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Question 501Question →

A nurse in a transitional care unit is assisting a 75-year-old client out of bed for the first time in the morning. Due to normal age-related cardiovascular changes, this client is at increased risk for orthostatic hypotension. Place the following nursing actions in the correct sequence to safely mobilize the client.

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Answer

The correct sequence for safe mobilization is: Raise the head of the bed, assist the client to sit on the edge, have them dangle their legs, assess for dizziness, and finally support them to a standing position.
Age-related changes in the cardiovascular system include decreased baroreceptor sensitivity, which delays the body's ability to maintain steady blood pressure when changing positions. To prevent orthostatic hypotension and subsequent falls, position changes must be gradual. The client should first be elevated in bed, then pivoted to sit, allowed to dangle and stabilize, assessed for symptoms, and finally assisted to stand.

Step-by-Step Solution

1
Identify the primary risk associated with age-related cardiovascular changes during position changes.
The client is at risk for orthostatic hypotension due to decreased baroreceptor sensitivity.
Understanding the physiological aging process guides prioritizing safety interventions.
2
Determine the safest gradual progression from a supine to a standing position.
The progression must be gradual: elevating the head, sitting up, dangling, assessing for symptoms, and then standing.
Gradual position changes give the aging cardiovascular system adequate time to compensate, maintain cerebral perfusion, and prevent falls.

Key Concept

Orthostatic Hypotension Prevention in Older Adults
Question 502Question →

A practical nurse (PN) is planning to delegate feeding a client who had a cerebrovascular accident (CVA) 3 days ago and has residual right-sided weakness. Arrange the following actions in the chronological sequence the PN should perform to ensure safe delegation and collaboration.

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Answer

The correct chronological sequence for delegation is: verify the task appropriateness in the chart, assess the AP's competency, provide specific instructions, supervise the ongoing task, and finally document the outcome.
Safe and effective delegation follows a structured sequence based on the Five Rights of Delegation. First, the PN must verify the client's condition and orders to ensure the task is appropriate (Right Task/Circumstance). Second, the PN assesses whether the AP has the necessary skills (Right Person). Third, the PN provides clear, specific instructions on how to perform the task safely, including necessary precautions (Right Direction/Communication). Fourth, the PN monitors the AP's performance to ensure client safety (Right Supervision). Finally, the PN evaluates the client's response and documents the completed care (Right Evaluation).

Step-by-Step Solution

1
Verify client status and orders.
The PN reviews the health record for diet clearance.
This establishes the 'Right Task' and 'Right Circumstance' before initiating delegation.
2
Assess AP competency.
The PN asks the AP about their experience with similar clients.
This establishes the 'Right Person' is being assigned to the task.
3
Provide specific instructions.
The PN instructs the AP regarding the head of bed elevation.
This establishes the 'Right Direction/Communication' for safe care delivery.
4
Supervise the task execution.
The PN observes the feeding process shortly after it begins.
This fulfills the 'Right Supervision' requirement to catch any unsafe practices early.
5
Evaluate and document.
The PN records the intake after receiving the AP's verbal report.
This completes the delegation process through 'Right Evaluation'.

Key Concept

The delegation process requires sequential steps based on the Five Rights of Delegation: Right Task, Right Circumstance, Right Person, Right Direction/Communication, and Right Supervision/Evaluation.
Question 503Question →

A practical nurse (PN) receives the morning shift report and is assigned to care for a newly admitted client experiencing acute respiratory failure who requires continuous mechanical ventilation and frequent complex assessments. The PN determines that this client's care requirements exceed the PN scope of practice. Place the following actions the PN should take to address this unsafe assignment in the correct order of escalation.

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Answer

The PN must first identify the scope violation, then address the charge nurse, escalate to the nursing supervisor if unresolved, and ultimately refuse the specific assignment if necessary to protect the client and their license.
When faced with an unsafe or out-of-scope assignment, the PN must follow a sequential process. First, the PN identifies the mismatch between client acuity and legal scope. Second, the PN follows the chain of command by addressing the charge nurse who made the assignment. If the charge nurse refuses to adjust the assignment, the third step is escalating to the nursing supervisor. Finally, if the issue remains unresolved, the PN is legally and ethically obligated to refuse the assignment, as accepting an out-of-scope assignment violates the Nurse Practice Act and endangers client safety. Refusing an assignment before accepting care does not constitute client abandonment.

