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Question 461Question →

During a home care visit, the practical nurse (PN) observes a bedbound client who spends most of the day in a dimly lit room. The client suddenly becomes agitated, attempts to pull out their indwelling urinary catheter, and yells, "Get these snakes off my legs!" The PN recognizes a perceptual alteration likely caused by sensory deprivation. In which order should the PN perform the following interventions? Arrange the actions from first to last.

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Answer

The correct sequence prioritizes immediate physical safety, followed by therapeutic communication, environmental modification, sensory distraction, and finally, collaboration with the healthcare team.
The correct sequence of actions follows the nursing priorities of safety, therapeutic communication, environmental intervention, and collaboration. The highest priority is preventing physical injury by safely guiding the client's hands away from the catheter. Next, presenting reality helps ground the frightened client. Then, the underlying sensory deprivation is addressed by increasing lighting, which removes shadows that can cause illusions. Offering a tactile distraction prevents recurrence of the unsafe behavior. Finally, the RN is notified of the acute change in the client's condition for further evaluation.

Step-by-Step Solution

1
Secure the urinary catheter.
The client is prevented from self-harm and traumatic removal of the device.
Physical safety takes precedence over all other interventions.
2
Present reality to the client.
The client's fears are validated but grounded in reality.
Therapeutic communication de-escalates the acute panic associated with hallucinations or illusions.
3
Increase room lighting.
Sensory deprivation is reduced and visual misperceptions are eliminated.
Addressing the root cause of the perceptual alteration helps clear the acute confusion.
4
Provide a distraction object.
The client's hands are safely occupied.
Tactile stimulation redirects anxious energy away from pulling at medical devices.
5
Notify the registered nurse.
The healthcare team is informed of the acute change.
Collaboration is necessary for ongoing assessment and potential changes to the care plan.

Key Concept

Prioritization of nursing care for a client experiencing perceptual alterations requires addressing immediate physical safety first, followed by reorientation, environmental modifications, and reporting.
Question 462Question →

A newborn who is preparing for discharge requires a routine neonatal metabolic screening test via heel stick. Arrange the following procedural actions the nurse should take to obtain the capillary blood sample in the correct chronological sequence.

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Answer

The correct sequence is to first warm the heel, cleanse and dry the site, puncture the appropriate outer edge, wipe away the first drop of blood, collect the specimen on the filter paper, and finally apply pressure to stop the bleeding.
Following this specific sequence ensures the infant's safety by avoiding bone injury, prevents infection, and guarantees an uncontaminated, high-quality blood sample necessary for accurate metabolic screening.

Step-by-Step Solution

1
Warm the heel
Increases local perfusion
Promotes adequate blood flow to avoid milking or squeezing the foot, which can cause hemolysis.
2
Cleanse and air-dry the site
Skin is sanitized
Prevents introduction of pathogens and avoids alcohol contamination of the blood sample.
3
Puncture the outer edge of the heel
Capillary bed is accessed safely
Targeting the lateral or medial aspects avoids the calcaneus bone to prevent osteomyelitis.
4
Wipe away the first blood drop
Removes tissue fluid
Ensures the collected specimen is pure capillary blood, not diluted by interstitial fluid.
5
Collect the blood drops on filter paper
Circles are fully saturated
Provides a sufficient and unsmeared sample for the laboratory to run the metabolic assays.
6
Apply pressure to the site
Hemostasis is achieved
Prevents ongoing bleeding and localized bruising.

Key Concept

Newborn Capillary Blood Sampling (Heel Stick) Sequence
Question 463Question →

A practical nurse is preparing to administer an intramuscular injection of iron dextran to a client with iron-deficiency anemia using the Z-track method. Arrange the following steps of the administration procedure in the correct chronological sequence.

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Answer

The correct sequence is: pull the skin laterally, insert the needle at a 90-degree angle, inject the medication slowly, wait 10 seconds, and finally withdraw the needle while simultaneously releasing the retracted skin.
The Z-track method is essential for medications that cause tissue irritation or staining. The procedure begins by pulling the skin laterally to displace the tissue planes. While holding the skin in this position, the needle is inserted at a 90-degree angle and the medication is injected slowly. The nurse then waits 10 seconds to allow the medication to disperse within the muscle. Finally, the needle is withdrawn and the skin is released simultaneously, creating a zig-zag path that effectively seals the medication within the muscle belly.

Step-by-Step Solution

1
Pull the overlying skin and subcutaneous tissue laterally 1 to 1.5 inches.
The skin and subcutaneous tissue are displaced from the underlying muscle.
This creates an offset pathway that will seal the needle track after the injection is complete.
2
Insert the needle smoothly and swiftly at a 90-degree angle.
The needle reaches the deep muscle tissue.
A 90-degree angle ensures the medication is deposited directly into the muscle belly rather than the subcutaneous layer.
3
Inject the medication slowly and steadily into the muscle.
The medication is deposited into the muscle tissue.
A slow injection rate minimizes tissue trauma and pain while allowing the muscle fibers to accommodate the fluid volume.
4
Wait 10 seconds before removing the needle.
The medication begins to disperse deeply into the muscle.
This pause prevents the medication from tracking back up the needle pathway immediately following the injection.
5
Withdraw the needle and immediately release the retracted skin.
The tissue planes slide back into their original, unretracted positions.
Releasing the skin breaks the alignment of the needle track, permanently trapping the medication in the muscle layer and preventing superficial staining or irritation.

