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Question 441Question →

During a central venous access device tubing change, the catheter accidentally disconnects. The client immediately exhibits severe dyspnea, cyanosis, and tachycardia. In what order must the nurse perform the following emergency actions to mitigate the risk of a fatal air embolism?

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Answer

The correct emergency sequence for a suspected air embolism is to clamp the catheter, position the client in left lateral Trendelenburg, administer oxygen, activate the rapid response team, and then obtain vital signs.
In a life-threatening emergency where an active hazard is present, the first priority is to stop the source of harm (clamping the catheter). The next priority is immediate physiological stabilization to prevent the complication from becoming fatal (positioning to trap the air, followed immediately by oxygen to treat hypoxia). Once these rapid, life-saving physical actions are completed, the nurse must call for advanced medical help. Finally, continuous assessment (obtaining vital signs) is performed to monitor the client's baseline and response to treatment while waiting for the rapid response team to arrive.

Step-by-Step Solution

1
Clamp the central venous catheter.
Stops further air from entering the circulatory system.
The absolute first step in any hazard is to halt the immediate source of harm.
2
Place the client in the left lateral Trendelenburg position.
Traps the air bubble in the right atrium and ventricle.
Gravity and positioning prevent the air embolus from traveling into the pulmonary circulation, which would cause a fatal obstruction.
3
Administer high-flow oxygen.
Increases blood oxygenation and accelerates nitrogen absorption.
Treats the immediate hypoxia caused by the embolism and helps shrink the size of the air bubble.
4
Activate the rapid response team.
Summons advanced medical providers.
The client requires critical care interventions that exceed the practical nurse's scope of practice.
5
Obtain vital signs.
Establishes a hemodynamic baseline.
Monitors the client's physiological stability and response to the initial emergency interventions.

Key Concept

Emergency management and prioritization of an air embolism to reduce the risk of cardiopulmonary collapse.
Question 442Question →

A practical nurse is assigned to care for an older adult client admitted with mild dehydration linked to an age-related diminished thirst sensation. The healthcare provider orders the initiation of an oral rehydration protocol. In what chronological order should the nurse perform the following actions?

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Answer

First, evaluate swallowing safely. Second, provide the oral fluids. Third, record the intake volume. Fourth, assess physical signs of hydration improvement. Finally, provide ongoing education about scheduling fluid intake.
The correct sequence strictly follows the nursing process and safety prioritization. Safety (swallow assessment) must precede implementation (administering fluids). Implementation must be immediately followed by documentation (intake log) and then evaluation (turgor and membranes). Health promotion and teaching are reserved for when the client is physiologically stable.

Step-by-Step Solution

1
Assess the client's swallow reflex and airway safety.
Determines if the client can safely tolerate oral intake.
Airway protection and aspiration prevention take physiological priority before any oral intervention.
2
Administer the prescribed oral rehydration solution.
Begins correcting the fluid deficit.
Once safety is established, the primary acute intervention must be implemented to address the dehydration.
3
Document the fluid intake accurately.
Updates the medical record with the exact intake volume.
Immediate documentation prevents errors in total fluid calculation and guides further treatment.
4
Assess skin turgor over the sternum and check mucous membranes.
Evaluates the effectiveness of the hydration therapy.
The nurse must monitor the client's physiological response to the intervention using age-appropriate assessment sites.
5
Provide client education on scheduled fluid intake.
Equips the client with strategies to manage age-related decreased thirst.
Teaching is most effective after the client is physiologically stable and addresses the root cause of the admission.

Key Concept

Prioritization of nursing care for older adults experiencing dehydration due to age-related physiological changes.
Question 443Question →

A practical nurse (PN) receives a telephone call from the laboratory reporting a critical serum potassium level of 6.26.2 mEq/L for a client. The client's morning medications, which include the potassium-sparing diuretic spironolactone, are currently due. In what order should the PN perform the following actions to minimize the risk of complications? (Arrange the steps in the correct order of priority.)

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Answer

The correct priority sequence is to first verify the lab result, withhold the contraindicated medication, assess the client's cardiac status, notify the provider, and finally document the event.
When receiving a critical laboratory value via telephone, the absolute first priority is safety and accuracy, which requires writing down and reading back the result. Next, the nurse must immediately protect the client from further harm by holding any medications that could worsen the condition (spironolactone). Before notifying the provider, the nurse must assess the client (vital signs, apical pulse) to have a complete clinical picture for the SBAR report. Notification of the RN and provider follows to secure emergency orders. Finally, all steps and communications are documented in the client's medical record.