Step-by-Step Solution

1
Evaluate the assignment against the legal scope of practice.
The PN recognizes the assignment involves an unstable client requiring comprehensive assessment.
Nurses are legally accountable for accepting only assignments that fall within their scope of practice and personal competency.
2
Address the charge nurse.
The PN directly communicates the scope of practice concern.
The chain of command requires addressing issues first with the person directly responsible for the decision.
3
Escalate to the nursing supervisor.
The PN involves higher management.
If the immediate supervisor does not correct an unsafe situation, it must be escalated up the chain of command.
4
Refuse the assignment.
The PN protects the client and their nursing license.
A nurse cannot be forced to accept an assignment that is outside their legal scope of practice; doing so is illegal and unsafe.

Key Concept

Scope of Practice and Chain of Command in Unsafe Assignments
Question 504Question →

A 48-hour-old term neonate with hyperbilirubinemia is prescribed conventional phototherapy. The practical nurse is assigned to initiate the treatment in the newborn nursery. Arrange the following actions the nurse should take to safely begin the therapy in the correct chronological order.

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Answer

The correct chronological sequence is: verify the neonate's identity, remove clothing except the diaper, apply opaque eye shields, place the neonate in the bassinet under the lights, and finally turn on the unit and document the start time.
The chronological sequence prioritizes safety and efficacy. Verification of the right patient and prescription must occur first. Next, maximizing skin exposure by removing clothes (except the diaper) ensures the therapy will be effective. Crucially, opaque eye patches must be applied while the neonate is away from the light source to prevent accidental retinal exposure. Only after the neonate is fully prepped and protected should they be placed under the unit and the lights activated. Finally, documentation provides a legal and clinical record of the start time.

Step-by-Step Solution

1
Verify the neonate's identity against the phototherapy prescription.
Confirmation that the correct treatment is being given to the right patient.
Safety protocols dictate that patient verification must always precede the initiation of any clinical procedure.
2
Remove the neonate's clothing, leaving only a well-fitting diaper.
The neonate's skin is adequately exposed.
Phototherapy relies on light absorption through the skin to isomerize bilirubin into an excretable form; clothing blocks this process.
3
Close the neonate's eyes and apply opaque protective eye shields.
The neonate's eyes are completely covered and protected.
Continuous exposure to phototherapy lights can cause severe retinal damage if the eyes are not shielded prior to treatment.
4
Place the neonate in the bassinet under the light unit.
The neonate is properly positioned for the therapy.
The patient must be physically situated in the designated therapeutic environment once preparations are complete.
5
Turn on the light unit and document the initiation time.
Therapy actively begins and is officially recorded.
Turning on the lights starts the clinical intervention, and immediate documentation ensures accurate tracking of therapy duration.

Key Concept

Safe Initiation of Newborn Phototherapy
Question 505Question →

A practical nurse (PN) is caring for a client who is scheduled for a cardiac catheterization. As the PN is preparing the insertion site, the client suddenly pulls away and states, "I changed my mind. I don't want anyone putting a tube in my heart. I am not doing this." Arrange the following actions the PN should take in the correct order of priority from first to last.

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Answer

The correct sequence is to first stop the physical preparation, then acknowledge the client's right to refuse, explore their concerns, notify the healthcare provider and charge nurse, and finally document the event.
When a client withdraws consent, the practical nurse must follow a logical sequence based on the nursing process and safety prioritization. Safety and honoring autonomy come first, meaning all preparation must stop immediately. Next, acknowledging the client's right to refuse builds trust, which facilitates the data collection phase (exploring concerns). Once data is gathered, the nurse acts as an advocate by communicating the situation to the healthcare provider. Finally, the nurse legally protects all parties by documenting the sequence of events.

Step-by-Step Solution

1
Prioritize client safety and autonomy by halting the procedure preparation.
The physical preparation is immediately stopped.
Continuing to prepare a client who has explicitly withdrawn consent violates their legal rights and constitutes battery.
2
Support the client's decision.
The nurse acknowledges the client's right to refuse.
This action validates the client's autonomy and builds therapeutic trust during a potentially stressful moment.
3
Collect data regarding the refusal.
The nurse explores the client's underlying concerns.
Understanding why the client is refusing (e.g., fear, misunderstanding) provides essential data for the healthcare team.
4
Advocate and communicate the change in status.
The healthcare provider and charge nurse are notified.
The provider must be informed that consent is withdrawn so they can either speak with the client to provide primary education or cancel the procedure.
5
Record the event in the medical record.
The client's exact words and the provider notification are documented.
Accurate documentation is a legal requirement that must occur after all immediate patient care and advocacy actions are completed.

