Examkin

All practice questions

636 questions

All types2,933Multiple choice1,506Multiple select653Numeric68Matching70Ordering636
Question 481Question →

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

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first position the wheelchair on the client's strong (left) side, then lock all wheels, assist the client to sit on the edge of the bed, apply the transfer belt, instruct the client to reach for the armrest with their strong hand, and finally pivot the client into the chair.
Safe client handling for a client with unilateral weakness (hemiparesis) requires leveraging their functional abilities while minimizing fall risks. Positioning the chair on the unaffected side (left) is the critical first step because it ensures the client will pivot on their strong leg. Locking the wheels is a mandatory safety prerequisite before initiating any movement. Bringing the client to a seated position allows for cardiovascular accommodation and provides access to properly apply the gait belt around the waist. Finally, directing the client to reach with their strong arm stabilizes their descent into the chair as the nurse physically assists the pivot.

Step-by-Step Solution

1
Place the equipment on the client's strong side.
The wheelchair is positioned on the left side at a 45-degree angle.
Maximizes the use of the client's unaffected side for weight-bearing during the pivot.
2
Lock the wheels on all equipment.
The bed and wheelchair are immobilized.
Prevents the equipment from rolling away, which is a primary cause of transfer-related falls.
3
Bring the client to a sitting position.
The client is sitting at the edge of the bed with feet flat on the floor.
Allows the cardiovascular system to adjust, preventing dizziness, and establishes a stable base of support.
4
Apply the transfer belt.
The belt is secured securely around the client's waist.
Provides the nurse with a safe, ergonomic hold on the client's center of gravity without pulling on their arms.
5
Guide the client's movement.
The client reaches for the wheelchair armrest with their left (unaffected) hand.
Uses the strong arm to stabilize the body and guide the hips into the center of the seat.
6
Execute the pivot transfer.
The client is successfully seated in the wheelchair.
Completes the transfer by utilizing the strength of the unaffected leg to bear the body's weight.

Key Concept

Safe client handling and mobility transfer principles for a client with hemiparesis.
Question 482Question →

A practical nurse (PN) is working in a behavioral health facility. A client with acute methamphetamine intoxication is pacing the hallway, shouting aggressively at unseen individuals, and clenching their fists. Arrange the following nursing actions in the correct sequence from highest to lowest priority.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first ensure personal safety, then call for backup, protect bystanders, attempt verbal de-escalation, and finally assist with chemical interventions.
In any situation involving acute aggression and substance-induced psychosis, the hierarchy of response focuses on safety and the principle of least restrictive intervention. The nurse must first ensure personal safety by maintaining distance, as an injured nurse cannot provide care. Next, calling for backup ensures sufficient personnel are present to manage potential violence safely. The third step is protecting bystanders by clearing the area. Once the environment is secure, the nurse attempts verbal de-escalation as the least restrictive direct intervention. Finally, if verbal methods fail to reduce the danger, assisting the registered nurse with prescribed medications serves as the appropriate next step for chemical restraint.

Step-by-Step Solution

1
Ensure personal safety.
The nurse maintains a safe physical distance.
Personal safety is the absolute first priority in any psychiatric emergency to prevent injury to the healthcare provider.
2
Call for staff assistance.
Additional staff members are alerted to the situation.
Engaging a potentially violent, intoxicated client alone is dangerous; backup is required before initiating direct intervention.
3
Clear the area of bystanders.
Other clients are directed to a safe location.
Removing other clients prevents them from being harmed by the aggressive client or triggering further paranoia.
4
Attempt verbal de-escalation.
The nurse addresses the client calmly.
Least restrictive interventions must be attempted first once the environment is secure.
5
Prepare pharmacological interventions.
The PN assists the RN with PRN medication.
If verbal de-escalation is ineffective, pharmacological support is necessary to manage methamphetamine-induced psychosis and aggression.

Key Concept

Prioritization of safety and least restrictive interventions in acute substance-induced psychosis
Question 483Question →

An older adult client with generalized weakness is preparing to get out of bed for the first time today. In what order should the following actions be performed to safely transfer the client to a wheelchair? (Arrange the steps in the correct sequence, from first to last.)

Drag items to arrange them in the correct order

Show answer & explanation

Answer

First, lock the wheels on the bed and wheelchair. Second, assist the client to sit on the edge of the bed. Third, place the transfer belt. Fourth, assist the client to stand and pivot. Finally, have the client grasp the armrests while sitting down.
Safe transfer protocols require establishing a stable environment first by locking all wheels. Next, physiological safety is ensured by allowing the client to adjust to sitting. Then, physical safety devices like a transfer belt are applied. Only after these preparations should the physical movement (standing and pivoting) occur, ending with a controlled descent using the armrests.

