saving interventions and escalation of care have been completed.

Key Concept

Prioritization in Autonomic Dysreflexia: Position, Stimulus Removal, Escalation
Question 424Question →

A practical nurse is preparing to apply knee-high anti-embolism stockings for a client who has been sitting in a chair for the past hour. 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 elevate the client's legs, invert the stocking down to the heel pocket, fit the stocking over the toes, align the heel pocket on the client's heel, and finally smooth the remaining fabric up the calf.
Applying anti-embolism stockings requires a specific sequence to be both effective and safe. Because the client has been sitting, gravity has caused venous pooling; elevating the legs first allows this fluid to drain. Inverting the stocking facilitates a smooth application starting from the toes. Anchoring the heel in the pocket ensures proper placement, and finishing with a wrinkle-free fit over the calf maintains an even, distal-to-proximal pressure gradient without restricting circulation.

Step-by-Step Solution

1
Assist the client to a supine position and elevate the legs for 15 to 30 minutes.
Dependent fluid drains from the lower extremities.
Applying stockings while blood is pooled in the lower legs traps the fluid, defeating the purpose of the compression.
2
Reach inside the stocking and turn it inside out down to the heel pocket.
The stocking is prepared for application.
This technique minimizes friction and prevents overstretching the fabric during application.
3
Slip the foot of the stocking over the client's toes and instep.
The distal end of the stocking is anchored.
Starting at the toes ensures the graduated compression is applied properly from distal to proximal.
4
Stretch the fabric and align the heel pocket correctly over the client's heel.
The heel is properly seated in the reinforced pocket.
Misaligned heels can cause the fabric to bunch, leading to pressure injuries and impaired blood flow.
5
Unroll the remaining fabric evenly up the calf and smooth out any wrinkles.
The stocking fits snugly and evenly across the leg.
Wrinkles or a rolled top edge can act as a tourniquet, dangerously restricting venous return and causing ischemia.

Key Concept

Proper application of anti-embolism stockings to promote venous return and prevent complications.
Question 425Question →

A practical nurse is initiating a 24-hour urine collection to evaluate a client's renal function. To ensure the accuracy of the diagnostic test and prevent measurement errors, arrange the following nursing actions in the correct chronological sequence.

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Answer

The correct sequence is to first have the client void and discard the urine, then document this exact time as the start time, collect all subsequent urine on ice for the next 24 hours, instruct the client to void exactly 24 hours later, and finally add this last specimen to the container before sending it to the laboratory.
A 24-hour urine collection requires precise timing to accurately measure renal function or hormone levels. The client must begin the test with an empty bladder, meaning the very first void is always discarded. The time of this discarded void becomes the official start time. All subsequent urine must be collected and properly stored (usually on ice or refrigerated) to prevent chemical degradation of the specimen. Exactly 24 hours after the start time, the client must void one final time to complete the collection. This final void is added to the container, which is then immediately dispatched to the laboratory.

Step-by-Step Solution

1
Initiate the test with an empty bladder.
The client voids, and the urine is discarded.
This ensures that urine produced prior to the 24-hour period is not included in the total volume, preventing falsely elevated diagnostic results.
2
Document the start time.
The exact time of the initial discarded void is recorded in the client's health record.
Provides the definitive starting mark for the 24-hour collection period.
3
Collect and preserve all subsequent urine.
Every void over the next 24 hours is transferred to a cooled collection jug.
Cooling prevents the degradation of urinary components and inhibits bacterial growth, which could skew laboratory values.
4
Obtain the final void.
The client voids exactly 24 hours after the start time.
Captures the urine produced at the very end of the 24-hour window to complete the collection.
5
Complete and transport the collection.
The final void is added to the container and immediately sent to the laboratory.
Finalizes the total volume for accurate laboratory analysis and ensures prompt processing.

Key Concept

Diagnostic Test Preparation and Specimen Collection Protocols
Question 426Question →

A practical nurse (PN) enters the room of a client who was recently admitted to a hospice facility. The client's sibling is sitting at the bedside crying and states, "I do not know what I am going to do without them. We have lived together for over 60 years." Arrange the PN's actions in the most appropriate therapeutic sequence. All options must be used.