Key Concept

The Z-track method is an intramuscular injection technique designed to prevent irritating or staining medications from leaking back into the subcutaneous tissue.
Question 464Question →

A practical nurse (PN) is reinforcing teaching for an older adult client about independent denture care. In what order should the client perform the following steps to ensure safety and proper hygiene? Arrange the actions in the correct sequence.

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Answer

The correct sequence for independent denture care is: line the sink with a washcloth, remove the dentures, brush all surfaces, rinse under cool water, and store in water.
Safe and effective denture care requires a specific sequence to protect the prosthesis from damage while ensuring proper hygiene. Preparing the environment by lining the sink is the essential first step to prevent breakage. After removal, brushing with appropriate non-abrasive materials removes plaque. Rinsing with cool or tepid water (never hot) removes the cleanser without warping the material. Finally, proper storage in liquid prevents drying and cracking.

Step-by-Step Solution

1
Place a washcloth or small towel in the bottom of the sink.
The sink is lined with a protective cushion.
This crucial first step prevents the brittle denture material from chipping or breaking if accidentally dropped into the hard sink basin.
2
Remove the dentures carefully from the mouth.
The dentures are safely in the client's hands.
Dentures must be removed to ensure all surfaces, including the side that rests on the gums, are properly cleaned.
3
Brush all denture surfaces with a soft-bristled brush and non-abrasive cleanser.
Food particles, plaque, and stains are mechanically removed.
A soft brush and non-abrasive cleanser prevent scratching the denture surface, which could harbor bacteria.
4
Rinse the dentures thoroughly under cool or tepid running water.
All cleanser and debris are washed away.
Cool or tepid water is required because hot water can warp the plastic material, altering the fit of the dentures.
5
Store the dentures in a covered container filled with water or soaking solution.
The dentures are safely stored and kept moist.
Dentures must be kept moist when not in use to prevent them from drying out, cracking, or losing their shape.

Key Concept

Independent and Safe Denture Care
Question 465Question →

A client with type 2 diabetes mellitus is prescribed a combined subcutaneous injection of regular and NPH insulin. Place the following actions the nurse must take to draw up the medication in the correct chronological sequence.

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Answer

The correct sequence for mixing insulins is to roll the NPH vial, inject air into the NPH vial, inject air into the regular vial, withdraw the regular insulin, and finally withdraw the NPH insulin.
To safely prepare a mixed dose of insulin, the nurse must follow the 'clear before cloudy' sequence. First, the NPH (cloudy) insulin is rolled to resuspend the particles. Then, air is injected into the NPH vial followed by the regular (clear) vial. The regular insulin is drawn up first to prevent contaminating the rapid-acting clear insulin with the longer-acting cloudy insulin. Finally, the NPH insulin is withdrawn.

Step-by-Step Solution

1
Resuspend the intermediate-acting insulin.
The cloudy suspension is mixed evenly without bubbles.
Rolling rather than shaking prevents bubble formation, which can cause dosing errors.
2
Pressurize both vials with air, starting with the intermediate-acting (cloudy) insulin.
Air is placed in both vials, leaving the needle in the regular insulin vial.
Pressurizing prevents a vacuum. Starting with NPH prevents contaminating the regular insulin needle.
3
Draw up the insulins, starting with the short-acting (clear) insulin.
Regular insulin is drawn up first, followed by NPH insulin.
Drawing clear before cloudy ensures the regular insulin vial is not contaminated by intermediate-acting insulin.

Key Concept

Safe Preparation of Mixed Insulins
Question 466Question →

A practical nurse is caring for a client who sustained a closed head injury 12 hours ago. The client, who was previously alert and oriented, suddenly becomes lethargic and extremely difficult to arouse. The nurse notes that the client's systolic blood pressure has significantly increased, and the heart rate has dropped to 54 beats/min. Arrange the following nursing actions in the correct chronological order of priority.

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Answer

The correct sequence of actions is to first verify airway and oxygenation, then elevate the head of the bed to 30 degrees, subsequently notify the registered nurse and provider, implement seizure precautions, and finally document the event.
In any acute neurological decline involving suspected increased intracranial pressure, the ABCs (Airway, Breathing, Circulation) take strict precedence. The nurse must first ensure the brain is receiving oxygen to prevent massive vessel dilation. Next, the nurse uses physical positioning to drain fluid from the head. Only after these immediate stabilization steps are complete should the nurse escalate the emergency to higher-level providers, secure the environment against secondary complications, and chart the event.