Step-by-Step Solution

1
Secure all equipment by locking the wheels.
The bed and wheelchair are completely stationary.
Prevents accidental movement that could lead to a fall during the transfer.
2
Help the client sit up on the side of the bed.
The client is dangling their legs over the edge of the mattress.
Allows the cardiovascular system to adjust to the upright position, reducing the risk of dizziness.
3
Apply the transfer belt around the client's waist.
The care provider has a safe, secure handhold on the client.
Provides mechanical advantage and prevents injury to both the client and the provider during the physical lift.
4
Assist the client to stand up and pivot.
The client is standing and aligned with the wheelchair.
Moves the client's center of gravity from the bed to the chair in a controlled motion.
5
Guide the client to reach for the armrests and sit.
The client is safely seated in the wheelchair.
Reaching for the armrests provides stability and allows for a controlled descent into the chair.

Key Concept

Safe client transfer techniques and basic mobility assistance
Question 484Question →

A practical nurse is preparing to administer a large-volume cleansing enema to an adult client experiencing severe constipation. Arrange the following procedural steps in the correct sequential order to ensure client safety, procedure effectiveness, and comfort.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first position the client in the left lateral Sims position, lubricate the tubing tip, insert the tubing 3 to 4 inches toward the umbilicus, elevate the container 12 to 18 inches while opening the clamp, and finally, lower the container if severe cramping occurs.
Administering an enema safely requires a highly specific sequence encompassing anatomical positioning, preparation, careful insertion, controlled instillation, and complication management. The client must first be in the left lateral Sims position to allow gravity to assist fluid flow into the descending and sigmoid colon. The tubing tip must then be lubricated to ensure atraumatic insertion. Next, the tube is safely inserted 3 to 4 inches, following the anatomical direction of the umbilicus. Once the tube is secured in the rectum, the fluid is instilled by elevating the bag 12 to 18 inches to provide safe hydrostatic pressure. Finally, the nurse continuously evaluates the client's tolerance, lowering the bag immediately if rapid distention causes severe cramping.

Step-by-Step Solution

1
Position the client.
Client is in the left lateral Sims position.
Follows the natural curvature of the descending and sigmoid colon, using gravity to assist fluid flow.
2
Lubricate the tubing.
The distal tip is fully coated with a water-soluble lubricant.
Prevents tissue trauma and sphincter spasm during the invasive insertion.
3
Insert the tubing.
The tube is placed safely 3 to 4 inches into the rectum.
Bypasses the internal sphincter securely when aimed forward toward the umbilicus.
4
Administer the solution.
Fluid flows into the bowel at a safe hydrostatic pressure.
Holding the bag strictly 12 to 18 inches high prevents excessively rapid bowel distention.
5
Monitor for complications.
The flow rate is immediately decreased by lowering the bag if cramping occurs.
Allows the bowel musculature to relax without having to completely abandon and restart the procedure prematurely.

Key Concept

Procedural Sequence for Safe Cleansing Enema Administration
Question 485Question →

A practical nurse is preparing an adult client with severe hepatic cirrhosis and ascites for a bedside abdominal paracentesis. Arrange the following pre-procedure actions in the correct chronological sequence to minimize the risk of procedural complications.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: Verify informed consent, instruct the client to empty their bladder, obtain baseline measurements, position the client upright, and finally set up the sterile tray.
The correct sequence prioritizes legal readiness, then proceeds to crucial physiological risk reduction. The client must void first to prevent accidental bladder perforation by the trocar. Once the bladder is empty, an accurate baseline weight, abdominal girth, and vital signs can be obtained. The client is then positioned upright to pool the fluid, and the sterile tray is opened last to maintain strict asepsis immediately prior to insertion.

Step-by-Step Solution

1
Verify informed consent.
Legal authorization is confirmed.
Must be completed before any physical preparation begins.
2
Instruct client to empty bladder.
Bladder size is reduced.
Prevents accidental puncture of the bladder during trocar insertion.
3
Obtain baseline measurements.
Accurate dry weight and baseline vital signs are recorded.
Crucial for detecting post-procedure hypovolemic shock caused by rapid fluid shifts.
4
Position the client upright.
Ascitic fluid pools in the lower abdomen.
Uses gravity to facilitate safe and effective fluid aspiration.
5
Prepare the sterile tray.
Sterile field is established.
Must be done immediately prior to the procedure to minimize contamination risk.

Key Concept

Risk reduction during paracentesis preparation involves preventing bladder perforation, establishing baselines for shock detection, and ensuring proper gravity pooling of fluid.
Question 486Question →

A practical nurse is caring for an older adult client receiving continuous enteral nutrition via a nasogastric tube. The client suddenly experiences forceful coughing, tachypnea, and expels enteral formula from their mouth. In which order should the practical nurse perform the following actions to minimize the client's risk for severe complications?