Key Concept

Client Autonomy and the Right to Refuse Treatment
Question 506Question →

A nurse is preparing to enter the isolation room of a client who requires both droplet and contact precautions due to bacterial meningitis and a methicillin-resistant *Staphylococcus aureus* (MRSA) wound infection. Arrange the following steps for donning the required personal protective equipment (PPE) in the correct chronological sequence.

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Answer

The correct sequence is: cleanse hands, put on the isolation gown, apply the procedure mask, place the eye protection, and finally apply the examination gloves.
According to standard infection control guidelines, the proper sequence for donning full PPE begins with hand hygiene to ensure clean handling of the equipment. The gown goes on first to cover the torso and uniform. Next, the mask and eye protection are applied to protect the face and respiratory tract. Finally, gloves are donned last so they can be pulled securely over the cuffs of the gown, creating an uninterrupted barrier against both contact and droplet transmission.

Step-by-Step Solution

1
Cleanse hands thoroughly.
Hands are free of pathogens.
Prevents contamination of the clean PPE before donning.
2
Fasten the ties of the isolation gown.
Torso and clothing are covered.
Provides a primary barrier and allows the gloves to eventually overlap the sleeves.
3
Secure a standard procedure mask.
Respiratory tract is protected.
Provides a barrier against droplet transmission.
4
Place eye protection over the face.
Eyes are shielded.
Protects mucous membranes from infectious splashes or sprays.
5
Apply non-sterile examination gloves.
Hands and wrists are covered.
Completes the continuous barrier by covering the cuffs of the gown.

Key Concept

Standardized Sequence for Donning Personal Protective Equipment
Question 507Question →

A practical nurse (PN) has finished providing care for a client isolated with a highly contagious respiratory infection. The PN must now remove personal protective equipment (PPE) before leaving the client's room. Arrange the following steps for PPE removal in the correct sequence to minimize the risk of self-contamination and injury.

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Answer

The correct sequence for removing personal protective equipment is: remove gloves, remove goggles or face shield, remove gown, remove mask or respirator, and finally perform hand hygiene.
According to standard infection control protocols, PPE must be removed in a sequence that minimizes the risk of self-contamination. Gloves are considered the most contaminated and are removed first. The goggles or face shield are removed next by the clean straps. The gown is then carefully removed and rolled inside out. The mask is removed last to protect the respiratory system from particles that may have been disturbed during the removal of the other items. Hand hygiene is the mandatory final step to eliminate any transient flora acquired during the doffing process.

Step-by-Step Solution

1
Remove the gloves.
The most heavily contaminated items are removed from the hands.
Prevents the contaminated gloves from transferring pathogens to the face, hair, or clean areas of other PPE during removal.
2
Remove the goggles or face shield.
The mucous membranes of the eyes are safely uncovered.
Handling only the clean ear pieces or headbands with bare hands prevents self-contamination.
3
Remove the gown.
The body is freed from the contaminated gown without spreading pathogens.
Rolling the gown inside out traps pathogens inside the bundle, protecting the nurse's uniform and the environment.
4
Remove the mask or respirator.
Respiratory protection is safely removed.
The mask is removed last to ensure the respiratory tract remains protected from any airborne particles disturbed while taking off the other garments.
5
Perform hand hygiene.
Any residual pathogens on the hands are completely destroyed or washed away.
This is the essential final step to prevent cross-contamination and ensure the nurse's hands are clean before interacting with other clients or surfaces.

Key Concept

Accident, Error, and Injury Prevention: PPE Doffing Sequence
Question 508Question →

A client is brought to the emergency department after ingesting synthetic cathinones ('bath salts'). The client exhibits extreme agitation, paranoia, and begins verbally threatening the staff. Arrange the following practical nursing actions in the correct order of priority.

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Answer

The correct sequence prioritizes immediate environmental safety, followed by calling for assistance, attempting verbal de-escalation, assisting with medication administration, and finally collecting physiological data once it is safe to approach the client.
In behavioral emergencies involving substance-induced psychosis or extreme agitation, Maslow's hierarchy and safety principles guide nursing actions. The nurse must first protect themselves and bystanders by creating physical distance. Second, additional help must be summoned, as a violent client cannot be safely managed alone. Third, the least restrictive intervention (verbal de-escalation) is attempted. If verbal methods fail, chemical restraints are utilized to ensure safety. Finally, once the client is physically subdued and the environment is secure, the nurse can safely approach the client to collect physiological data and monitor vital signs.