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Answer

The most appropriate therapeutic sequence begins with establishing a supportive presence, followed by validating the sibling's feelings, actively listening to their stories, assessing for personal support systems, and finally offering interdisciplinary resources.
In psychosocial interventions involving acute anticipatory grief, the nursing process prioritizes immediate emotional safety and therapeutic presence. Nonverbal communication (offering tissues, sitting quietly) establishes trust and a safe environment. Next, verbal validation (using reflection) acknowledges the significance of the relationship and encourages the expression of feelings. Active listening allows the individual to process their grief. Only after the immediate emotional peak has stabilized and feelings have been expressed should the nurse transition to assessing personal support systems (family or friends) and offering interdisciplinary interventions (chaplain or bereavement counselor).

Step-by-Step Solution

1
Provide a box of tissues and sit quietly at the bedside.
Establishes a therapeutic, non-judgmental presence.
Immediate nonverbal support and therapeutic silence take priority in an acute emotional crisis.
2
State, "It sounds like you and your sibling share a very deep bond."
Validates the sibling's feelings and acknowledges their pain.
Reflection encourages the individual to open up and establishes trust.
3
Utilize active listening while the sibling shares stories about their shared life.
Facilitates the expression of anticipatory grief.
Allowing the client to verbalize memories helps them process the impending loss without interruption.
4
Ask the sibling if there are other family members or friends they would like to call.
Assesses personal support networks.
Once the immediate emotional need is addressed, practical and personal support systems should be evaluated.
5
Offer to arrange a visit from the facility's chaplain or bereavement counselor.
Provides long-term interdisciplinary resources.
Connecting the family with specialized professionals ensures ongoing psychosocial support as part of the care plan.

Key Concept

Therapeutic Communication Sequence in Anticipatory Grief
Estimated Time:1m 30s
Question 427Question →

A practical nurse (PN) is co-leading a group activity on an inpatient psychiatric unit. A client suddenly stands up, begins hyperventilating, grips their chest, and says, "I am having a heart attack and I am going to die!" Medical causes have been previously ruled out, and the PN recognizes an acute panic attack. In what order should the PN perform the following actions? Arrange the interventions in the correct sequence from first to last.

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Answer

The correct sequence of actions is: 1) Remain with the client, 2) Escort to a quiet environment, 3) Communicate with short phrases, 4) Coach deep breathing, and 5) Document the event.
When managing an acute panic attack, prioritizing safety and immediate presence is paramount. The nurse first stays with the client to ensure safety, then alters the environment by removing them from high stimuli. Next, communication is adjusted to short, simple phrases because the client's perceptual field is severely narrowed. This clear communication paves the way to successfully coach physical interventions like deep breathing. Finally, post-crisis documentation is completed once the client is stable.

Step-by-Step Solution

1
Remain with the client.
The client's immediate safety is ensured.
Clients in panic states should never be left alone due to extreme fear and risk of injury.
2
Move the client to a quiet area.
Environmental triggers are minimized.
Decreasing sensory input helps lower the client's overall anxiety level.
3
Use short, simple sentences.
The client comprehends the nurse's instructions.
Severe anxiety narrows the perceptual field, making complex sentences impossible to process.
4
Coach deep breathing.
Hyperventilation is corrected.
Physiological symptoms of panic must be managed with direct, guided interventions once the client can focus.
5
Document the incident.
The healthcare team is informed.
Post-crisis documentation is required by nursing standards of practice.

Key Concept

Nursing Management of Acute Panic Attacks
Question 428Question →

A practical nurse is reinforcing teaching for a client who has a right fractured tibia and is prescribed strict non-weight-bearing status. The client is using axillary crutches and needs to ascend a flight of stairs. In what order should the nurse instruct the client to perform these actions? (Arrange the steps from first to last.)