Step-by-Step Solution

1
Write down and read back the critical laboratory result.
Ensures the accuracy of the critical information received over the telephone.
Verifying verbal communication is a mandatory safety standard to prevent life-threatening errors.
2
Withhold the scheduled dose of spironolactone.
Prevents the introduction of additional potassium or retention of existing potassium.
Spironolactone is a potassium-sparing diuretic that would exacerbate the critical hyperkalemia and increase the risk of cardiac arrest.
3
Assess vital signs and apical heart rhythm.
Identifies any immediate clinical manifestations of severe hyperkalemia.
Current assessment data is required to communicate the client's immediate physiological status to the provider effectively.
4
Report the findings to the supervising registered nurse (RN) and healthcare provider.
Escalates the critical situation to the appropriate clinicians.
The provider must prescribe emergency pharmacological interventions (such as calcium gluconate, regular insulin, or sodium polystyrene sulfonate) to lower the serum potassium level.
5
Document all findings and actions in the medical record.
Creates a permanent legal and clinical record.
Documentation should always occur after the client's immediate safety is secured and care has been escalated.

Key Concept

Prioritizing nursing actions for critical laboratory values and medication safety
Question 444Question →

A practical nurse is assisting a client who is postoperative from abdominal surgery to transfer from the bed to a chair for the first time. Arrange the following actions in the correct sequence to ensure a safe transfer.

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Answer

The correct order is to first secure and lower the bed, second assist the client to sit on the edge of the bed, third apply a transfer belt, and fourth guide the client to stand and pivot into the chair.
The correct sequence prioritizes client safety and fall prevention during a postoperative transfer. First, the bed must be secured in the lowest position with wheels locked to prevent movement. Second, the client should sit on the edge of the bed to prevent orthostatic hypotension. Third, a transfer belt is applied to provide a secure handhold. Finally, the client is assisted to stand, pivot, and sit in the chair.

Step-by-Step Solution

1
Secure the environment
The bed is lowered to its lowest height and the wheels are locked.
This prevents the bed from moving during the transfer and minimizes the distance to the floor.
2
Position the client
The client is assisted to sit on the edge of the bed.
Allowing the client to dangle their legs stabilizes blood pressure and prevents dizziness.
3
Apply safety equipment
A transfer belt is applied around the client's waist.
The belt provides a secure handhold to support the client's weight safely.
4
Execute the transfer
The client stands, pivots, and sits in the chair.
This completes the safe transfer from the bed to the chair.

Key Concept

Safe postoperative mobility requires environmental safety, prevention of orthostatic hypotension, and the use of assistive devices like a transfer belt.
Question 445Question →

A practical nurse (PN) at a community health center is assisting with a client who is starting a comprehensive lifestyle modification program. Arrange the PN's actions in the most appropriate chronological order from first to last.

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Answer

The correct order follows the practical nursing process: collect baseline physical data, assess motivation and readiness, reinforce the teaching plan, provide supporting written materials, and establish evaluation criteria for the next visit.
The practical nursing process requires data collection to occur before implementation. The PN must first determine the client's current baseline lifestyle habits, followed by their readiness to change. Only after data collection is complete can the PN effectively reinforce the registered nurse's teaching plan and provide supporting written materials. Finally, the PN establishes a method for evaluation by setting up follow-up tracking.

Step-by-Step Solution

1
Collect baseline data regarding current habits.
The PN understands what the client is currently eating and how much they are exercising.
Data collection is the first step of the practical nursing process and forms the foundation for all subsequent care.
2
Determine the client's motivation and readiness to change.
The PN identifies potential psychosocial barriers and the client's willingness to learn.
Educational reinforcement is ineffective if the client's readiness to learn and change has not been established.
3
Reinforce the RN's teaching on the new lifestyle choices.
The client receives verbal instruction on their specific portion control and walking goals.
Implementation of the educational plan occurs after a thorough assessment of baseline needs and readiness.
4
Supply written educational materials.
The client receives a brochure summarizing the verbal instructions.
Written materials reinforce verbal education and accommodate different learning styles while providing an at-home reference.
5
Instruct the client on follow-up documentation.
The client knows to keep a journal to bring to the next visit.
Establishing a tracking method sets up the evaluation phase of the nursing process, allowing the healthcare team to measure outcomes at the next appointment.