Step-by-Step Solution

1
Maintain a safe physical distance and clear the area of bystanders.
Immediate physical safety is established for staff and other clients.
Protecting individuals from imminent physical harm is the highest priority in a behavioral emergency.
2
Activate the facility's security and behavioral emergency response system.
Additional trained personnel are dispatched to assist.
A violently agitated client poses a severe risk; nurses must secure adequate resources and never attempt physical intervention alone.
3
Attempt to verbally de-escalate the client using a calm, clear, and non-confrontational voice.
The client is provided an opportunity to regain control without the use of force.
Nursing principles mandate attempting the least restrictive interventions before resorting to chemical or physical restraints.
4
Assist the registered nurse (RN) in preparing and administering prescribed acute sedatives.
The client's severe agitation is medically managed.
Chemical sedation is necessary when verbal de-escalation fails and the client poses an ongoing threat to self or others.
5
Assess the client's vital signs and monitor for adverse effects of the medication.
Physiological stability is confirmed and documented.
Data collection is crucial following chemical restraint but must be deferred until the environment is safe.

Key Concept

Prioritization of safety and the use of least restrictive interventions in behavioral emergencies related to acute substance intoxication.
Question 509Question →

A competent adult client is admitted to the medical-surgical unit for a scheduled high-risk cardiac catheterization. While the practical nurse (PN) is reviewing the final pre-procedure checklist, the client suddenly states, 'I have changed my mind. I am not having this done.' Arrange the following actions the PN should take in the correct order of priority.

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Answer

The correct priority sequence is: 1) Cease all ongoing physical preparations, 2) Ask open-ended questions to explore the client's concerns, 3) Notify the registered nurse and healthcare provider, 4) Wait for the healthcare provider to counsel the client, and 5) Document the entire event.
When a client revokes consent, the immediate priority is to stop any related interventions to respect client autonomy and prevent battery. Next, the nurse explores the client's reasoning to understand the sudden change. The nurse then escalates the situation by notifying the RN and provider. The provider must then explain the clinical risks of refusing the procedure, as this is outside the PN's scope. Finally, accurate documentation is completed to reflect the client's wishes, the provider's involvement, and the protection of legal rights.

Step-by-Step Solution

1
Cease all ongoing physical preparations.
The client is no longer being prepared for a procedure they have refused.
Continuing to prepare a client who has explicitly revoked consent is a violation of their rights and constitutes medical battery.
2
Ask open-ended questions to explore concerns.
The nurse gathers data regarding the client's fears or potential knowledge deficits.
Understanding the client's underlying rationale allows the healthcare team to address specific anxieties or misinformation effectively.
3
Notify the registered nurse (RN) and the performing healthcare provider.
The interdisciplinary team is made aware of the revoked consent.
The PN must escalate the situation so the provider can formally address the refusal.
4
Wait for the healthcare provider to counsel the client on the medical consequences of refusal.
The client receives comprehensive clinical information regarding their decision.
Explaining the risks and benefits of a procedure, or the refusal thereof, is strictly within the provider's scope of practice, not the practical nurse's.
5
Document the client's exact statements and the actions taken.
A permanent, legal record of the consent revocation is established.
Thorough documentation protects the client's legal rights and limits institutional liability, and is best completed after the immediate situation is managed.

Key Concept

Informed Consent Revocation and PN Scope of Practice
Estimated Time:1m 30s
Question 510Question →

A practical nurse is completing care for a client diagnosed with norovirus and seasonal influenza. The nurse is wearing an isolation gown, clean gloves, a surgical mask, and a face shield. Arrange the steps for doffing the personal protective equipment (PPE) and performing hand hygiene in the correct chronological order.

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Answer

The correct sequence for doffing PPE is to remove the gloves first, followed by the face shield, then the isolation gown, then the surgical mask, and finally perform hand hygiene using soap and water.
According to standard Centers for Disease Control and Prevention (CDC) guidelines for doffing personal protective equipment, the items considered most contaminated should be removed first. Gloves are removed first, followed by eyewear such as a face shield or goggles. The gown is removed next, taking care to roll it inside out. The mask is removed last to protect the respiratory tract during the doffing of other items. Finally, hand hygiene must be performed; in the case of norovirus, soap and water must be used instead of alcohol-based hand rub.

Step-by-Step Solution

1
Remove the gloves.
The most contaminated PPE is safely discarded.
Gloves touch the client and environment most directly and must be removed first to avoid contaminating the head or face.
2
Remove the face shield.
Eye protection is removed without contaminating the face.
The outside of the face shield is contaminated; handling only the headband prevents exposure.
3
Remove the isolation gown.
The gown is contained and discarded.
The gown is peeled away from the neck and shoulders and rolled inside out to securely contain pathogens.
4
Remove the surgical mask.
Respiratory protection is safely removed.
The mask remains on until other contaminated items are removed to protect the respiratory tract from aerosolized pathogens.
5
Perform hand hygiene with soap and water.
Any residual pathogens on the hands are completely eradicated.
Norovirus requires mechanical friction and soap and water for effective removal; hand sanitizer is insufficient.