Step-by-Step Solution

1
Verify airway patency and ensure oxygen delivery.
Prevents cerebral hypoxia and hypercapnia.
Hypoxia and retained carbon dioxide cause cerebral blood vessels to dilate, which severely and rapidly increases intracranial pressure.
2
Elevate the head of the bed and align the neck.
Facilitates venous return from the brain.
A 30-degree elevation with a neutral neck alignment uses gravity to drain blood through the jugular veins, decreasing cranial volume and pressure.
3
Notify the RN and healthcare provider.
Escalates the clinical emergency to advanced providers.
The client is exhibiting Cushing's triad (bradycardia, hypertension, altered mental status), which signals impending brainstem herniation requiring urgent medical intervention.
4
Implement seizure precautions and lower stimuli.
Protects the client from secondary injury and reduces cerebral metabolic demand.
A damaged, pressurized brain is highly susceptible to seizure activity, and environmental stress can further elevate intracranial pressure.
5
Document the event and vital signs.
Creates an accurate chronological record of the clinical decline.
Documentation provides critical data for the healthcare team but is an administrative task that should never delay life-saving bedside interventions.

Key Concept

Prioritization of nursing actions for increased intracranial pressure (ICP) and recognition of Cushing's triad.
Question 467Question →

A practical nurse is preparing to transfer a client who has right-sided weakness from the bed to a wheelchair. In which order should the nurse perform the following actions? (Arrange the items in the correct sequence from first to last.)

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Answer

The correct sequence ensures maximum safety by first establishing the environment (positioning and locking the wheelchair on the strong side), stabilizing the client (sitting and dangling), applying safety equipment (gait belt), and finally executing the transfer.
Safe client mobility requires a rigid sequential approach: environmental preparation (chair placement and locking) must occur before client preparation (positioning and safety devices), which must occur before the physical movement (standing and pivoting).

Step-by-Step Solution

1
Place the wheelchair on the client's left side at a 45-degree angle to the bed.
The wheelchair is properly positioned on the client's unaffected side.
Because the client has right-sided weakness, placing the chair on the left allows them to use their stronger arm and leg to support their weight and guide the transfer.
2
Lock the brakes on both the bed and the wheelchair.
The environment is completely immobilized.
Locking the brakes prevents sudden, unexpected movement of the bed or chair, which is a primary cause of transfer-related injuries.
3
Lower the bed and assist the client to sit on the edge with feet flat on the floor.
The client is in a dangling position with a solid base of support.
Dangling allows the cardiovascular system to adjust to the upright position, minimizing dizziness, while flat feet provide necessary stability.
4
Securely fasten a transfer (gait) belt around the client's waist.
Safety equipment is in place.
Applying the gait belt while the client is safely seated ensures a snug fit, providing the nurse with a secure hold to safely guide the client's movements.
5
Assist the client to stand and pivot on the strong leg toward the wheelchair.
The client safely completes the transfer to the wheelchair.
Pivoting on the unaffected left leg ensures the client can support their own weight securely during the transition into the chair.

Key Concept

Safe Client Transfer and Mobility Principles
Question 468Question →

A licensed practical nurse is coordinating with assistive personnel to turn a client who is 1 day postoperative following a lumbar spinal fusion. In what chronological order should the nurse perform the following actions to safely logroll the client?

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Answer

The correct sequence is to first flatten the bed, then position the client's limbs with a pillow between the knees, position the staff on the destination side, grasp the draw sheet on the far side, and finally roll the client as a single unit on a count of three.
Logrolling is a mobility technique used to turn a client whose spine must be kept in straight alignment, particularly after spinal fusion surgery. The procedure requires careful sequential preparation: flattening the bed to align the spine, positioning the limbs to prevent dragging and maintain hip alignment, organizing the staff around the bed, establishing a firm grip on the draw sheet, and executing a coordinated turn as a single unit to prevent spinal torque.

Step-by-Step Solution

1
Lower the head of the bed to ensure the mattress is completely flat.
The client is in a flat, supine position.
A flat surface is required to prevent spinal flexion and maintain straight alignment during the maneuver.
2
Cross the client's arms over their chest and place a pillow between their knees.
The client's extremities are secured and aligned.
Crossing the arms prevents dragging, and the pillow keeps the hips and lumbar spine aligned without twisting.
3
Position two staff members on the side of the bed toward which the client will be turned.
Staff are optimally positioned for the transfer.
Positioning on the destination side allows the staff to safely pull the client's weight toward their own center of gravity.
4
Reach across the client and firmly grasp the draw sheet on the opposite side.
Staff have a secure hold on the friction-reducing device.
The draw sheet distributes the pulling force evenly across the client's body length.
5
Roll the client smoothly as a single unit on a coordinated count of three.
The client is successfully turned onto their side.
Moving the body as one continuous unit (logrolling) prevents any dangerous torque or twisting on the postoperative spine.