Key Concept

Nursing Process in Lifestyle Modification
Question 446Question →

A practical nurse (PN) is preparing to administer a prescribed transdermal nitroglycerin patch to a client. In what order should the PN perform the following steps? (Arrange the steps in the correct sequence, from first to last.)

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Answer

The correct sequence is: perform hand hygiene and put on clean gloves, remove the old patch, select a new site, and then apply the new patch.
Safe administration of a transdermal patch requires a specific logical sequence. First, the nurse must perform hand hygiene and put on gloves to prevent absorbing the medication into their own skin. Next, the old patch must be removed to prevent an accidental overdose. Then, the nurse selects a new, hairless site to rotate placement and reduce skin irritation. Finally, the new patch is applied and secured.

Step-by-Step Solution

1
Determine the priority of infection control and self-protection.
The nurse must perform hand hygiene and don gloves before handling the medication.
Nitroglycerin can be absorbed through the nurse's skin, which may cause headaches or hypotension.
2
Identify the next safety measure before applying a new dose.
The previously applied patch must be removed.
Leaving an old patch on while applying a new one can lead to a dangerous medication overdose.
3
Identify the site preparation step.
A new, appropriate site is selected and prepared.
Site rotation prevents skin breakdown and ensures consistent medication absorption.
4
Determine the final step of administration.
The new patch is applied to the skin.
Application is the final physical step of this administration sequence.

Key Concept

Safe Administration of Transdermal Medications
Question 447Question →

A practical nurse is preparing to obtain a capillary blood glucose measurement for a client with diabetes mellitus. In which order should the nurse perform the following actions to ensure an accurate result and reduce the risk of complications? Arrange the steps from first to last.

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Answer

The correct sequence is to first verify the client's identity, cleanse the site and allow it to air-dry, puncture the fingertip, wipe away the first drop of blood, and finally apply the second drop of blood to the test strip.
To safely and accurately obtain a capillary blood glucose measurement, the nurse must follow a specific sequence. First, verifying client identity is a mandatory safety standard to prevent errors. Next, cleansing the site and letting it air-dry reduces the risk of infection and prevents chemical interference from the alcohol. Puncturing the lateral aspect of the finger minimizes pain. Wiping away the first drop of blood is a critical step to reduce risk potential, because it contains interstitial fluid and alcohol that can skew results. Finally, testing the newly formed second drop ensures an accurate representation of the client's capillary blood glucose.

Step-by-Step Solution

1
Identify the foundational safety requirement before any procedure.
Verifying the client's identity using two identifiers is the first step.
This prevents medical errors and ensures the correct client is being tested.
2
Determine the necessary site preparation.
The nurse must cleanse the site with an antiseptic swab and let it air-dry completely.
This reduces the risk of introducing infection and prevents residual alcohol from chemically altering the test result.
3
Identify the correct technique for obtaining the sample.
The side of the fingertip is punctured with a sterile lancet.
The lateral side of the finger pad has fewer nerve endings, minimizing client discomfort.
4
Determine the proper handling of the blood sample.
The nurse must wipe away the first drop of blood with dry gauze.
The first drop contains tissue fluid that can cause a falsely altered glucose reading.
5
Identify the final action for testing.
The second drop of blood is applied to the test strip.
This ensures the glucose monitor reads a pure capillary blood sample.

Key Concept

Capillary Blood Glucose Specimen Collection Protocol
Question 448Question →

A practical nurse is preparing to administer an intramuscular injection of iron dextran to an adult client diagnosed with severe iron deficiency anemia (hemoglobin 7.2 g/dL). To prevent medication leakage and permanent skin staining, the nurse must use the Z-track method. Arrange the following steps of the Z-track administration technique in the correct chronological order.

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Answer

The correct sequence for the Z-track method is to first change the needle, then displace the skin laterally, insert the needle and inject slowly, wait 10 seconds, and finally withdraw the needle while immediately releasing the skin.
The Z-track method is a specialized intramuscular injection technique designed to prevent leakage of irritating or staining medications into the subcutaneous tissue. The correct sequence ensures a clean needle enters the skin, the superficial tissues are displaced to create a staggered track, the medication is deposited and given time to disperse in the muscle, and finally, the track is permanently sealed by releasing the skin simultaneously as the needle is withdrawn.