Key Concept

Standard and Transmission-Based Precautions (PPE Doffing Sequence)
Question 511Question →

A practical nurse is changing a wound dressing for an older adult client who has age-related thinning of the epidermis and decreased skin elasticity. Arrange the following actions in the correct chronological sequence to safely complete the dressing change and prevent skin tears.

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Answer

The correct sequence is to first moisten the old tape, gently remove it parallel to the skin, assess the exposed skin, apply a liquid skin barrier, and finally secure the new dressing with silicone tape.
The correct sequence prioritizes minimizing mechanical trauma to the aging client's fragile epidermis. Moistening the adhesive and pulling parallel to the skin prevents epidermal stripping. Assessing the skin ensures integrity before applying a skin barrier, which protects the tissue from the new, gentle silicone tape.

Step-by-Step Solution

1
Moisten and loosen the old tape.
The adhesive bond is weakened.
To prevent forcefully pulling on the fragile aging epidermis.
2
Remove the tape parallel to the skin.
The tape is removed without upward tension.
Upward pulling can separate the epidermis from the dermis, causing a painful skin tear in older adults.
3
Assess the periwound skin.
Skin integrity is evaluated.
To identify any damage or epidermal stripping caused by the previous dressing.
4
Apply a skin barrier wipe.
A protective film forms over the skin.
To protect the vulnerable aging skin from trauma when the new tape is eventually removed.
5
Secure the new dressing.
The wound is covered and secured.
Using a gentle tape like silicone minimizes the risk of future skin tears.

Key Concept

Protecting fragile, aging skin from mechanical trauma and skin tears during dressing changes.
Question 512Question →

A practical nurse (PN) enters a client's room and discovers the client lying on the floor beside the bed. The client is awake and states, 'I slipped while trying to get to the bathroom.' Arrange the following actions in the correct priority sequence the PN should perform.

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Answer

The correct sequence is to first assess ABCs, then inspect for trauma, obtain vital signs, safely transfer the client to bed, and finally notify the provider and document the incident.
Post-fall management requires a highly structured, systematic approach based on prioritization of physiological needs. Life-threatening conditions (ABCs) must be assessed first. Next, a targeted physical assessment ensures there are no injuries, such as a hip or cervical fracture, that would contraindicate movement. Vital signs are then taken while the client is on the floor to verify hemodynamic stability. Only after completing these three assessment phases is it safe to move the client back to bed using appropriate lift equipment. Finally, secondary tasks like provider notification and incident reporting are performed.

Step-by-Step Solution

1
Assess airway, breathing, circulation, and level of consciousness.
Immediate life threats are ruled out.
Basic life support principles dictate that physiological integrity (ABCs) is the absolute highest priority.
2
Examine for bleeding, deformities, and head trauma.
Specific physical injuries are identified.
Identifying occult injuries like fractures or spinal trauma before any movement occurs is critical to prevent severe secondary complications.
3
Obtain a complete set of vital signs.
Hemodynamic stability is established.
Baseline vital signs confirm it is physiologically safe to move the client and help detect internal bleeding or shock.
4
Assist the client back into bed.
The client is moved to a safe resting environment.
Safe patient handling equipment prevents musculoskeletal injury to both the client and the nursing staff.
5
Notify the healthcare provider and file an incident report.
The care team is informed and the event is properly documented.
Communication and administrative duties follow clinical stabilization and environmental safety.

Key Concept

Prioritization in Post-Fall Management
Question 513Question →

A licensed practical/vocational nurse (LPN/VN) is caring for a client receiving continuous enteral tube feedings. The LPN/VN plans to delegate morning oral hygiene and repositioning to an assistive personnel (AP). Arrange the steps of this delegation process in the correct chronological sequence based on the National Council of State Boards of Nursing (NCSBN) guidelines.

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Answer

The correct sequence follows the NCSBN Five Rights of Delegation: first assessing the client's stability (Right Circumstance/Task), second verifying the AP's competency (Right Person), third providing clear instructions (Right Direction/Communication), and fourth following up on the care (Right Supervision/Evaluation).
Effective and safe delegation requires a systematic approach based on the NCSBN Five Rights. The nurse must first ensure the client is stable enough for the task to be delegated (Right Circumstance/Task). Next, the nurse must ensure the chosen delegate is competent (Right Person). Then, the nurse must provide clear, specific instructions including safety parameters (Right Direction). Finally, the nurse remains accountable and must follow up to evaluate the outcome (Right Supervision).