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first pause the feeding pump, then turn the client to a side-lying position, suction the oral cavity, auscultate lung sounds with oxygen saturation, and finally report the findings to the registered nurse.
In any acute respiratory emergency where a clear causative agent is actively being introduced, the absolute priority is to stop the agent (pause the pump). Following the ABCs (Airway, Breathing, Circulation), the next immediate steps are to physically protect the airway (lateral position) and clear it (suction). Only after the airway is secured and the immediate physical threat is neutralized should the practical nurse proceed to data collection (auscultation and oxygen saturation) and escalation of care (notifying the RN).

Step-by-Step Solution

1
Pause the continuous enteral feeding pump.
The flow of enteral formula into the client is halted.
This immediately removes the source of the aspiration, which is the absolute highest priority to prevent further volume from entering the lungs.
2
Turn the client into a lateral side-lying position.
The client's airway is protected by gravity.
This position facilitates the immediate drainage of the expelled formula out of the mouth rather than allowing it to pool and travel down into the trachea.
3
Use a Yankauer catheter to suction the oral cavity.
Visible formula is removed from the oropharynx.
Suctioning physically clears the upper airway, establishing patency and minimizing the risk of secondary aspiration of residual formula in the mouth.
4
Auscultate bilateral lung sounds and obtain an oxygen saturation reading.
Baseline respiratory compromise is quantified.
Once the airway is completely secured and the immediate threat is neutralized, the nurse must assess the extent of the client's physiological reaction to guide further medical interventions.
5
Report the clinical findings and interventions to the registered nurse.
The healthcare team is alerted to the critical event.
Escalation to the supervising RN is required so that higher-level interventions, such as a chest radiograph or provider notification, can be initiated based on the assessment data.

Key Concept

Prioritization of immediate life-saving interventions (stopping the source and protecting the airway) over data collection during an acute aspiration event.
Question 487Question →

While preparing a client's morning medications, a practical nurse needs to combine prescribed doses of regular insulin and NPH insulin into one syringe. Place the actions required to safely prepare this mixed insulin injection into the correct chronological sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to roll the NPH vial, inject air into the NPH vial, inject air into the regular insulin vial, withdraw the regular insulin, and finally withdraw the NPH insulin.
The standard procedure for mixing insulins dictates that the intermediate-acting NPH insulin (cloudy) must be gently rolled first to mix the suspension. To avoid negative pressure without contaminating the needle, air is injected into the NPH vial first, followed by injecting air into the regular insulin (clear) vial. The regular insulin is then withdrawn first ('clear before cloudy') to ensure that no intermediate-acting insulin accidentally contaminates the rapid or short-acting regular insulin vial. Finally, the NPH insulin is withdrawn.

Step-by-Step Solution

1
Roll the vial of NPH insulin gently between the palms of the hands.
The cloudy insulin suspension is mixed uniformly.
NPH insulin is a suspension that settles. Rolling mixes it gently without creating bubbles that could lead to an inaccurate dose.
2
Inject a volume of air equal to the prescribed dose into the NPH insulin vial.
The NPH vial is pressurized.
Injecting air first prevents the creation of a vacuum later. The needle touches only air, remaining uncontaminated for the next vial.
3
Inject a volume of air equal to the prescribed dose into the regular insulin vial.
The regular insulin vial is pressurized.
The regular insulin vial must be pressurized immediately before drawing up the medication.
4
Withdraw the prescribed dose of regular insulin into the syringe.
The clear insulin is drawn into the syringe.
The clear (regular) insulin is always drawn first to prevent the cloudy (NPH) insulin from entering and contaminating the regular insulin vial.
5
Withdraw the prescribed dose of NPH insulin into the syringe.
The exact dose of cloudy insulin is added to the syringe.
The cloudy insulin is drawn last to complete the mixture. If too much NPH is drawn inadvertently, the entire syringe must be discarded as the insulins are already mixed.

Key Concept

Safe Preparation of Mixed Insulins (Clear before Cloudy)
Question 488Question →

A practical nurse (PN) is performing a routine dressing change for a client who is 4 days postoperative following an abdominal surgery. The client suddenly coughs forcefully, and the PN observes a loop of bowel protruding through the incision line. Arrange the following actions in the order the PN should perform them, from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The PN must first call for immediate assistance while remaining with the client, then position the client to decrease abdominal tension, cover the evisceration with sterile moist dressings, and finally monitor vital signs for shock.
Wound evisceration is a critical surgical emergency. The nurse's first priority is to call for help while staying with the client to ensure safety and rapidly mobilize the team. Next, positioning the client in low Fowler's with flexed knees reduces intra-abdominal pressure. Third, covering the wound with sterile, saline-soaked dressings protects the tissue viability. Finally, obtaining vital signs establishes a baseline to monitor for impending shock.