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Answer

The client should first assume a tripod position, shift weight onto the crutches, step up with the unaffected left leg, transfer weight to that left leg, and finally bring the crutches and affected right leg up.
When ascending stairs with axillary crutches, the core principle is to lead with the strong leg (often remembered as 'up with the good'). The client must first establish balance in a tripod stance and support their weight entirely on the crutches. This enables the strong, unaffected leg to step up first and provide the necessary power to lift the body's mass. Once the weight is safely transferred to the strong leg on the higher step, the crutches and the affected leg can follow together without bearing weight.

Step-by-Step Solution

1
Assume the tripod position facing the bottom of the stairs.
A stable base of support is established.
Safety requires a solid foundation before initiating a complex transfer.
2
Shift body weight securely onto the handgrips of both crutches.
Weight is offloaded from the lower extremities.
This allows the client to freely lift the unaffected leg without losing balance.
3
Advance the unaffected left leg up onto the next stair tread.
The strong leg is positioned on the higher step.
The unaffected leg must lead the upward movement to provide lifting power.
4
Transfer body weight from the crutches to the unaffected left leg.
The center of gravity is moved to the higher step.
This stabilizes the body on the new step and frees the crutches to be moved.
5
Bring both crutches and the non-weight-bearing right leg up to the stair.
The sequence for one step is completed.
The crutches always move with the affected leg to maintain non-weight-bearing status and provide continuous support.

Key Concept

Crutch walking on stairs (Ascending)
Question 429Question →

A practical nurse is preparing to administer a combination of regular insulin and neutral protamine Hagedorn (NPH) insulin to a client with diabetes mellitus. Arrange the following steps for preparing the mixed insulin injection in the correct chronological order.

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Answer

The correct chronological sequence is to roll the NPH vial, inject air into the NPH vial, inject air into the regular insulin vial, withdraw the regular insulin, and finally withdraw the NPH insulin.
The 'clear before cloudy' procedure is a standard pharmacological safety protocol. It ensures that the short-acting (clear) regular insulin is not contaminated by the intermediate-acting (cloudy) NPH insulin. Contamination would unpredictably change the pharmacokinetics of the regular insulin remaining in the vial.

Step-by-Step Solution

1
Roll the NPH insulin vial.
The intermediate-acting insulin suspension is thoroughly mixed.
NPH is a suspension that settles when standing; rolling mixes it without creating bubbles that could lead to inaccurate dosing.
2
Inject air into the NPH insulin vial and remove the needle.
The NPH vial is pressurized.
Injecting air equal to the prescribed dose prevents a vacuum from forming when the medication is withdrawn later.
3
Inject air into the regular insulin vial and keep the needle inserted.
The regular insulin vial is pressurized and ready for withdrawal.
Pressurizing the vial allows the medication to flow easily into the syringe.
4
Invert the regular insulin vial and withdraw the prescribed dose.
The clear insulin is loaded into the syringe.
Drawing the clear insulin first ensures that no cloudy NPH insulin can accidentally enter and contaminate the regular insulin vial.
5
Insert the needle into the NPH vial and withdraw the prescribed dose.
The exact total volume of mixed insulin is achieved.
The cloudy insulin is added last to complete the mixture, ensuring the 'clear before cloudy' safety principle is maintained.

Key Concept

Safe Preparation and Mixing of Insulins (Clear Before Cloudy)
Estimated Time:1m 30s
Question 430Question →

A practical nurse at a community clinic is participating in a health education session for preadolescent females and their caregivers. When reinforcing teaching about the expected physiological transitions of female puberty, the nurse describes the sequence of developmental milestones. Place the following physiological milestones in the chronological order in which they typically occur. (Arrange from first to last)

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Answer

The correct chronological sequence of female pubertal milestones is: development of breast buds, followed by the appearance of initial pubic hair, then the period of most rapid linear growth, and finally the occurrence of the first menstrual period.
The established developmental sequence of female puberty begins with thelarche (breast budding), which is followed by pubarche (pubic hair growth). Following these changes, the adolescent experiences peak height velocity (a rapid growth spurt), and the sequence concludes with menarche (the first menstrual period).