Step-by-Step Solution

1
Determine client stability and appropriateness of the task.
Review the client's current respiratory status and aspiration risk.
Ensures the 'Right Circumstance' and 'Right Task' before initiating delegation.
2
Select the appropriate personnel.
Confirm that the specific AP has the documented skill competency.
Ensures the 'Right Person' is assigned to perform the care safely.
3
Communicate specific instructions.
Instruct the AP on the exact parameters, including keeping the head of the bed elevated.
Ensures 'Right Direction/Communication' so expectations and safety measures are clear.
4
Follow up and evaluate.
Examine the client's oral cavity afterward and verify documentation.
Ensures 'Right Supervision/Evaluation' to confirm the task was completed correctly and the client tolerated it well.

Key Concept

NCSBN Five Rights of Delegation for LPN/VN Practice
Estimated Time:1m 30s
Question 514Question →

During a shift on a long-term care unit, a practical nurse prepares to assign morning hygiene and mobility tasks to an assistive personnel (AP). Sequence the following steps of the delegation process in the correct chronological order to ensure safe client care.

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Answer

The correct chronological sequence aligns with the nursing delegation process: evaluating client stability (Right Circumstance), confirming AP competency (Right Person), giving specific instructions (Right Direction), monitoring performance (Right Supervision), and assessing outcomes (Right Evaluation).
The delegation process must follow a logical sequence to ensure client safety and legal compliance. It begins with assessing the client's needs and physiological stability (Right Circumstance). Next, the nurse must ensure the chosen delegate is competent (Right Person). Only then can the nurse provide clear instructions and expectations (Right Direction). During the task execution, the nurse monitors performance (Right Supervision), and finally, the nurse evaluates the client's response and the task outcome (Right Evaluation).

Step-by-Step Solution

1
Determine the stability and predictability of the clients' conditions to ensure the tasks are safe to delegate.
Establishes the 'Right Circumstance' for safe delegation.
The nurse must first verify that the client is stable; unstable clients require the continuous clinical judgment of a licensed nurse and cannot have care delegated to an AP.
2
Confirm that the AP possesses the required skills and documented competency for the assigned tasks.
Verifies the 'Right Person' is chosen for the tasks.
Before giving instructions, the nurse must ensure the specific AP has the training and facility approval to perform the required care safely.
3
Communicate specific instructions and clear parameters for reporting abnormal findings.
Provides the 'Right Direction/Communication'.
The AP needs explicit, clear, and concise directions, including exactly what physiological changes or observations must be immediately reported back to the nurse.
4
Monitor the AP's progress and provide guidance as needed during task execution.
Ensures the 'Right Supervision' is maintained.
The nurse remains legally accountable for the delegated tasks and must periodically observe the AP to ensure care is being delivered correctly.
5
Assess the final outcomes of the delegated tasks and provide feedback to the AP.
Completes the 'Right Evaluation' phase.
The final chronological step involves reviewing the client's response to the care, documenting the clinical outcomes, and providing professional feedback to the AP.

Key Concept

The nursing delegation process and chronological application of the NCSBN Five Rights of Delegation.
Estimated Time:1m 30s
Question 515Question →

A practical nurse (PN) is preparing to apply bilateral soft wrist restraints to a client with severe agitation who is actively disrupting life-saving medical devices. The least restrictive alternatives have been unsuccessful. Arrange the following steps for restraint application in the correct chronological order.

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Answer

The correct sequence is: Verify the prescription, assess baseline skin/neurovascular status, pad and apply the restraints, secure to the movable bed frame, verify the fit using two fingers, and document the procedure.
Applying restraints requires a systematic approach prioritizing legality and safety. The nurse must first ensure an order exists. Next, a baseline assessment is vital before placing the padded device on the client. Securing the device safely to the movable bed frame and verifying the tightness follow to prevent injury. Finally, the entire process must be promptly documented according to legal standards.

Step-by-Step Solution

1
Verify the provider's prescription.
Legal authorization for the specific restraint is confirmed.
Restraints require a valid medical order detailing the specific type and clinical justification.
2
Inspect baseline skin and neurovascular status.
Baseline data is collected for future comparison.
The nurse must know the initial circulatory and integumentary status to detect any impairment caused by the restraints later.
3
Pad the wrists and apply the restraint.
The device is placed on the client safely.
Padding prevents skin breakdown and friction injuries during patient movement.
4
Secure the straps to the movable portion of the bed frame.
The restraints are anchored securely.
Anchoring to the movable frame (not side rails) prevents injury if the bed position is adjusted.
5
Check the fit with two fingers.
Optimal tightness is confirmed.
The two-finger rule ensures the restraint is tight enough to restrict unwanted movement but loose enough to maintain adequate blood flow.
6
Document the procedure.
A legal and clinical record is established.
Thorough documentation immediately after application is required to prove compliance with safety protocols and scope of practice.