Step-by-Step Solution

1
Change the needle on the syringe after drawing up the prescribed dose of iron dextran.
The needle shaft entering the client is completely clean.
Prevents tracking of the dark, irritating iron medication through the superficial subcutaneous tissues upon insertion.
2
Use the non-dominant hand to pull the skin and subcutaneous tissue 1 to 1.5 inches laterally from the injection site.
The tissue layers are misaligned.
Prepares the Z-track zigzag pathway required to lock the medication deep within the muscle.
3
Insert the needle at a 90-degree angle and push the plunger slowly to administer the medication.
Medication is deposited into the deep muscle layer.
Intramuscular administration requires a 90-degree angle for proper depth, and slow injection minimizes tissue tearing.
4
Leave the needle inserted in the muscle for 10 seconds after the medication is completely injected.
The medication begins to absorb and disperse.
Prevents the medication from pooling and being forced back up the track upon immediate needle removal.
5
Withdraw the needle smoothly and immediately release the taut skin.
The tissue layers slide back into their original, aligned position.
Closes off the needle track, effectively sealing the irritating iron dextran within the muscle tissue and preventing leakage.

Key Concept

Pharmacological Therapies
Question 449Question →

A practical nurse (PN) is observing a client who is receiving continuous enteral tube feedings. The client suddenly begins coughing forcefully and appears dyspneic. Arrange the following nursing actions in the priority order the PN should perform them.

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Answer

The correct sequence is to first stop the feeding, then position the client, check respiratory status, and finally notify the RN.
In any acute respiratory event during a continuous feeding, the immediate priority is to stop the feeding to prevent further aspiration. Next, the airway must be protected by positioning the client appropriately. Once the immediate threat is mitigated, the nurse gathers data on the client's respiratory status to determine the severity of the event. Finally, the nurse reports the findings and actions to the RN.

Step-by-Step Solution

1
Stop the continuous enteral feeding pump.
Further risk of aspiration is immediately halted.
According to the airway, breathing, circulation (ABC) priority framework, removing the source of airway compromise is the most critical first action.
2
Position the client on their side or in high Fowler's position.
The airway is cleared and protected.
This positioning utilizes gravity to prevent aspiration of any remaining fluids in the oropharynx.
3
Check the client's oxygen saturation level and count the respiratory rate.
The client's clinical status is evaluated.
Data collection determines the severity of the respiratory compromise and guides further interventions.
4
Notify the registered nurse (RN).
Higher-level care is initiated.
The PN must report acute changes in condition to the RN for potential modifications to the plan of care.

Key Concept

Airway and breathing prioritization during continuous enteral feeding complications
Question 450Question →

A practical nurse is assisting an 84-year-old client who experiences age-related dysphagia and a diminished gag reflex with their meal. To prevent aspiration and promote safe swallowing, arrange the nursing actions in the correct chronological order.

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Answer

The correct sequence is to first elevate the head of the bed, then provide a small bite of food, instruct the client to use the chin-tuck maneuver, inspect the mouth for pocketed food, and finally maintain an upright position after the meal.
The sequence of interventions prioritizes safety from the preparation phase through the post-meal phase. Proper upright positioning is the foundation of safe swallowing. Introducing a small amount of food followed by the chin-tuck maneuver protects the airway during the active phase of swallowing. Post-swallow assessment ensures no food remains that could be aspirated later. Finally, maintaining an upright posture prevents delayed aspiration from reflux, directly addressing age-related gastrointestinal changes.

Step-by-Step Solution

1
Ensure optimal positioning.
The client is placed in a high-Fowler's position.
Gravity assists the passage of food and reduces the immediate risk of aspiration before any intake occurs.
2
Administer food safely.
A small bite is placed in the mouth.
Smaller boluses are easier to manage for older adults with delayed swallowing reflexes.
3
Implement swallowing strategies.
The client performs the chin-tuck maneuver.
This physical action mechanically narrows the airway and widens the esophagus to protect the trachea during the swallow.
4
Evaluate the swallow.
The oral cavity is checked for pocketing.
Age-related sensory decline can cause clients to be unaware of retained food inside their cheeks.
5
Provide post-meal safety.
The client remains upright for at least 30 minutes.
This prevents reflux caused by an age-related decrease in lower esophageal sphincter tone.

Key Concept

Nursing interventions for age-related dysphagia and aspiration prevention.
Question 451Question →

A practical nurse is caring for a client who has a T4 spinal cord injury. The client suddenly reports a severe, pounding headache. The nurse notes profuse diaphoresis above the level of the injury and measures a blood pressure of 210/110 mm Hg. In which order should the nurse perform the following actions? (Arrange the items in the correct sequence, starting with the most immediate priority).