Key Concept

Procedural sequencing for logrolling and postoperative spinal positioning
Question 469Question →

A client with a seizure disorder is receiving continuous enteral nutrition via a percutaneous endoscopic gastrostomy (PEG) tube. The practical nurse must administer a scheduled dose of phenytoin oral suspension through the tube. Arrange the following actions in the correct sequence to ensure safe administration and maximize drug absorption.

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Answer

The correct sequence requires stopping the feeding 1-2 hours before, verifying tube placement/residual, flushing with water, administering the phenytoin, flushing again with water, and leaving the feeding off for another 1-2 hours.
Phenytoin has a well-documented and severe interaction with enteral nutritional formulas. The formula significantly decreases the gastrointestinal absorption of the drug, which can lead to subtherapeutic serum levels and seizures. Therefore, the feeding must be stopped 1 to 2 hours before administration. Standard tube medication safety follows: verify placement and residual, flush with water, administer the medication, and flush again. Finally, the feeding must remain off for an additional 1 to 2 hours to allow the drug to absorb fully without interference.

Step-by-Step Solution

1
Stop the continuous enteral feeding 1 to 2 hours prior to the scheduled medication time.
The stomach empties of formula before the medication arrives.
Enteral formula contains proteins and calcium that heavily bind to phenytoin, leading to subtherapeutic drug levels and potential breakthrough seizures.
2
Verify gastrostomy tube placement and measure the gastric residual volume.
Safe route for administration is confirmed.
Checking placement and residual prevents pulmonary aspiration and ensures the gastrointestinal tract is tolerating fluids.
3
Flush the gastrostomy tube with 30 mL of water.
The internal lumen of the tube is cleared of formula.
This prevents direct physical incompatibility and crystallization between the enteral formula and the phenytoin suspension inside the tube.
4
Administer the prescribed dose of liquid phenytoin suspension.
The therapeutic agent is delivered.
Phenytoin must be given as an isolated suspension to ensure proper absorption.
5
Flush the gastrostomy tube with an additional 30 mL of water.
The medication is completely cleared from the tubing.
Ensures the client receives the full prescribed dose and prevents tube occlusion from the medication.
6
Keep the enteral feeding paused for 1 to 2 hours before restarting the continuous infusion.
The drug absorbs fully across the gastrointestinal mucosa without interference.
Immediate resumption of feeding would cause the formula to bind to the phenytoin in the stomach, rendering the medication ineffective.

Key Concept

Enteral administration of phenytoin requires strictly holding continuous nutritional feedings 1 to 2 hours before and after administration to prevent decreased drug bioavailability due to protein binding.
Question 470Question →

A practical nurse is reinforcing physical therapy instructions for a client who is non-weight-bearing on the right lower extremity and is learning to use axillary crutches. Arrange the following actions in the correct chronological sequence for safely navigating up a single step.

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Answer

To ascend a step, the client starts in a tripod stance, shifts weight onto the crutches, steps up with the unaffected leg, shifts weight onto the unaffected leg, and finally brings the crutches and affected leg up together.
The fundamental principle for ascending stairs with an assistive device is 'up with the good.' The client must first establish stability in a tripod position. By bearing weight on the hands, the client can safely lift the strong, unaffected leg onto the step. Once the strong leg is anchored on the higher level, the client shifts their weight onto it. This strong leg now acts as the elevator for the rest of the body, allowing the client to safely bring up the crutches and the non-weight-bearing injured leg simultaneously without compromising balance or the surgical/injury site.

Step-by-Step Solution

1
Assume the tripod stance close to the base of the stairs.
A wide, stable base of support is established.
Proper alignment prevents backward falls when initiating the upward movement.
2
Bear the full body weight evenly on the handgrips of both crutches.
The legs are completely unweighted.
This allows the client to freely lift the unaffected leg without losing balance.
3
Advance the unaffected left leg onto the step above.
The strong leg is planted on the higher elevation.
The unaffected leg must lead to provide the necessary power to lift the body.
4
Shift the body weight from the crutches onto the unaffected left leg.
The upper body and crutches are now unweighted.
Weight must be on the strong leg so the crutches can be safely lifted off the lower level.
5
Lift the affected right leg and both crutches simultaneously to the step.
The client is now standing with both feet and crutches on the new step.
This completes the movement while ensuring zero weight is placed on the injured extremity.

Key Concept

Basic Care and Comfort: Safe Mobility and Assistive Devices
Estimated Time:1m 30s
Question 471Question →

A practical nurse (PN) is assisting with the monitoring of a client who is receiving a packed red blood cell (PRBC) transfusion. The client suddenly reports severe lower back pain, chills, and shortness of breath. Arrange the following nursing actions in the correct sequence of priority to reduce the client's risk of further complications.