Step-by-Step Solution

1
Stay with the client and call for immediate assistance.
Additional nursing staff is alerted to bring supplies and notify the provider.
An evisceration is a medical emergency requiring teamwork; the nurse cannot leave the client unattended to gather sterile supplies.
2
Place the client in a low Fowler's position with the knees flexed.
Intra-abdominal pressure is minimized.
Flexing the hips and knees relaxes the abdominal wall, preventing further visceral protrusion from the wound.
3
Cover the protruding organs with sterile, saline-soaked dressings.
The exposed bowel is kept moist and protected from contaminants.
Drying of the viscera can cause irreversible tissue damage. Using sterile technique prevents severe intra-abdominal infection.
4
Assess the client's vital signs to monitor for symptoms of shock.
The client's hemodynamic status is documented.
Evisceration can trigger a massive fluid shift or hemorrhage leading to hypovolemic shock, requiring close monitoring.

Key Concept

Management of Wound Evisceration
Question 489Question →

A practical nurse is administering a prescribed dose of intramuscular iron dextran to a client with severe iron deficiency anemia. To prevent tissue irritation and staining, the nurse utilizes the Z-track method. Arrange the following actions in the correct chronological sequence for this procedure.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to pull the skin laterally, insert the needle at a 90-degree angle, inject the medication slowly, leave the needle in place for 10 seconds, and finally withdraw the needle while releasing the skin.
The Z-track method is explicitly designed to prevent dark-colored or highly irritating medications, such as iron dextran, from leaking into the subcutaneous tissue and causing permanent skin staining or irritation. By displacing the skin prior to insertion, the needle track through the subcutaneous tissue and the muscle layer become misaligned once the skin is released, sealing the medication within the muscle.

Step-by-Step Solution

1
Pull the overlying skin and subcutaneous tissue laterally approximately 1 to 1.5 inches.
The skin and subcutaneous tissue planes are shifted.
Displacing the tissue creates an offset pathway that will trap the medication once the tissue is released.
2
Insert the needle firmly at a 90-degree angle into the ventrogluteal muscle.
The needle penetrates through the displaced skin and subcutaneous tissue into the muscle.
A 90-degree angle ensures the medication is delivered deeply into the muscle layer.
3
Depress the plunger slowly to inject the medication into the muscle.
The iron dextran is delivered into the ventrogluteal muscle.
Slow injection allows the muscle fibers to accommodate the fluid volume, reducing pain.
4
Keep the needle in place for 10 seconds after the medication is fully injected.
The medication begins to absorb into the surrounding muscle tissue.
Providing a brief waiting period prevents the medication from immediately tracking back up the puncture path.
5
Withdraw the needle smoothly and immediately release the displaced skin.
The skin slides back to its original position.
Releasing the skin misaligns the needle tracks in the skin, subcutaneous tissue, and muscle, effectively sealing the irritating medication deep inside.

Key Concept

Z-track Intramuscular Injection Technique
Estimated Time:1m 30s
Question 490Question →

To evaluate a client's risk for falls related to suspected fluid volume deficit, orthostatic vital sign monitoring is prescribed. Arrange the procedural steps for performing this assessment in the correct clinical sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

First, position the client supine for 3 to 5 minutes, then measure baseline vital signs. Next, assist the client to stand, wait 1 to 3 minutes, and finally measure the standing vital signs.
Proper measurement of orthostatic vital signs requires establishing a stable supine baseline first (after 3 to 5 minutes of rest). Once baseline measurements are recorded, the client is assisted to an upright position. A critical waiting period of 1 to 3 minutes is then necessary to observe the body's compensatory mechanisms before taking the final standing measurements.

Step-by-Step Solution

1
Position the client supine and wait for 3 to 5 minutes.
The cardiovascular system reaches a resting baseline state.
Establishing a true resting baseline is essential for an accurate comparison.
2
Measure and record the baseline blood pressure and pulse rate.
Resting physiological parameters are documented.
These values serve as the control measurement before gravity affects blood return.
3
Assist the client into a standing position.
The client is upright, causing blood to pool in the lower extremities.
Standing provokes the physiological response being evaluated.
4
Wait for 1 to 3 minutes after the position change.
The body attempts to compensate for the fluid shift through vasoconstriction and increased heart rate.
Reading vital signs immediately upon standing may capture normal transient changes rather than true orthostatic instability.
5
Obtain and record the standing blood pressure and pulse rate.
Standing vital signs are documented.
These measurements are compared to the supine baseline to identify orthostatic hypotension (a significant drop in systolic or diastolic pressure).