Step-by-Step Solution

1
Identify the initial physiological sign of female puberty.
The development of breast buds (thelarche) is the first milestone.
This transition marks the beginning of pubertal changes and is the earliest physical manifestation.
2
Determine the milestone that directly follows breast development.
The appearance of initial pubic hair (pubarche) occurs next.
The growth of pubic hair typically begins a few months after thelarche.
3
Identify the timing of the adolescent growth spurt.
The period of most rapid linear growth (peak height velocity) is placed third.
The growth spurt reaches its peak approximately 1 to 2 years after the onset of breast development and typically concludes before menarche.
4
Determine the final transition in this sequence.
The occurrence of the first menstrual period (menarche) is the final milestone.
Menarche is a late event in the sequence of female puberty, reliably occurring roughly 2 to 2.5 years after breast buds first appear.

Key Concept

The typical chronological sequence of physiological milestones during female puberty is thelarche (breast development), pubarche (pubic hair growth), peak height velocity (rapid linear growth), and menarche (first menstruation).
Question 431Question →

A practical nurse (PN) responds to a call light and finds an older adult client with age-related presbycusis and diminished visual acuity attempting to climb over the bed rails. The client, who is currently hospitalized for pneumonia, appears restless and states they need to go look for their spouse. Arrange the following practical nursing actions in the priority order they should be implemented. (Place the highest priority action first.)

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Answer

The correct priority order is to first secure physical safety, then accommodate sensory changes, collect physiological data, provide cognitive reorientation, and finally report the findings.
In an older adult client exhibiting sudden confusion and unsafe behavior, the first priority according to the nursing process and Maslow's Hierarchy of Needs is immediate physical safety (preventing a fall). Next, the nurse must accommodate age-related sensory deficits (presbycusis and vision changes) by improving lighting and communicating clearly, which helps de-escalate the situation. Once the client is safe and calm, the nurse collects physiological data (vital signs and oxygen saturation) to rule out physical causes of delirium, such as hypoxia from pneumonia. After data collection, therapeutic cognitive reorientation can be attempted. Finally, the nurse reports the acute changes and assessment data to the supervising RN for further evaluation and intervention.

Step-by-Step Solution

1
Secure the client's physical safety.
The client is guided back to a safe position in bed.
Preventing immediate injury or falls is always the first priority when a client is engaged in an unsafe behavior like climbing over bed rails.
2
Accommodate age-related sensory changes.
Room lights are turned on and the PN speaks directly to the client's face.
Presbycusis and decreased visual acuity exacerbate confusion; maximizing sensory input helps de-escalate the situation and calms the older adult.
3
Perform focused data collection.
Vital signs and oxygen saturation are obtained.
Acute confusion (delirium) in older adults is frequently a symptom of an underlying physical issue like hypoxia from pneumonia.
4
Implement cognitive reorientation.
The client is reminded of their location and situation.
Verbal reorientation is therapeutic but requires the client to be physically safe and sensually engaged first to be effective.
5
Communicate with the healthcare team.
The supervising RN is notified of the acute changes.
The PN must report the findings to ensure the medical plan of care is updated, which is done after the client is safe and initial data is gathered.

Key Concept

Prioritization of safety, sensory accommodation, and physiological assessment during acute delirium in older adults.
Question 432Question →

A practical nurse (PN) is preparing to collect a wound culture specimen from a client's stage 3 pressure injury. In what order should the PN perform the following actions to ensure an accurate specimen and reduce the risk of contamination? Arrange the actions in the correct sequence.

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Answer

The correct sequence for obtaining a wound culture is to first remove the soiled dressing, then cleanse the wound with normal saline, next swab the viable tissue, followed by placing the swab in the culture tube, and finally labeling the specimen at the bedside.
Following the correct sequence ensures that the wound culture identifies the actual pathogen causing the infection rather than surface flora, and prevents cross-contamination or misidentification of the specimen.