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Answer

The correct sequence is: Stop the transfusion immediately, maintain IV access with new tubing and 0.9% sodium chloride, assess vital signs and cardiopulmonary status, report findings to the supervising RN, and finally collect required blood and urine specimens.
In any emergency where a therapeutic intervention causes severe harm (such as a hemolytic transfusion reaction), the absolute first priority is to stop the intervention. Following immediate cessation, the nurse must secure the IV line with normal saline using new tubing to prevent further infusion of the blood while keeping the vein open for emergency drugs. Next, the nurse assesses the client to gather critical physiological data, reports these findings to the RN for medical escalation, and finally executes post-reaction protocol steps such as collecting diagnostic specimens.

Step-by-Step Solution

1
Stop the administration of the blood product immediately.
The infusion of the potentially incompatible blood is halted.
This is the most critical first step to reduce the risk of life-threatening complications by preventing further antigen exposure.
2
Maintain intravenous access with a new tubing set primed with 0.9% sodium chloride.
The IV line remains patent without infusing more of the reacted blood.
Vascular access is required for emergency medications. Flushing with the old tubing would incorrectly push the remaining blood in the line into the client, worsening the reaction.
3
Obtain the client's vital signs and complete a focused cardiopulmonary assessment.
Objective baseline data regarding the severity of the reaction is gathered.
The nurse needs precise assessment data (e.g., blood pressure, oxygen saturation, lung sounds) to accurately report the client's physiological status.
4
Report the assessment findings and suspected reaction to the supervising registered nurse (RN).
The RN is alerted to escalate the situation to the healthcare provider.
Effective escalation requires providing the RN with current, accurate assessment data so they can collaborate on immediate medical management.
5
Collect required blood and urine specimens to evaluate for potential hemolysis.
Samples are prepared for laboratory and blood bank analysis.
Diagnostic evaluation for hemolytic or other adverse reactions occurs safely only after the client's acute airway and circulatory needs are secured.

Key Concept

The priority sequence for managing a blood transfusion reaction focuses on immediately removing the risk (stopping blood), maintaining access safely (new tubing), assessing severity, and escalating care.
Question 472Question →

A practical nurse (PN) is evaluating an alert and oriented client with diabetes mellitus who reports sudden shakiness, weakness, and diaphoresis. The client's capillary blood glucose level is 54 mg/dL (3.0 mmol/L). Arrange the following nursing actions in the correct chronological order of implementation.

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Answer

The correct sequence is to first administer a fast-acting carbohydrate (apple juice), wait 15 minutes, recheck the capillary blood glucose, and finally provide a complex carbohydrate and protein snack.
For a conscious client experiencing acute hypoglycemia (blood glucose less than 70 mg/dL), the standard evidence-based protocol is the 'Rule of 15'. The nurse must first administer 15 grams of a fast-acting, easily digestible carbohydrate (such as 4 ounces of juice) to quickly raise the blood sugar. The nurse then waits exactly 15 minutes to allow for absorption before rechecking the blood glucose level to see if it has risen above 70 mg/dL. Once the acute hypoglycemia is resolved, a complex carbohydrate and protein snack (like peanut butter and crackers) is provided to maintain the blood glucose level and prevent a subsequent drop.

Step-by-Step Solution

1
Provide 4 ounces of apple juice.
Introduces 15 grams of simple carbohydrates into the digestive system.
Rapidly raises blood glucose levels in a conscious client experiencing hypoglycemia.
2
Wait 15 minutes.
Provides necessary time for digestion and systemic circulation.
Ensures the simple carbohydrates have enough time to absorb and affect the blood glucose concentration.
3
Recheck the blood glucose level.
Yields an updated capillary blood glucose reading.
Evaluates the effectiveness of the initial intervention to determine if another 15 grams of carbohydrates are needed.
4
Offer peanut butter and crackers.
Introduces fat, protein, and complex carbohydrates.
Stabilizes the blood sugar over a longer period to prevent a secondary hypoglycemic episode.

Key Concept

Rule of 15 for Hypoglycemia Management
Question 473Question →

A practical nurse is caring for a client with a T4 spinal cord injury who suddenly reports a severe, pounding headache and blurred vision. The nurse notes that the client's face is flushed and profusely sweating. In which order should the practical nurse prioritize the following actions? (Arrange from first action to last action)

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Answer

The correct sequence of actions for a client experiencing autonomic dysreflexia is to first elevate the head of the bed, then measure the blood pressure, followed by assessing the urinary catheter for blockages, notifying the registered nurse, and finally documenting the event.
Autonomic dysreflexia is a life-threatening neurological emergency characterized by severe hypertension, triggered by a noxious stimulus below the level of the spinal cord injury (typically T6 or higher). The absolute priority is to immediately lower the blood pressure by utilizing orthostatic hypotension, which is achieved by sitting the client upright. Once the immediate risk is slightly mitigated through positioning, the nurse must assess the blood pressure to establish a baseline. Following assessment, the nurse must systematically hunt for and remove the triggering stimulus (most commonly a full bladder or kinked urinary catheter). After these independent actions are taken, the RN or provider must be notified for further collaborative orders, and finally, all findings and actions are documented in the client's medical record.