Key Concept

Orthostatic Vital Sign Measurement
Question 491Question →

A practical nurse (PN) observes an unlicensed assistive personnel (UAP) speaking forcefully to an older adult client and tightly grabbing their arm to keep them still during care. The client appears frightened and tries to pull away. In what order should the PN perform the following actions to advocate for the client and ensure safety? Arrange the actions in the correct sequence from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first intervene to stop the behavior, then assess the client for injury, reassure the client, report the incident to the supervisor, and finally document the event objectively.
When a nurse witnesses potential abuse or a violation of client rights, the priority action is always to protect the client by stopping the harmful behavior immediately. Once the client is secure, the nurse must apply the nursing process by assessing for injuries and providing emotional reassurance. After the client's immediate physical and psychosocial needs are met, the nurse must report the incident up the chain of command to ensure proper administrative and legal actions are taken. Finally, the nurse must document the incident objectively according to facility policy.

Step-by-Step Solution

1
Prioritize immediate client safety by stopping the unsafe behavior.
The UAP is separated from the client, preventing further potential harm.
In any situation involving potential abuse or safety risks, the immediate physical protection of the client is the highest priority.
2
Assess the client's physical and emotional status.
The PN identifies any injuries, such as bruising on the arm, and assesses the client's level of fear or distress.
Following the nursing process, assessment must occur immediately after securing the environment to determine if medical intervention is needed.
3
Provide therapeutic communication and reassurance.
The client feels supported and understands that the behavior they experienced was unacceptable and will be addressed.
Advocacy includes protecting the client's psychosocial integrity and helping them feel safe after a distressing event.
4
Notify the charge nurse or nursing supervisor.
The chain of command is activated to investigate the incident and fulfill mandatory reporting requirements for suspected elder abuse.
Nurses are mandatory reporters. The supervisor must be informed promptly to take administrative action and ensure facility protocols are followed.
5
Complete objective documentation of the incident.
A factual, chronological record of the event is created in an incident report, separate from the client's main medical record.
Accurate, objective documentation is legally required but should be completed after immediate client needs and reporting have been addressed.

Key Concept

Client Advocacy and Protection from Abuse
Question 492Question →

During a group activity session in the facility lounge, a client seated in a wheelchair suddenly develops a generalized tonic-clonic seizure. Arrange the following safety interventions in the chronological order the practical nurse (PN) should implement them, from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first guide the client to the floor, then protect their head, followed by loosening restrictive clothing, and finally rolling them onto their side.
During a seizure, the primary goal is to prevent injury. The first action is to safely ease the client to the floor to prevent a sudden, uncontrolled fall. Next, the nurse must protect the head from trauma using a soft cushion or barrier. Then, restrictive clothing around the neck is loosened to prevent airway compromise. Finally, placing the client in a side-lying (lateral) position promotes drainage of oral secretions and prevents aspiration.

Step-by-Step Solution

1
Address the most immediate risk of injury from falling.
The nurse assists the client from the wheelchair to the floor.
A client having a seizure in a chair is at high risk for a traumatic fall. Easing them to the ground minimizes this drop.
2
Protect the client from blunt force trauma caused by the seizing movements.
The nurse places a soft barrier under the client's head.
The head is highly vulnerable to injury from striking the floor during tonic-clonic movements.
3
Eliminate external restrictions to breathing.
The nurse loosens tight clothing around the neck.
Neckties, tight collars, or scarves can restrict the airway or blood flow as the client's muscles contract.
4
Maintain internal airway patency.
The nurse positions the client on their side.
The lateral position prevents the tongue from blocking the airway and allows saliva or emesis to drain out of the mouth, preventing aspiration.

Key Concept

Seizure Safety and Injury Prevention
Question 493Question →

The practical nurse (PN) is preparing to transfer a client who has right-sided weakness from the bed to a wheelchair using the stand-and-pivot technique. In what order should the PN perform the following actions? Arrange the steps from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: Position the wheelchair, assist the client to sit, apply the gait belt, brace the weak leg, and then stand and pivot.
Safe patient transfer requires a systematic approach to prevent injury to both the client and the nurse. The environment must first be prepared by locking the wheelchair on the strong side. The client is then assisted to a stable sitting position before applying a gait belt. Bracing the weak extremity is essential right before the pivot to prevent falls, culminating in the stand-and-pivot motion.