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Answer

The correct priority sequence is to first elevate the client's head to a high-Fowler's position, then assess for a triggering stimulus such as a kinked catheter, followed by notifying the registered nurse, and finally documenting the event.
Autonomic dysreflexia is a life-threatening neurological emergency that affects clients with spinal cord injuries at or above the T6 level. The sudden, massive sympathetic response causes severe hypertension. The nurse's absolute first action must be to sit the client upright, which uses gravity to pool blood in the lower extremities and rapidly decrease blood pressure. The next priority is to find and eliminate the cause, which is most often a distended bladder or impacted bowel. Therefore, checking the catheter is the second step. After independent nursing actions are taken to stabilize the client and gather data, the RN is notified. Documentation is always the final step after the emergency is managed.

Step-by-Step Solution

1
Place the client in a high-Fowler's (sitting) position.
Induces orthostatic hypotension.
Immediately lowers the dangerously high blood pressure to prevent a cerebral vascular accident (stroke).
2
Inspect the indwelling urinary catheter tubing for kinks or obstruction.
Identifies potential noxious stimuli.
Bladder distention is the most common trigger for autonomic dysreflexia. Identifying and resolving it stops the abnormal sympathetic response.
3
Notify the registered nurse (RN) of the assessment findings.
Activates the broader healthcare team.
The RN and healthcare provider must be aware of the emergency to prescribe or administer rapid-acting antihypertensive medications if necessary.
4
Document the acute event and the client's response to interventions.
Maintains the legal and medical record.
Documentation must reflect the exact sequence of events, vital signs, and interventions, but it is always performed after client stabilization.

Key Concept

Prioritization of interventions for a client experiencing autonomic dysreflexia, focusing on immediate risk reduction followed by identifying the triggering stimulus.
Question 452Question →

A client is admitted to a private room under airborne precautions. On the third day of isolation, the client becomes extremely anxious and reports hearing whispering voices and seeing dark shadows moving across the walls. Arrange the practical nurse's interventions in the priority order of implementation. (Place the first action at the top and the last action at the bottom.)

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Answer

The practical nurse should first provide a reality anchor, assess for command hallucinations to ensure safety, use therapeutic communication to validate distress, and finally modify the environment to prevent further episodes.
The nursing process and principles of prioritizing safety dictate the sequence of actions for a client experiencing perceptual alterations from sensory deprivation. First, the nurse must interrupt the episode by entering the room, increasing lighting, and identifying themselves to provide a strong reality anchor. Second, the nurse must assess for command hallucinations to ensure immediate safety. Third, the nurse uses therapeutic communication to validate the client's fear while presenting reality. Finally, long-term environmental modifications (such as providing natural light and a clock) are implemented to increase meaningful sensory input and prevent future episodes.

Step-by-Step Solution

1
Enter the room, turn on the overhead lights, and clearly state one's name and role.
The client is provided with an immediate reality anchor.
Establishing a therapeutic presence and providing adequate lighting are the first steps to disrupt a sensory illusion or hallucination.
2
Ask the client directly what the voices are saying to assess for potential harm.
The nurse determines if the client is experiencing command hallucinations.
Client safety is the highest priority; the nurse must rule out hallucinations instructing the client to harm themselves or others.
3
Acknowledge the client's distress while calmly presenting reality about the room.
The client feels heard and validated.
Validating the emotional response without agreeing with the hallucination builds trust and gently grounds the client in reality.
4
Open the window blinds and place a clock within the client's direct line of sight.
The client's environment is enriched with meaningful stimuli.
Sensory deprivation caused by prolonged isolation requires environmental modifications, such as natural light and orientation tools, to prevent further perceptual alterations.

Key Concept

Management of sensory deprivation and perceptual alterations
Question 453Question →

An uncircumcised adult client requires assistance with personal hygiene while on strict bed rest. In what sequence should the practical nurse execute the steps for male perineal care? Arrange the actions from first to last.

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Answer

The correct sequence is to first position and drape the client, retract the prepuce, cleanse the glans from the meatus outward, dry the glans and immediately replace the prepuce, and finally wash the shaft and scrotum.
The principles of medical asepsis require cleaning from the least contaminated area to the most contaminated. For an uncircumcised male, the sequence begins with proper positioning and draping to respect dignity. Next, the prepuce (foreskin) is retracted to expose the meatus. The glans is washed from the meatus outward to prevent introducing microorganisms into the urethra. Crucially, the prepuce must be immediately returned to its natural position after drying the glans to prevent paraphimosis (swelling and compromised circulation). Finally, the shaft and scrotum, which are considered more contaminated, are washed.