Step-by-Step Solution

1
Elevate the head of the bed to a sitting position (90 degrees).
Induces orthostatic hypotension.
This is the most rapid way to lower the client's blood pressure, reducing the immediate risk of a cerebrovascular accident.
2
Measure the client's blood pressure.
Quantifies the severity of hypertension.
Establishes a vital sign baseline to monitor the effectiveness of interventions and communicate clearly with the healthcare team.
3
Check the urinary catheter for kinks or obstruction.
Identifies the potential noxious stimulus.
Bladder distention is the most common cause of autonomic dysreflexia; removing the stimulus often resolves the crisis.
4
Notify the registered nurse (RN) or provider.
Escalates care for the medical emergency.
Facilitates advanced collaborative interventions, such as administering prescribed rapid-acting antihypertensives, if the crisis continues.
5
Document all findings and interventions.
Provides an accurate medical record.
Ensures continuity of care and legal accountability after the client's immediate safety is secured.

Key Concept

Prioritization of Care for Autonomic Dysreflexia
Question 474Question →

While providing care for a client with chronic angina, a practical nurse prepares to apply a new transdermal nitroglycerin patch. Place the following nursing actions in the correct chronological sequence.

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Answer

The correct chronological sequence is: perform hand hygiene and put on gloves, remove the old patch, clean the old site, select a new site, and finally apply and label the new patch.
Administering a transdermal patch requires strict adherence to safety protocols for both the client and the nurse. The nurse must first protect themselves by donning gloves. Next, the old patch must be removed and the area cleansed to prevent an accidental overdose from residual medication. Finally, site rotation is practiced by selecting a new, hairless area before applying and labeling the new patch.

Step-by-Step Solution

1
Perform hand hygiene and put on clean gloves.
The nurse's hands are protected from inadvertent medication absorption.
Transdermal medications are easily absorbed through the skin. The nurse must protect themselves before handling the medication or the client's old patch.
2
Remove the old patch and fold it in half with the adhesive sides together.
The old medication source is safely removed and contained.
Leaving an old patch on while applying a new one can cause a dangerous overdose, leading to severe adverse effects such as profound hypotension.
3
Clean and dry the skin area where the old patch was located.
The previous application site is free of residual medication.
Residual medication left on the skin can continue to be absorbed if not washed away.
4
Select a new, intact, and hairless site on the client's upper body.
A safe and effective location is identified for the new dose.
Site rotation prevents skin breakdown and irritation while ensuring predictable medication absorption.
5
Apply the new patch and document the date, time, and initials on it.
The medication is administered and the action is clearly communicated.
Labeling the patch informs other nurses when the patch was placed and when it is due for removal or replacement.

Key Concept

Safe Administration of Transdermal Medications
Question 475Question →

A practical nurse is collecting data on the uterine involution of a client who experienced a spontaneous vaginal birth 14 hours ago. In which order should the nurse perform the steps of the fundal assessment? Arrange the actions from first to last.

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Answer

The correct sequence requires preparing the client by emptying the bladder and optimizing positioning, then applying standard precautions to check baseline bleeding, and finally using a two-handed technique starting with lower uterine support before pressing on the fundus.
A systematic approach to fundal assessment ensures accurate data collection and client safety. An empty bladder prevents upward and lateral displacement of the uterus. Positioning with flexed knees relaxes the abdominal muscles for easier palpation. Donning gloves and checking lochia first provides a baseline assessment of bleeding before uterine manipulation. Finally, supporting the lower uterine segment is a mandatory clinical safety measure before fundal palpation to prevent uterine inversion.

Step-by-Step Solution

1
Instruct the client to void.
The bladder is emptied.
Prevents upward and lateral displacement of the uterus, ensuring accurate assessment.
2
Position the client supine with knees flexed.
The abdominal muscles relax.
Facilitates accurate and comfortable palpation of the abdominal organs.
3
Don gloves and observe the perineal pad.
Standard precautions are established and baseline lochia is noted.
Protects the nurse and identifies the current amount of bleeding before uterine manipulation.
4
Place one hand above the symphysis pubis.
The lower uterine segment is supported.
Prevents downward prolapse or inversion of the uterus when pressure is applied from above.
5
Palpate the fundus with the other hand.
Fundal height and tone are evaluated.
Completes the data collection regarding uterine involution.

Key Concept

Postpartum Uterine Fundal Assessment Sequence
Question 476Question →

A practical nurse is preparing to collect a urine specimen for culture and sensitivity from a client who has an indwelling urinary catheter. Arrange the following steps for this procedure in the correct chronological sequence.