Step-by-Step Solution

1
Remove the soiled wound dressing and dispose of it in the appropriate receptacle.
The wound bed is exposed for assessment and collection.
The old dressing contains surface bacteria and exudate that are not representative of the true infection and must be removed first.
2
Cleanse the wound bed with prescribed sterile normal saline to remove surface exudate.
Surface exudate and colonizing flora are washed away.
Culturing uncleaned exudate often yields colonizing bacteria rather than the pathogen responsible for the tissue infection, which can lead to inappropriate antibiotic therapy.
3
Rotate the sterile culture swab over an area of clean, viable granulation tissue.
The specimen is collected from actively infected, living tissue.
Pathogens grow best in viable tissue; swabbing slough or necrotic tissue may yield inaccurate diagnostic results.
4
Insert the swab into the sterile culture tube without touching the outside of the container.
The specimen is secured in the transport medium.
This maintains the sterility of the container's exterior, protecting healthcare workers and laboratory personnel from exposure to the pathogen.
5
Label the specimen container in the presence of the client before sending it to the laboratory.
The specimen is accurately identified with the correct client information.
Labeling at the bedside immediately after collection eliminates the risk of mixing up specimens and ensures accurate diagnostic reporting.

Key Concept

Wound Culture Specimen Collection Principles
Question 433Question →

An assigned client with generalized weakness needs to be transferred from the bed to a bedside wheelchair. Arrange the following nursing actions in the correct sequence from first to last.

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Answer

The correct sequence for a bed-to-wheelchair transfer is: position and lock the wheelchair, assist the client to sit on the edge of the bed, apply the transfer belt, and finally pivot the client into the wheelchair.
When transferring a client from a bed to a wheelchair, the nurse must first prioritize environmental safety by placing the wheelchair in the proper position and locking the brakes. Second, the nurse assists the client to sit on the edge of the bed to allow their blood pressure to adjust, reducing the risk of dizziness or fainting. Third, while the client is safely seated, a transfer belt is applied around the waist to provide a secure grip. Finally, the nurse assists the client to stand, bear weight, and pivot safely into the wheelchair.

Step-by-Step Solution

1
Position the wheelchair and lock the brakes.
The wheelchair is secured and ready to receive the client safely.
Preparing the environment prevents the wheelchair from rolling backward during the transfer, averting potential falls.
2
Assist the client to a sitting position on the edge of the bed.
The client is seated with their legs dangling over the side of the mattress.
This allows the client to adjust to an upright position and minimizes the risk of orthostatic hypotension.
3
Apply the transfer belt securely.
The nurse has a safe, designated way to grip and support the client's weight.
A transfer belt protects both the client and the nurse from injury during the weight-bearing and pivot phases.
4
Pivot the client into the wheelchair.
The client is successfully seated in the wheelchair.
This action completes the mobility transfer using safe body mechanics and proper support.

Key Concept

Safe client mobility transfers and prioritization of safety measures.
Question 434Question →

A practical nurse (PN) is assigned to care for a 48-hour-old neonate born at 38 weeks gestation who has been prescribed conventional overhead phototherapy for hyperbilirubinemia. Arrange the following actions in the correct sequence to safely initiate this therapy.

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Answer

The correct sequence is: verify the prescription and reinforce education, undress the neonate to a diaper, apply opaque eye shields, turn on the phototherapy lights, and finally document the initiation and monitoring schedule.
The correct sequence logically flows from pre-procedure safety checks, to physical preparation of the body, to targeted safety application (eye shields), to equipment activation, and concludes with post-procedure documentation. Applying eye shields before undressing the baby could result in the shields becoming displaced while removing clothing, so the infant must be undressed first.

Step-by-Step Solution

1
Verify the provider's prescription and reinforce education with the parents about the procedure.
Ensures the correct client receives the correct treatment and parents understand the intervention.
Safe practice standards require verification and informed care before any physical intervention begins.
2
Remove the neonate's clothing and blankets, leaving only a standard diaper in place.
Exposes maximum skin surface area.
Bilirubin breakdown requires therapeutic ultraviolet light exposure directly to the skin. Undressing the infant first prevents the risk of dislodging eye shields later.
3
Secure properly sized opaque eye shields over the neonate's gently closed eyes.
Protects the delicate retina from the phototherapy light.
High-intensity phototherapy lights can cause irreversible retinal damage; protection must be secured immediately prior to activation.
4
Turn on the overhead phototherapy unit positioned at the manufacturer-recommended distance.
Initiates the prescribed therapy.
The neonate is now completely exposed and safely protected, allowing therapy to begin without hazard.
5
Document the initiation time and establish a schedule for monitoring axillary temperature.
Creates a legal health record and ensures proper follow-up care.
Continuous monitoring for complications like hyperthermia, hypothermia, and dehydration is an essential nursing responsibility during phototherapy.