Step-by-Step Solution

1
Set up the environment by positioning the wheelchair on the client's strong side (left) and locking the brakes.
The wheelchair is secure and placed to allow the client to lead with their strong side.
Prevents the wheelchair from rolling and maximizes the client's functional ability.
2
Help the client sit on the edge of the bed and place their feet flat on the floor.
The client is in a stable dangling position with a solid base of support.
Allows the client to adjust to an upright position and prepares them for weight-bearing.
3
Securely fasten a gait belt around the client's waist.
The nurse has a safe, secure hold on the client's center of gravity.
Reduces the risk of falls and prevents the nurse from inappropriately lifting the client by their arms or clothing.
4
Block or brace the client's weak right leg using your own knee or foot.
The client's weak leg is physically supported.
Prevents the weak knee from buckling when the client bears weight during the stand.
5
Guide the client to stand, pivot on their strong leg, and sit in the wheelchair.
The client safely completes the transfer into the wheelchair.
Maintains proper body mechanics for the nurse and utilizes the client's remaining strength safely.

Key Concept

Safe patient transfer techniques using the stand-and-pivot method
Question 494Question →

A client with a newly established tracheostomy is receiving care on a respiratory unit. The client suddenly becomes severely agitated and aggressively grasps at the tracheostomy ties, attempting to remove the artificial airway. Verbal reassurance is entirely ineffective, and the client's oxygen saturation begins to drop. The practical nurse (PN) determines that emergency physical restraints are immediately required. In what order should the PN perform the following actions? (Arrange the steps from first to last.)

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence prioritizes immediate client safety (getting help and applying restraints), then verifies physical safety (checking circulation), followed by administrative requirements (obtaining the provider order and documenting).
The correct chronological order ensures the immediate safety of the client and staff while adhering to legal and clinical standards. When a client poses an imminent threat to a life-sustaining device (tracheostomy), the nurse must immediately gather assistance, apply the restraints to secure the airway, ensure the restraints are not causing neurovascular harm, legally validate the action by contacting the provider, and finally document the entire incident.

Step-by-Step Solution

1
Obtain physical assistance.
Additional staff arrives at the bedside.
Restraining an agitated client alone risks severe injury to both the nurse and the client.
2
Apply the physical restraints.
The client's hands are secured, and the airway is protected.
The immediate threat of airway removal must be stopped to preserve life.
3
Check the fit and distal circulation.
Two fingers fit comfortably under the restraint.
Ensures the restraints do not compromise neurovascular status and cause ischemic tissue damage.
4
Notify the healthcare provider.
An emergency restraint prescription is obtained.
Legal and facility protocols require a provider's order immediately following an emergency application.
5
Document the event.
The medical record reflects the emergency intervention.
Maintains an accurate legal and clinical record of the emergency and the rationale for the restraint.

Key Concept

Emergency application of restraints to prevent life-threatening harm prioritizes immediate safety and airway protection over waiting for a prior medical prescription.
Question 495Question →

A client with severe alcohol withdrawal syndrome becomes acutely confused, extremely agitated, and actively attempts to disconnect their continuous intravenous (IV) medication infusion. De-escalation techniques and diversionary activities have been unsuccessful. The practical nurse (PN) determines that emergency physical restraints are immediately required to prevent life-threatening harm. Arrange the following nursing actions in the correct sequence from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: Apply restraints, check the fit with two fingers, assess distal neurovascular status, notify the provider for a prescription, and finally document the event.
In an acute emergency where a client poses an immediate threat to themselves (e.g., removing a critical IV), the priority is client safety. Therefore, the nurse must first apply the restraints. Immediately following application, the nurse must verify the mechanical fit (two-finger rule) to prevent acute injury, followed by a thorough neurovascular assessment (pulses, capillary refill) to ensure adequate circulation. Only after the client is physically secure and assessed should the nurse leave the bedside or use the phone to notify the healthcare provider for the required prescription. Finally, comprehensive documentation is completed once all clinical and communication tasks are stabilized.

Step-by-Step Solution

1
Apply the restraints and secure to the movable bed frame.
The client is immediately prevented from removing the critical IV line.
Immediate physical safety is the highest priority in an emergency situation.
2
Check the mechanical fit by inserting two fingers.
The restraints are confirmed to have enough slack to prevent skin tearing or immediate constriction.
This is a basic, immediate mechanical check of the device placement.
3
Assess radial pulses, temperature, and capillary refill.
Adequate distal tissue perfusion and nerve function are confirmed.
Physiological monitoring ensures the restraint is not compromising blood flow, which could lead to tissue necrosis.
4
Contact the healthcare provider for a prescription.
Legal and regulatory requirements for restraint use are initiated.
While nurses can apply restraints in an emergency, a provider's prescription must be obtained promptly afterward.
5
Document the entire event in the medical record.
An accurate, legal record of the incident and nursing interventions is created.
Documentation is crucial but should only occur after the client is safe and clinical tasks are completed.