Step-by-Step Solution

1
Position and drape the client.
Exposes only the necessary area.
Maintains client dignity and provides a clear workspace.
2
Retract the prepuce (foreskin).
Exposes the glans penis and urethral meatus.
Allows for the removal of smegma and bacteria that collect under the foreskin.
3
Cleanse the glans from the meatus outward.
Removes secretions without pushing bacteria into the urethra.
Follows the medical asepsis principle of cleaning from the least to most contaminated area.
4
Dry the glans and replace the prepuce.
Restores normal anatomical position.
Prevents paraphimosis, a medical emergency that can cause severe edema and tissue ischemia if the foreskin is left retracted.
5
Wash the penile shaft and scrotum.
Cleans the remaining external genitalia.
These areas are considered more contaminated than the meatus and are therefore washed last using downward strokes.

Key Concept

Basic Hygiene and Infection Control: Male Perineal Care
Question 454Question →

A practical nurse is preparing to provide a complete bed bath for an adult client who is on strict bed rest. In which order should the nurse wash the following body areas? Arrange the actions from first to last.

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Answer

The correct sequence is: Wash the client's eyes and face, then the arms and chest, followed by the legs and feet, and finally the perineal area.
A complete bed bath must follow the fundamental principle of infection control: cleaning from the cleanest area to the least clean area. The eyes and face are the cleanest and are always washed first. The nurse then moves systematically down the body to the arms and chest, followed by the legs and feet. The perineal area is the most contaminated region and must always be washed last to prevent the spread of microorganisms to other body parts.

Step-by-Step Solution

1
Identify the primary principle of hygiene care and bed baths.
The nurse must always wash from the cleanest area to the least clean area.
This prevents cross-contamination and the spread of microorganisms.
2
Determine the cleanest area to begin the bath.
The eyes and face are washed first.
Washing the face first prevents transferring bacteria from other body parts to the delicate ocular tissues.
3
Determine the sequence for the rest of the body.
Care progresses down the body, washing the arms and chest, followed by the legs and feet.
This continues the progression from cleaner areas to less clean areas.
4
Identify the least clean area to be washed last.
The perineal area is washed at the very end of the procedure.
The perineal area contains the highest concentration of microorganisms.

Key Concept

Basic Hygiene and Bed Bath Sequencing
Question 455Question →

A practical nurse is providing care for a client who sustained a T3 spinal cord injury two months ago. The client suddenly reports a severe, pounding headache and exhibits profuse diaphoresis and facial flushing. Arrange the following nursing actions in the correct priority sequence.

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Answer

The correct sequence is to first position the client in high Fowler's, then measure the blood pressure, followed by checking the urinary catheter, and finally notifying the registered nurse.
In the event of autonomic dysreflexia, the primary goal is to prevent a catastrophic hypertensive stroke. Elevating the head of the bed immediately lowers blood pressure through orthostasis. Once the client is safe, confirming the hypertension via a blood pressure check guides further care. The nurse then seeks to eliminate the most common cause (bladder distention) by checking the catheter. Finally, escalating to the RN ensures advanced medical intervention if the crisis persists.

Step-by-Step Solution

1
Place the client in a high Fowler's position.
The client is sitting upright, utilizing gravity to induce orthostatic changes.
This is the most critical and rapid independent action to lower intracranial pressure and blood pressure, reducing the immediate risk of a cerebrovascular accident.
2
Obtain the client's current blood pressure reading.
The severity of the hypertensive crisis is accurately quantified.
Measuring the blood pressure confirms the suspected autonomic dysreflexia and provides necessary clinical data before proceeding to investigate the trigger.
3
Inspect the indwelling urinary catheter system for kinks.
A potential noxious stimulus (bladder distention) is identified and resolved.
A full bladder or obstructed catheter is the leading cause of autonomic dysreflexia; removing this stimulus often resolves the crisis.
4
Notify the supervising registered nurse of the assessment findings.
The RN is made aware of the acute physiological alteration and the interventions performed.
The RN coordinates further pharmacological therapy if conservative nursing measures fail to stabilize the client's blood pressure.