Key Concept

Phototherapy Initiation and Neonatal Safety
Question 435Question →

A client is making a lifestyle modification to eliminate high-sugar beverages from their diet. Arrange the client's statements in chronological order, representing their progression through the sequential stages of behavioral change (from the earliest stage to the final stage).

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Answer

The correct chronological sequence aligns with the Transtheoretical Model of Change: Precontemplation (denial), Contemplation (ambivalence), Preparation (small steps), Action (active change for less than six months), and Maintenance (sustained change for over six months).
The Transtheoretical Model of Change dictates that individuals modifying a lifestyle choice progress through five distinct stages. They begin with denial or unawareness (precontemplation), move to acknowledging the issue while remaining hesitant (contemplation), take small preliminary steps to get ready (preparation), execute the behavioral change (action), and finally sustain the change long-term to prevent relapse (maintenance).

Step-by-Step Solution

1
Identify the statement reflecting the earliest phase of change, known as the Precontemplation stage.
The client denying any link between sodas and weight gain is placed first.
In the earliest stage, individuals do not intend to take action and often remain unaware that their behavior is problematic.
2
Identify the statement reflecting the Contemplation stage.
The client acknowledging the health effects but remaining ambivalent is placed second.
During this phase, individuals recognize their lifestyle choice may be problematic but are not yet fully committed to making a change.
3
Identify the statement reflecting the Preparation stage.
The client buying a water bottle and stopping soda purchases is placed third.
The individual is ready to take action soon and takes small preliminary steps toward the behavior change.
4
Identify the statement reflecting the Action stage.
The client successfully replacing sodas with water for three weeks is placed fourth.
The individual has actively changed their behavior and intends to keep moving forward, though it has been less than six months since the change began.
5
Identify the statement reflecting the final phase, known as the Maintenance stage.
The client avoiding sugary beverages for over eight months is placed last.
The individual has sustained their behavior change for more than six months and has successfully integrated the new habit into their lifestyle.

Key Concept

Transtheoretical Model of Behavioral Change
Question 436Question →

A client with suspected acute cocaine toxicity is brought to the emergency department. The client is profoundly restless, diaphoretic, and reports severe, crushing chest pain. In what order should the practical nurse (PN) prioritize the following actions? Arrange the actions from first to last.

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Answer

The correct sequence is to first verify airway patency, then attach cardiac monitoring, obtain complete vital signs, decrease environmental stimuli, and finally assist with administering the prescribed benzodiazepine.
In acute substance toxicity emergencies, care is prioritized using Maslow's hierarchy of needs and the ABCs (Airway, Breathing, Circulation). The nurse must first ensure an open airway and adequate breathing. Next, because cocaine toxicity severely compromises the cardiovascular system, continuous cardiac monitoring is established to detect life-threatening dysrhythmias. Following this, completing the primary data collection with full vital signs (including temperature to check for hyperthermia) is essential. Once physiological stability is assessed, the nurse implements environmental safety measures by decreasing stimuli to reduce agitation. Finally, the nurse assists the RN with pharmacological interventions, such as benzodiazepines, which are the treatment of choice for cocaine-induced agitation and cardiovascular toxicity.

Step-by-Step Solution

1
Assess airway and breathing.
Ensures the client has adequate oxygenation.
Airway and breathing (ABCs) are the highest priority in any physiological emergency to sustain life.
2
Initiate cardiac monitoring.
Allows for immediate detection of lethal arrhythmias.
Cocaine causes severe vasoconstriction and tachycardia, making myocardial infarction or arrhythmias the most immediate life-threatening complications.
3
Obtain full vital signs.
Completes the primary data collection.
Vital signs, especially temperature, are critical to detect hyperthermia, a common complication of stimulant overdose.
4
Modify the environment.
Reduces external triggers.
A low-stimulus environment decreases sympathetic nervous system activation and cardiac workload.
5
Assist with medication preparation.
Prepares for pharmacological intervention.
Medications are administered only after immediate physiological assessments and safety measures are established.