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Answer

The correct sequence is to first clamp the drainage tubing, then scrub the collection port, aspirate the urine with a sterile syringe, transfer it to a sterile container, and finally unclamp the drainage tubing.
The proper procedure for collecting a sterile urine specimen from a closed urinary drainage system minimizes the risk of introducing pathogens and ensures accurate laboratory results. Clamping the tube allows fresh urine to collect. Scrubbing the port maintains sterility. Aspirating and transferring the specimen completes the sterile collection, and unclamping the tube ensures client safety by restoring normal urinary drainage.

Step-by-Step Solution

1
Clamp the drainage tubing.
Fresh urine accumulates near the collection port.
Urine collected from the drainage bag is not sterile; fresh urine must be collected directly from the catheter tubing.
2
Scrub the collection port with an antiseptic wipe.
The surface of the port is disinfected.
This prevents bacteria from being pushed into the catheter system or contaminating the sample during aspiration.
3
Aspirate urine using a sterile syringe.
The required volume of fresh urine is obtained.
A sterile syringe maintains the closed system while safely extracting the sample.
4
Transfer the urine to a sterile specimen container.
The specimen is safely secured for transport.
Maintaining the sterility of the container's interior ensures accurate laboratory culture results.
5
Unclamp the drainage tubing.
Continuous urine flow into the drainage bag is restored.
Prolonged clamping can cause severe bladder distention and increases the risk of urinary tract infection.

Key Concept

Sterile Specimen Collection and Risk Reduction
Question 477Question →

A practical nurse (PN) enters the room of a client receiving total parenteral nutrition (TPN) and discovers that the central venous catheter tubing has accidentally disconnected from the hub. The client is suddenly gasping for air, clutching their chest, and appears cyanotic. In what order should the PN perform the following actions? Arrange the actions in the correct sequence from first to last.

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Answer

The correct priority sequence is to first clamp the catheter, then position the client on their left side with the head lowered, followed by administering oxygen, and finally collecting vital signs.
In the event of a central venous catheter disconnection leading to an air embolism, the PN must follow strict prioritized steps. The very first action is to clamp the catheter to stop further air from being drawn into the venous system by negative intrathoracic pressure. Second, the client must be placed in the left lateral Trendelenburg position; this uses gravity to trap the air in the right atrium or right ventricle, preventing it from blocking the pulmonary artery. Third, high-flow oxygen is administered to combat the resulting severe hypoxia and help wash out nitrogen from the air bubble. Finally, once these immediate life-saving actions are complete, the PN collects a full set of vital signs to provide crucial hemodynamic data to the rapid response team and healthcare provider.

Step-by-Step Solution

1
Clamp the open lumen of the central venous catheter.
Further air entry is immediately halted.
The direct cause of the emergency (an open line into the central venous system) must be eliminated before any other intervention to prevent a larger, more lethal air embolism.
2
Turn the client onto their left side with the head of the bed lowered.
The air bubble is physically trapped.
The left lateral Trendelenburg position utilizes gravity to keep the air bubble in the apex of the right ventricle or atrium, preventing it from traveling into the pulmonary artery and causing a right ventricular outflow tract obstruction.
3
Administer high-flow supplemental oxygen via a non-rebreather mask.
Tissue hypoxia is treated.
The air embolism causes severe ventilation/perfusion mismatch and hypoxia; high-flow oxygen helps reverse the hypoxemia and may assist in resorbing the nitrogen gas bubble.
4
Collect a complete set of vital signs to report to the rapid response team.
Baseline data is gathered for the arriving team.
Hemodynamic status must be evaluated after initial life-saving measures to report to the registered nurse and emergency providers.

Key Concept

Emergency management of a suspected central line air embolism prioritizes immediately stopping air entry, then utilizing positional gravity to trap the air, followed by oxygenation and hemodynamic monitoring.
Estimated Time:1m 30s
Question 478Question →

A practical nurse is monitoring a client who began receiving a packed red blood cell (PRBC) transfusion 15 minutes ago. The client suddenly reports severe lower back pain, acute chills, and a sensation of chest tightness. Arrange the following nursing actions in the correct sequence of priority from first to last.

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Answer

The correct sequence prioritizes immediate cessation of the offending agent, followed by securing safety (new IV line), escalating care (notifying RN), collecting critical data (vital signs), and finally completing diagnostic protocols (returning blood, collecting urine).
The sequence follows the airway, breathing, circulation (ABC) and nursing process prioritization frameworks. Stopping the transfusion immediately removes the life-threatening trigger. Changing the tubing ensures the client receives necessary IV fluids without receiving the residual incompatible blood left in the old line. Notifying the RN brings advanced life support. Taking vital signs provides necessary data to the RN upon arrival. Returning the blood bag and collecting a urine sample are diagnostic and administrative tasks that must wait until the client is stabilized.