Key Concept

Prioritization of interventions for autonomic dysreflexia in clients with high-level spinal cord injuries.
Estimated Time:2m 0s
Question 456Question →

The healthcare provider prescribes knee-high graduated compression stockings for a client who is immobile. The practical nurse prepares to apply the stockings at the beginning of the morning shift. Arrange the following actions in the correct chronological sequence.

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Answer

The correct sequence begins with positioning the client supine for 15 minutes, followed by measuring the leg, inverting the stocking down to the heel, slipping it over the foot and heel, and finally pulling it smoothly up the calf.
Applying graduated compression stockings requires ensuring the leg is free of dependent edema before sizing and application. The client must be supine for 15 to 30 minutes to promote venous return. Once edema is minimized, precise measurements of the calf and leg length determine the correct size. To apply the tight garment, the nurse turns it inside out down to the heel, anchors it over the foot and heel, and smoothly pulls the rest over the calf. The nurse must never roll the top edge, as this restricts circulation.

Step-by-Step Solution

1
Maintain the client in a supine position for at least 15 minutes.
Venous return is promoted and lower extremity edema is reduced.
If legs are dependent, blood pools and swells the leg, which leads to measuring for an incorrect size and potentially trapping fluid when the stocking is applied.
2
Measure the circumference of the calf and the length of the lower leg.
The appropriate size of compression stocking is selected.
An incorrectly sized stocking can either provide inadequate compression or act as a dangerous tourniquet, compromising arterial and venous blood flow.
3
Turn the stocking inside out down to the heel pocket.
The foot portion of the stocking is isolated for initial application.
Compression stockings are highly elastic and tight; this specific inversion technique minimizes friction and struggling during the application process.
4
Slip the foot portion of the stocking over the toes and align the heel.
The stocking is properly anchored onto the client's foot.
Correct heel placement ensures the gradient pressure is distributed properly according to the manufacturer's therapeutic design.
5
Smoothly pull the remaining fabric upward over the calf without rolling the top band.
The stocking is completely applied without wrinkles or constricting bands.
Wrinkles or a rolled top edge can constrict blood flow, causing skin breakdown and drastically increasing the risk of deep vein thrombosis.

Key Concept

Application Sequence for Graduated Compression Stockings
Question 457Question →

A practical nurse (PN) is preparing to collect an anaerobic wound culture from a client with a deep, foul-smelling stage 4 pressure injury. To ensure a viable specimen and reduce the risk of a false laboratory result, in what chronological order should the PN perform the following actions? (Arrange the steps from first to last.)

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Answer

The correct sequence is to cleanse the wound, swab the deep tissue, insert the swab into the tube, crush the ampule, and label the specimen.
To reduce the risk of inaccurate laboratory results and improper treatment, the practical nurse must first clear away surface contaminants using normal saline. Next, because anaerobic bacteria die in the presence of oxygen, the swab must be taken from deep, tunneling tissue and immediately placed into the designated transport tube. Activating the ampule at the base is critical because it releases an oxygen-scavenging medium that preserves the anaerobes. Finally, the tube must be labeled at the bedside to ensure safe and accurate processing.

Step-by-Step Solution

1
Cleanse the wound bed thoroughly with sterile normal saline.
Surface exudate and colonizing skin flora are removed.
Reduces the risk of a false laboratory result caused by culturing non-pathogenic surface bacteria.
2
Rotate the sterile swab deep inside the tunneling tissue of the wound.
Pathogens responsible for the deep infection are collected.
Anaerobic bacteria cannot survive in oxygen-rich environments and must be collected from deep, unexposed tissues.
3
Insert the swab immediately into the designated anaerobic culture tube.
The specimen is secured in the transport container.
Minimizes the time the anaerobic bacteria are exposed to ambient room oxygen, which is lethal to them.
4
Crush the ampule at the base of the culture tube to activate the medium.
The transport medium coats the swab.
The chemical medium eliminates remaining oxygen inside the sealed tube, maintaining viability during transport to the laboratory.
5
Affix the client's identification label to the tube and document the procedure.
The specimen is accurately identified and ready for transport.
Ensures client safety and prevents laboratory processing errors.

Key Concept

Anaerobic Specimen Collection Protocol
Question 458Question →

A practical nurse (PN) is reinforcing teaching for a client with severe osteoarthritis of the hips who is learning to use a sock aid to dress independently. In which order should the PN instruct the client to perform the following steps? (Arrange the actions in the correct chronological sequence.)