Key Concept

Prioritization of Care in Substance Toxicity (ABCs and Nursing Process)
Question 437Question →

A practical nurse and an unlicensed assistive personnel (UAP) are preparing to reposition a client who is 24 hours postoperative following a right total hip arthroplasty (posterior approach). Arrange the following actions in the correct sequence to safely turn the client onto their left side.

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Answer

The correct sequence is to first control pain and adjust the bed, then place the abduction pillow, prepare the client and draw sheet, log-roll onto the unaffected side, and finally support the new position with additional pillows.
Safe repositioning post-total hip arthroplasty requires meticulous joint protection. Pain management and caregiver ergonomics are the priority foundational steps. Most critically, the abduction wedge must be placed between the legs before any movement occurs to ensure the hip remains abducted. Preparing the draw sheet and arms follows joint stabilization. The client is then log-rolled as a single unit onto the unaffected side to maintain pelvic alignment, and finally, supportive pillows are placed to sustain the position and prevent internal rotation.

Step-by-Step Solution

1
Verify that the client's pain is adequately controlled and adjust the bed to a safe working height.
Ensures client comfort and caregiver safety.
Pain management ensures the client can tolerate movement, while proper ergonomics prevent injury to the nurse and UAP.
2
Place a foam abduction pillow or wedge securely between the client's legs.
Stabilizes the hip joint in a safe, abducted position.
Following a posterior approach total hip arthroplasty, adduction must be avoided. The pillow must be in place before turning to prevent dislocation during movement.
3
Instruct the client to cross their arms over their chest and gather the edges of the draw sheet.
Prepares the client's body and the friction-reducing device for the turn.
Crossing the arms keeps them out of the way, and gathering the draw sheet provides the caregivers with a firm grip to control the turn.
4
Log-roll the client as a single unit onto their left, unaffected side in one coordinated motion.
Moves the client without twisting the spine or pelvis.
Log-rolling keeps the body in alignment. Turning onto the left side avoids placing direct pressure on the newly operated right hip.
5
Tuck pillows behind the client's back and ensure the right leg remains abducted and supported.
Maintains the lateral position and ensures continued joint stability.
Back support prevents the client from rolling supine, and continuous support of the right leg prevents internal rotation and adduction.

Key Concept

Following a posterior total hip arthroplasty, the operative leg must be kept in abduction and neutral alignment to prevent dislocation, requiring an abduction pillow to be placed prior to log-rolling the client.
Question 438Question →

A practical nurse is reinforcing teaching with a group of new parents about expected fine motor development during the first year of life. Arrange the following fine motor milestones in the chronological order in which they typically develop, from earliest to latest. All options must be used.

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Answer

The correct chronological order of fine motor development is: bringing hands to the midline, developing a palmar grasp, transferring objects between hands, and finally using a pincer grasp.
Fine motor development in infants progresses in a proximodistal pattern (from the center of the body outward to the extremities). Control of the arms develops before precise control of the fingers. Therefore, infants first learn to bring their hands to the midline (2 to 3 months). Next, they develop a voluntary palmar grasp using the whole hand (5 months). As bilateral coordination improves, they learn to transfer objects from one hand to the other (7 months). Finally, they develop the fine, precise pincer grasp using the thumb and index finger (9 to 10 months).

Step-by-Step Solution

1
Identify the earliest fine motor skill in the list.
Bringing both hands to the midline typically occurs first, around 2 to 3 months of age.
Infants develop grosser proximal control of their arms before developing precise distal control of their fingers.
2
Determine the next milestone.
Grasping an object using the entire hand (palmar grasp) occurs next, around 5 months.
This shows the progression from basic arm control to basic hand control.
3
Identify the third milestone in the sequence.
Transferring an object from one hand to the other develops around 7 months.
This requires bilateral coordination and the ability to release an object voluntarily, which must logically follow the development of a basic palmar grasp.
4
Identify the final milestone.
Picking up a small object using the thumb and index finger (pincer grasp) occurs around 9 to 10 months.
The pincer grasp requires highly localized control of individual digits, representing the most advanced fine motor milestone in this sequence.