Key Concept

Emergency Restraint Application Sequence and Monitoring
Question 496Question →

A practical nurse (PN) observes a coworker exhibiting slurred speech, an unsteady gait, and the smell of alcohol while preparing to administer medications to clients. In which order should the PN take the following actions? Arrange the steps from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

First, the PN must intervene to ensure client safety, followed by notifying the supervisor, documenting objective findings, and finally submitting an incident report.
When dealing with an impaired coworker, basic safety principles mandate that protecting the client from immediate harm is the top priority. Therefore, stopping the impaired nurse from administering medications must come first. Next, the PN must report the situation up the chain of command to the supervisor so appropriate administrative action can be taken. Finally, the PN should document objective findings in the record and complete a formal incident report to comply with legal and facility requirements.

Step-by-Step Solution

1
Ensure immediate client safety.
The impaired coworker is stopped from administering medications.
According to the nursing process and safety principles, protecting the client from immediate, direct harm takes precedence over all other actions.
2
Report up the chain of command.
The nursing supervisor is notified of the situation.
Management must be informed immediately so they can remove the impaired nurse from the unit and arrange for safe client coverage.
3
Document objective facts.
The PN writes down exact, factual observations of the event.
Clear, objective documentation is legally required to support the claims of impairment without injecting personal bias.
4
File an incident report.
A formal facility document is submitted to risk management.
Internal protocols require a formalized record of adverse or potentially adverse events for legal and safety review.

Key Concept

Legal and Ethical Practice: Mandatory Reporting of Impaired Practice
Question 497Question →

The practical nurse (PN) is preparing to apply prescribed bilateral soft wrist restraints to a client who is severely agitated and repeatedly attempting to remove a central venous catheter. All alternative, less restrictive interventions have been unsuccessful. Arrange the following actions in the chronological order the PN should perform them. All options must be used.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: verify the prescription, explain the procedure to the client, wrap the padded restraints around the wrists, attach the straps to the movable part of the bed frame, check the fit with two fingers, and assess the distal neurovascular status.
Applying physical restraints requires a strict systematic approach to ensure patient safety and legal compliance. Verifying the prescription is always the first step. Communication with the patient follows to provide ethical care. Physical application involves padding the wrists, securing the straps to a movable bed frame using a quick-release knot, and verifying appropriate tightness by inserting two fingers. Finally, an immediate neurovascular assessment ensures the restraints are not compromising distal circulation.

Step-by-Step Solution

1
Verify the healthcare provider's prescription.
Legal and clinical justification for the restraint is confirmed.
Applying restraints requires a specific order outlining the reason, type, and duration to ensure it falls within legal and facility guidelines.
2
Explain the procedure to the client.
The client is informed of the action being taken.
Communication helps de-escalate anxiety and respects the client's right to information, even if they are agitated.
3
Wrap the padded portion around the wrists.
The restraint is positioned on the client's extremities.
Padding prevents skin breakdown and protects bony prominences from friction.
4
Attach the straps to the movable part of the bed frame using a quick-release tie.
The restraint is safely secured.
Tying to a movable part ensures the restraint moves with the patient if the bed is adjusted. A quick-release knot ensures immediate removal in emergencies.
5
Check the fit by inserting two fingers under the restraint.
Appropriate tightness is verified.
This physical check ensures the restraint is tight enough to be effective but loose enough to avoid circulatory compromise.
6
Assess distal neurovascular status.
Circulation, sensation, and movement are evaluated.
Monitoring pulses, temperature, and skin color confirms that blood flow to the extremity has not been impaired by the restraint.

Key Concept

Chronological procedure for the safe application and monitoring of physical restraints.
Question 498Question →

After safely evacuating clients and sounding the alarm for a small wastebasket fire, a licensed practical nurse prepares to use a portable fire extinguisher. What is the chronological sequence of actions the nurse must take to operate the fire extinguisher correctly?

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence for operating a fire extinguisher is to first pull the pin, then aim at the base, next squeeze the handle, and finally sweep from side to side.
The PASS acronym provides a simple, chronological guide for using a fire extinguisher during an emergency: Pull the pin, Aim at the base of the fire, Squeeze the handle, and Sweep from side to side.