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Answer

The correct sequence is to load the sock onto the trough on the lap, lower the device to the floor using the cords, insert the foot into the opening, pull the cords evenly to draw the sock up the leg, and finally remove the device.
The correct sequence follows the logical progression of preparing the assistive device (loading the sock), positioning it without breaking physical precautions (lowering with cords), engaging with the device (inserting the foot), executing the task (pulling the sock on), and finally removing the equipment. This step-by-step process maximizes client independence and safety by eliminating the need to bend at the waist or hips.

Step-by-Step Solution

1
Slide the sock over the plastic trough while the device is resting on the lap.
The sock is fully loaded onto the assistive device.
Preparing the device on the lap prevents painful and potentially dangerous bending at the hips.
2
Lower the device to the floor using the pull cords.
The device is positioned directly in front of the foot.
Using the cords to lower the device eliminates the need for the client to lean forward, maintaining independence and safety.
3
Insert the foot into the sock opening.
The foot is positioned inside the trough.
Proper foot placement ensures the sock will slide smoothly over the heel in the next step.
4
Pull evenly on both pull cords.
The sock glides up over the foot and calf.
Applying even tension prevents the device from twisting and ensures the sock goes on straight.
5
Pull the device completely out of the sock.
The sock is correctly worn and the device is freed.
Removing the device completes the dressing process while allowing the client to remain upright.

Key Concept

Promoting independence in ADLs using assistive equipment
Question 459Question →

A practical nurse in a pediatric clinic is reinforcing teaching with caregivers about expected speech and language development from early infancy through toddlerhood. Arrange the following communication milestones in the chronological order they typically occur, from earliest to latest.

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Answer

The correct chronological sequence of communication milestones is: producing cooing sounds (earliest), babbling with consonants, using simple gestures, and finally combining words into two-word phrases (latest).
Normal speech and language development follows a predictable progression. Infants begin with simple vocalizations like cooing, progress to babbling consonant-vowel sounds, develop nonverbal communication through gestures, and eventually combine words into simple phrases as toddlers.

Step-by-Step Solution

1
Identify the earliest milestone in the first few months of life.
Produces cooing and gurgling sounds.
Cooing is one of the earliest vocalizations, typically beginning around 2 months of age.
2
Identify the next milestone in mid-infancy.
Babbles using repeating consonant-vowel combinations.
Babbling typically emerges around 6 months of age as the infant experiments with consonant sounds.
3
Identify the milestone occurring near the end of the first year.
Uses simple gestures such as waving goodbye or pointing.
Purposeful nonverbal gestures typically develop between 9 and 12 months of age.
4
Identify the milestone associated with toddlerhood.
Combines words into simple two-word phrases.
Forming simple sentences or phrases is expected around 24 months (2 years) of age.

Key Concept

Chronological progression of speech and language developmental milestones from infancy to toddlerhood
Question 460Question →

A practical nurse is preparing to administer a prescribed transdermal nitroglycerin patch to a client with a history of angina. Arrange the following steps for applying the patch in the correct chronological order.

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Answer

The correct sequence is: perform hand hygiene and don gloves, remove the old patch, label the new patch, apply the new patch to a hairless area, and finally press firmly to ensure adhesion.
Chronological adherence to safety checks is essential in transdermal medication administration. Donning gloves protects the nurse. Removing the old patch first prevents medication overdose. Labeling before application is more comfortable for the client. Finally, placing the patch on a hairless site and pressing it firmly guarantees proper absorption and adhesion.

Step-by-Step Solution

1
Perform hand hygiene and put on a pair of clean gloves.
The nurse's skin is protected.
Maintains standard precautions and prevents the nurse from absorbing the active medication during handling.
2
Remove the previously applied patch and gently wipe the old site.
The old medication source is eliminated.
Prevents medication toxicity and overdose from having multiple patches active simultaneously.
3
Write the date, time, and your initials on the outside of the new patch.
The new patch is properly documented.
Writing on the patch before applying it avoids applying uncomfortable pressure to the client's underlying tissue.
4
Apply the new patch to a clean, hairless area of the skin on the chest or upper arm.
The medication patch is placed on the client.
Hairless, clean skin ensures optimal and consistent transdermal absorption of the medication.
5
Press firmly over the new patch with the palm of the hand for about 10 seconds.
The patch is secured to the skin.
Heat and pressure from the hand help the adhesive stick properly to the skin.

Key Concept

Safe administration of transdermal medications
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