Key Concept

Fine Motor Development in Infancy
Estimated Time:1m 0s
Question 439Question →

A practical nurse is preparing to administer a large-volume cleansing enema to an adult client who is experiencing constipation. Arrange the following actions in the correct sequence. (Place the first action at the top and the final action at the bottom.)

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Answer

The correct sequence is to first position the client, lubricate the tubing, insert the tubing into the rectum, elevate the enema bag to initiate flow, and finally, clamp the tubing if cramping occurs.
The proper sequence for administering an enema prioritizes anatomical alignment, safety, and client comfort. Placing the client in the left Sims' position uses gravity to aid fluid flow into the descending colon. Lubrication and proper insertion depth (3 to 4 inches) prevent tissue injury. Elevating the bag 12 to 18 inches ensures a controlled infusion rate. If cramping occurs, clamping the tubing is the correct immediate intervention to relieve spasms without aborting the care task.

Step-by-Step Solution

1
Position the client appropriately.
Client is in the left Sims' position.
Aligns the anatomy for optimal fluid flow into the descending colon using gravity.
2
Prepare the equipment for insertion.
The enema tip is lubricated.
Prevents friction and mucosal trauma during insertion.
3
Insert the enema tubing.
Tubing is inserted 3 to 4 inches (7.5 to 10 cm).
Safely bypasses the anal sphincter to deliver fluid directly into the rectum and colon.
4
Initiate the fluid infusion.
The bag is elevated 12 to 18 inches (30 to 45 cm) above the anus.
Controls the rate of fluid flow and internal pressure to prevent rapid bowel distention.
5
Monitor client tolerance.
Tubing is clamped if cramping is reported.
Allows intestinal spasms to subside without needing to remove the tubing or abort the procedure entirely.

Key Concept

Basic Care and Comfort: Enema Administration Sequence and Safety
Question 440Question →

A client on an oncology unit has just been informed by the provider that their cancer is no longer responding to treatment. The client's partner begins pacing the public hallway, breathing rapidly, and loudly stating, "This cannot be happening!" In which order should the licensed practical nurse (LPN) prioritize the following actions? (Arrange the actions from first to last.)

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Answer

The correct sequence is to first secure privacy (escort to a private area), second establish therapeutic presence (sit silently), third provide verbal validation (acknowledge the news is overwhelming), fourth mobilize resources (inquire about a support person), and finally perform administrative duties (document).
In psychosocial crises, the nursing process dictates prioritizing immediate safety and milieu management first (privacy), followed by nonverbal therapeutic techniques (presence), then verbal therapeutic techniques (validation), followed by mobilizing coping resources (support persons), and ending with administrative requirements (documentation).

Step-by-Step Solution

1
Ensure privacy and dignity by moving the partner out of the hallway.
The partner is in a safe, controlled environment away from other clients.
Milieu management and client/family dignity are foundational first steps during an acute emotional crisis.
2
Provide a silent, calming presence.
The partner has time and space to process the initial shock without pressure to communicate.
Offering self is a primary therapeutic communication technique that establishes trust when an individual is too overwhelmed for conversation.
3
Use verbal therapeutic communication to acknowledge the distress.
The partner's feelings of grief and disbelief are validated.
Stating that the news is overwhelming acknowledges the reality of the loss and opens the door for further expression of feelings.
4
Offer to contact external support systems.
The partner is connected with family, friends, or spiritual care.
The nurse assists with coping by integrating the family's preferred support network once the immediate panic has subsided.
5
Document the event in the medical record.
The health care team has an accurate record of the psychosocial event.
Documentation must always follow the completion of direct, immediate client or family care.

Key Concept

Nursing Management of Acute Grief and Loss
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