Key Concept

Procedural mechanics and safety guidelines for applying physical restraints.
Question 516Question →

While completing a medication pass at a long-term care facility, a practical nurse (PN) observes another nurse who appears drowsy, is slurring their words, and is about to administer an oral medication to a client. In what order should the PN take the following actions? Arrange the steps from first to last.

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Answer

The correct order of actions prioritizes immediate client safety, followed by client assessment, reporting to management, and finally, objective documentation.
According to the NCLEX-PN framework for safe and effective care, the first priority is always immediate client safety, which requires stopping the administration of medication by an impaired nurse. Next, the nurse must assess the client to ensure no harm has already occurred. Following the establishment of client safety, the nurse must follow the chain of command by notifying the supervisor to remove the impaired nurse from duty. Finally, objective documentation of the event is completed in a facility incident report, separate from the client's medical record.

Step-by-Step Solution

1
Prioritize immediate client safety.
The PN stops the coworker from administering the medication.
Preventing potential harm is always the highest priority in any clinical situation according to basic safety principles.
2
Assess the client's status.
The PN checks the client and their medication record.
To ensure no adverse events have already occurred prior to the intervention.
3
Follow the chain of command.
The PN reports the situation to the nursing supervisor.
Management must handle impaired staff according to facility policy, ethical duties, and legal requirements.
4
Document the incident.
The PN writes an objective incident report.
Accurate, factual documentation is legally required but must occur only after client safety and management notification are secured.

Key Concept

Priority Action for Impaired Coworker
Question 517Question →

A client who had an uncomplicated vaginal birth at 38 weeks of gestation is currently 2 hours postpartum. A practical nurse is preparing to evaluate the client's uterine fundus and lochia. Arrange the following actions in the order the practical nurse should perform them to safely complete this evaluation.

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Answer

The correct sequence begins with preparation (voiding and positioning), moves to infection control and observation (gloves and pad exposure), and concludes with the safe technique of palpation (supporting the lower segment before applying any downward pressure).
Safe fundal assessment requires a specific sequence: preparing the client by emptying the bladder and positioning to relax muscles, exposing the perineum to monitor lochia, and crucially, supporting the lower uterus before applying any downward palpation pressure.

Step-by-Step Solution

1
Instruct the client to void and explain the purpose of the evaluation.
The bladder is emptied and the client understands the process.
An overdistended bladder pushes the uterus up and out of the midline, causing inaccurate findings and potentially increasing bleeding.
2
Assist the client into a flat, supine position with her knees slightly flexed.
The client's abdominal muscles are relaxed.
Tight abdominal muscles make palpation difficult and uncomfortable; flexing the knees relieves this tension.
3
Put on clean gloves and pull down the perineal pad.
Standard precautions are established and the perineum is visible.
The nurse must observe the amount and character of lochia expelled while the fundus is being palpated.
4
Place one hand firmly just above the client's symphysis pubis.
The lower uterine segment is supported.
Failing to support the lower segment during fundal palpation can cause the uterus to invert, which is a medical emergency.
5
Cup the opposite hand and gently press downward to locate the top of the fundus.
The fundal height, firmness, and position are determined.
This action completes the data collection for postpartum uterine involution.

Key Concept

Postpartum Fundal Assessment Technique
Question 518Question →

An LPN/LVN has finished assisting with a wound dressing change for an adult client hospitalized with disseminated herpes zoster. The required protective attire for this airborne and contact precaution environment includes a fitted particulate respirator, a fluid-resistant gown, and examination gloves. Place the following steps in the correct chronological sequence for the safe removal of these items and exiting the area.

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Answer

The correct sequence for doffing personal protective equipment in an airborne and contact precaution room is to first remove the gloves, then remove the gown, perform hand hygiene, exit the isolation room, and finally remove the respirator.
In environments requiring airborne and contact precautions, personal protective equipment must be removed in an order that minimizes the risk of self-contamination and environmental exposure. The gloves are the most contaminated and are removed first. The gown is removed second. Hand hygiene must be performed to clean the hands before touching the door. The nurse then exits the negative-pressure room and closes the door. Finally, the respirator is removed outside the room to prevent inhalation of airborne particles.