Step-by-Step Solution

1
Halt the transfusion
Prevents further administration of incompatible red blood cells.
The client is exhibiting classic signs of an acute hemolytic transfusion reaction (lower back pain, chills, dyspnea). Removing the offending agent is the primary life-saving action.
2
Maintain intravenous access with new tubing and normal saline
Keeps the vein open for emergency drugs without infusing residual blood.
Flushing the old tubing would push more incompatible blood into the client. New tubing ensures safety while maintaining a route for vascular support.
3
Alert the registered nurse and emergency response team
Initiates advanced medical support.
The client will require medications and interventions beyond the practical nurse's scope of practice to manage potential shock and acute renal failure.
4
Assess vital signs and cardiopulmonary status
Provides critical baseline data regarding the severity of the reaction.
This data guides the incoming rapid response team in diagnosing the extent of hemodynamic instability or respiratory compromise.
5
Secure the blood bag and tubing for the laboratory
Preserves evidence for blood bank analysis.
The laboratory must crossmatch the blood again to determine the exact cause and type of the hemolytic reaction.
6
Obtain a urine specimen
Provides a sample to test for hemoglobinuria.
Hemolyzed red blood cells release free hemoglobin, which is filtered by the kidneys and can cause acute tubular necrosis. This confirms the systemic impact.

Key Concept

Prioritization of care during an acute hemolytic transfusion reaction requires immediate cessation of the blood product, maintaining venous access with sterile equipment, and rapid escalation of care before proceeding with secondary assessments and diagnostics.
Question 479Question →

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

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Answer

The correct sequence is to first stop the blood transfusion immediately, followed by initiating a normal saline infusion using new IV tubing. Next, the PN must notify the RN and healthcare provider, and finally, obtain a complete set of vital signs.
In any acute transfusion reaction, the primary goal is to limit the client's exposure to the offending antigen. Therefore, stopping the transfusion is the immediate first step. Venous access must be maintained to administer emergency drugs, but it must be done with entirely new tubing to prevent infusing residual blood. Once the immediate danger is halted and the line is secured, the PN must escalate the situation by notifying the RN and provider. Finally, obtaining vital signs provides essential data for the provider to direct further care.

Step-by-Step Solution

1
Stop the blood transfusion.
Prevents additional incompatible blood cells from entering the systemic circulation.
Lower back pain, chills, and dyspnea are classic signs of an acute hemolytic transfusion reaction, which is a life-threatening emergency requiring immediate cessation of the causative agent.
2
Disconnect the blood tubing and start normal saline with new tubing.
Maintains patent venous access for emergency medications while preventing further exposure.
Flushing the existing tubing would push the remaining incompatible blood into the client. New tubing must be attached directly to the IV catheter hub.
3
Notify the RN and healthcare provider.
Escalates the clinical emergency to the appropriate personnel.
The client will require immediate medical intervention, emergency medications, and activation of the facility's blood bank reaction protocol.
4
Obtain vital signs and monitor.
Provides objective baseline data regarding the client's hemodynamic and respiratory stability.
Continuous monitoring is required to assess the severity of the reaction and guide ongoing emergency treatment.

Key Concept

Management of Acute Hemolytic Transfusion Reactions
Question 480Question →

A client in the preoperative staging area is scheduled for an elective surgical procedure and has previously signed the informed consent document. When the practical nurse (PN) approaches to administer a prescribed preoperative sedative, the client abruptly declares, 'I have changed my mind. I am refusing this surgery.' Arrange the following nursing actions in the correct priority order from first to last.

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Answer

The correct sequence prioritizes client safety and legal capacity by first withholding the sedative, followed by exploring the client's concerns, notifying the provider and RN, and finally documenting the event.
The sequence follows the nursing process and clinical prioritization principles: safety first (holding the medication to preserve cognitive capacity), followed by data collection (assessing reasons), implementation and communication (notifying the provider), and finally, documentation.

Step-by-Step Solution

1
Withhold the administration of the prescribed preoperative sedative medication.
The client's cognitive capacity remains intact.
Administering a sedative would impair the client's mental state, preventing them from legally and clearly discussing their revocation of consent with the surgeon.
2
Ask open-ended questions to explore the client's reasons for withdrawing their consent.
The PN gathers relevant clinical data regarding the client's fears or misunderstandings.
Data collection is essential to determine if the refusal is due to anxiety, a need for more information, or a definitive decision, which must be reported to the team.
3
Notify the attending surgeon and the supervising registered nurse (RN) of the client's decision.
The healthcare provider is alerted to the situation and can intervene.
It is the provider's strict legal obligation to discuss the consequences of refusing the procedure and to formally accept the revocation of informed consent.
4
Document the client's exact verbal statement and the subsequent notifications in the medical record.
A permanent legal record of the event is established.
Accurate, objective documentation is required, but only after all immediate safety and communication interventions have been completed.

Key Concept

When a client revokes informed consent, the nurse must prioritize maintaining the client's cognitive capacity by withholding mind-altering medications, followed by data collection and immediate communication to the provider responsible for the procedure.
Estimated Time:1m 30s
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