Step-by-Step Solution

1
Recall the standard acronym for operating a fire extinguisher.
The acronym is PASS.
PASS is the universal protocol taught in healthcare facilities for fire extinguisher use.
2
Identify the first letter of the acronym (P).
Pull the safety pin.
The extinguisher is locked by default to prevent accidental discharge.
3
Identify the second letter of the acronym (A).
Aim at the base of the fire.
Targeting the fuel source is necessary to extinguish the fire.
4
Identify the third letter of the acronym (S).
Squeeze the handle lever.
This action mechanically releases the pressurized extinguishing agent.
5
Identify the fourth letter of the acronym (S).
Sweep from side to side.
Sweeping ensures the agent completely covers the fire's base.

Key Concept

PASS Protocol for Fire Extinguisher Operation
Question 499Question →

While working in an infectious disease unit, a licensed practical nurse must apply full personal protective equipment (PPE) before entering the isolation room of a client suspected of having avian influenza (H5N1). Arrange the following actions in the correct chronological order for applying the required PPE, from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: Perform hand hygiene, don the isolation gown, apply the N95 respirator, position the face shield, and finally don the gloves.
According to standardized infection control guidelines, the correct sequence for applying personal protective equipment (PPE) ensures maximum safety and prevents self-contamination. Hand hygiene is always performed first. The gown is applied next to cover the torso and arms. Respiratory protection (such as an N95 respirator) is applied and seal-checked before eye protection to ensure the respirator straps lie flat and the seal is unobstructed. Eye protection (face shield or goggles) is then placed. Finally, gloves are donned last so they can be pulled directly over the cuffs of the isolation gown, ensuring continuous coverage of the wrists.

Step-by-Step Solution

1
Select 'Perform thorough hand hygiene using soap and water or an alcohol-based hand rub.' as the first action.
Hands are clean before touching any clean PPE.
Hand hygiene prevents contamination of the clean PPE items during the donning process.
2
Select 'Fasten the ties of a fluid-resistant isolation gown at the neck and waist.' as the second action.
The torso and clothing are covered and protected.
The gown is the foundational piece of PPE and provides the largest coverage area.
3
Select 'Apply a fit-tested N95 respirator and perform a user seal check.' as the third action.
The respiratory system is protected against airborne pathogens.
The respirator must be placed and sealed directly against the face before eye protection is added.
4
Select 'Position a face shield over the eyes and adjust it for a secure fit.' as the fourth action.
The mucous membranes of the eyes are protected from potential splashes or droplets.
Eye protection goes on over the respirator to ensure it does not interfere with the N95 seal.
5
Select 'Pull clean, non-sterile gloves completely over the cuffs of the isolation gown.' as the final action.
Hands are protected and the gap between the gown and gloves is sealed.
Gloves are donned last so they can securely overlap the gown cuffs, ensuring continuous protection.

Key Concept

Standardized donning sequence for personal protective equipment (PPE)
Question 500Question →

A practical nurse (PN) enters the room of a post-operative client who is receiving pain management via a patient-controlled analgesia (PCA) pump. The PN finds the client unresponsive with a respiratory rate of 6 breaths per minute. Arrange the following nursing actions in the correct order of priority from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: Assess responsiveness, activate the rapid response team, stop the PCA pump, open the airway and assist with ventilation, and administer naloxone.
In the event of an acute opioid overdose characterized by unresponsiveness and severe respiratory depression, the practical nurse must follow the sequence of basic life support (BLS) integrated with immediate exposure control. The first action is to confirm unresponsiveness. Once confirmed, the nurse immediately calls for help, as managing an arrest requires a coordinated team. Next, the nurse must immediately stop the continuous administration of the opioid by turning off the PCA pump to prevent further toxicity. The nurse then focuses on the ABCs (Airway, Breathing, Circulation) by opening the airway and supporting ventilation. Finally, once life-sustaining BLS measures are established, the nurse administers the prescribed opioid antagonist, naloxone, to reverse the central nervous system depression.

Step-by-Step Solution

1
Assess the client's responsiveness.
Confirms whether the client is truly unresponsive.
Data collection is the first step in the nursing process before initiating emergency interventions.
2
Activate the rapid response team.
Calls for additional personnel and necessary equipment.
Advanced help must be on the way immediately to support a respiratory emergency.
3
Stop the PCA pump.
Halts further administration of the opioid.
Removing the source of the toxicity prevents the condition from worsening while other interventions are initiated.
4
Open the airway and support breathing.
Maintains oxygenation.
Airway and breathing are the highest physiological priorities (ABC framework) to sustain life.
5
Administer naloxone.
Reverses the opioid-induced respiratory depression.
Treats the direct pharmacological cause of the emergency once basic life support measures are in place.

Key Concept

Prioritization of care for acute inpatient opioid overdose integrates Basic Life Support (BLS) sequences with stopping the exposure and providing targeted pharmacological reversal.
Estimated Time:1m 30s
PreviousPage 25 / 32Next
All practice questions — NCLEX-PN | Examkin