Step-by-Step Solution

1
Remove the gloves.
The most contaminated items are safely discarded.
Prevents cross-contamination to the nurse's skin, face, or the clean areas of the gown.
2
Remove the gown.
The gown is bundled inside out and discarded.
The gown is the next most contaminated item; rolling it inside out traps contact pathogens.
3
Perform hand hygiene.
Hands are completely sanitized.
Any inadvertent contamination during glove and gown removal is eliminated before touching the environmental surfaces like the door handle.
4
Exit the isolation room.
The nurse leaves the contaminated airspace.
The respirator must remain securely on the face while inside the airborne precaution environment.
5
Remove the respirator outside the room.
The respiratory protection is safely discarded in a clean area.
Removing the mask outside the negative-pressure room prevents inhalation of airborne infectious particles like varicella-zoster.

Key Concept

Standard and Transmission-Based Precautions sequence for doffing PPE
Question 519Question →

A practical nurse (PN) discovers a confused client actively pulling at their newly inserted chest tube. After calling for assistance and attempting verbal de-escalation without success, the charge nurse initiates the emergency application of soft wrist restraints. Arrange the following actions in the correct chronological sequence for safe restraint application and management.

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Answer

The correct sequence is: (1) Implement a manual hold to prevent immediate harm, (2) Apply padding to the wrists, (3) Secure ties to the movable bed frame with a quick-release knot, (4) Assess neurovascular status, and (5) Notify the provider for a formal evaluation and order.
The correct chronological sequence prioritizes the immediate preservation of life (stopping the removal of the chest tube via manual hold), followed by the safe physical application of the restraint (padding, then securing to the movable frame). Once the client is safely secured, immediate clinical assessment (neurovascular check) is required to ensure no physical harm was caused by the application. Finally, the administrative and legal requirement of notifying the provider for a formal order is fulfilled.

Step-by-Step Solution

1
Prioritize immediate client safety.
A staff member manually holds the client's hands.
When a life-sustaining device like a chest tube is at risk, stopping the immediate mechanical action of pulling is the absolute first priority.
2
Prepare the extremity for device application.
Padding is applied to the client's wrists.
Protecting skin integrity is a foundational step before securing any restrictive mechanical device.
3
Apply and secure the restraint device safely.
Ties are secured to the movable bed frame with quick-release knots.
This positioning prevents injury if the head of the bed is raised or lowered, and the knot allows for rapid emergency release.
4
Evaluate the physiological impact of the applied restraints.
Neurovascular status (pulses, capillary refill) is assessed.
The nurse must verify that the applied device is not compromising blood flow or causing nerve damage.
5
Ensure legal and regulatory compliance.
The healthcare provider is notified.
Emergency application is legally permitted for immediate safety, but a provider must perform a face-to-face assessment and write the formal order immediately thereafter.

Key Concept

Emergency Restraint Application Sequence and Safety
Estimated Time:1m 30s
Question 520Question →

A practical nurse is preparing to assess the uterine involution of a multiparous client who is 12 hours postpartum. In which order should the nurse perform the following actions to safely and accurately assess the fundus? (Arrange the steps in the correct sequence from first to last.)

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Answer

The correct sequence is: Instruct the client to empty her bladder, assist her into a supine position with flexed knees, don gloves and observe the perineal pad, stabilize the lower uterine segment, and finally palpate the fundus.
A safe and accurate fundal assessment must follow a strict, logical sequence. First, the bladder must be empty to avoid uterine displacement. Second, the client must be positioned correctly (supine with knees flexed) to relax the abdomen. Third, the nurse applies gloves and checks current lochia as a baseline. Finally, when performing the physical palpation, the nurse must always stabilize the lower uterine segment with one hand before pressing on the fundus with the other hand to prevent uterine inversion.

Step-by-Step Solution

1
Ensure physiological readiness
The client empties her bladder.
A full bladder interferes with accurate assessment by pushing the uterus up and to the side, potentially causing false findings of a boggy uterus.
2
Position for comfort and access
The client is placed supine with flexed knees.
This specific position relieves tension on the abdominal muscles, making it easier to feel the uterus and more comfortable for the client.
3
Implement standard precautions and baseline observation
The nurse dons gloves and visualizes the perineal pad.
This protects the nurse from bodily fluids and allows assessment of bleeding before the uterus is manipulated, which could suddenly expel pooled blood.
4
Perform the bimanual palpation technique safely
The lower segment is supported while the top is palpated.
Supporting the bottom portion of the uterus prevents the life-threatening complication of uterine inversion while evaluating fundal tone.

Key Concept

Postpartum Fundal Assessment Technique
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