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Question 561Question →

A practical nurse is preparing to place a regular bedpan for a client who is on strict bed rest and unable to lift their hips. After donning gloves and ensuring privacy, in what order should the nurse perform the following actions? Arrange the steps from first to last.

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Answer

The correct sequence is: raise the bed and lower the head, assist the client to roll onto their side, position the bedpan firmly against the buttocks, roll the client back onto the bedpan, and finally elevate the head of the bed.
When assisting a client who cannot lift their hips onto a bedpan, the nurse must first prioritize safety and ergonomics by flattening the bed and raising it to working height. The client is then rolled to the side so the bedpan can be pressed against the buttocks. The nurse holds the bedpan steady while rolling the client back onto it. Finally, raising the head of the bed restores a functional, gravity-assisted position for elimination.

Step-by-Step Solution

1
Raise the bed to a comfortable working height and lower the head of the bed flat.
The nurse's back is protected, and the client is in a safe, flat position for turning.
Maintaining proper ergonomics and reducing the physical effort required to turn the client.
2
Assist the client to roll onto their side facing away from the nurse.
The client's buttocks are exposed and accessible.
Since the client cannot lift their hips, the log-rolling or side-lying method must be used to place the device.
3
Position the bedpan firmly against the client's buttocks.
The bedpan is properly aligned with the client's anatomy.
Ensuring the bedpan is secure prevents spillage and skin shearing during the return roll.
4
Roll the client back onto the bedpan while holding it in place.
The client is now supine and centered over the bedpan.
Holding the device securely during the maneuver ensures it remains under the client's buttocks.
5
Elevate the head of the bed to a semi-Fowler's position.
The client is sitting in a somewhat upright position.
An upright position mimics the natural posture for defecation or urination, utilizing gravity and intra-abdominal pressure.

Key Concept

Procedural sequencing for basic elimination care
Estimated Time:1m 30s
Question 562Question →

A practical nurse (PN) has completed wound care for a client on contact and droplet precautions. Arrange the following steps for removing personal protective equipment (PPE) in the correct chronological order to minimize the risk of self-contamination.

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Answer

The correct sequence for doffing PPE is to first remove the gloves, followed by the face shield, then the gown, then the mask, and finally perform hand hygiene.
The Centers for Disease Control and Prevention (CDC) guidelines dictate that PPE should be removed in a specific order that minimizes the risk of cross-contamination. Gloves are the most contaminated and are removed first. The face shield is removed next by handling only the clean headbands. The gown is then removed and rolled inside out to contain pathogens. The mask is removed last because it protects the respiratory tract from potential exposure during the removal of the other items. Finally, hand hygiene is universally required to remove any residual pathogens.

Step-by-Step Solution

1
Identify and remove the most contaminated item.
Gloves are removed first.
Gloves have direct contact with the client and contaminated environmental surfaces.
2
Protect the mucous membranes of the eyes.
The face shield or goggles are removed second.
This prevents splashes or transfer to the eyes while the gown is subsequently being manipulated.
3
Remove the bulk of the remaining contaminated equipment.
The gown is removed third by pulling it away and rolling it inside out.
Rolling the gown traps contaminants inside, protecting the nurse's bare arms and uniform.
4
Remove respiratory protection.
The mask is removed fourth.
The mask is kept on until all other contaminated PPE is safely discarded to protect the airway from potential airborne particles during doffing.
5
Eliminate any residual pathogens.
Hand hygiene is performed last.
This ensures any cross-contamination that occurred during the removal process is completely washed away.

Key Concept

Standard Sequence for Removing (Doffing) Personal Protective Equipment
Question 563Question →

A practical nurse (PN) enters the room of a client on a pulmonary unit to administer a prescribed pre-procedure sedative. The client, who is scheduled for a bronchoscopy in one hour, states, "I have decided not to go through with this test today." In which order should the PN perform the following actions? Arrange the actions from first to last.

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Answer

The correct sequence is to first withhold the medication, then clarify the client's concerns, followed by notifying the healthcare provider, and finally documenting the event.
In any situation where a client revokes consent, the absolute first priority is to stop the procedure or any preparatory actions (such as administering sedatives). Next, the nurse should assess the situation by asking the client to clarify their feelings. Third, the nurse must communicate the refusal to the healthcare provider, who is responsible for discussing the medical implications with the client. Finally, the nurse must document the entire event objectively in the medical record.

Step-by-Step Solution

1
Withhold the pre-procedure sedative medication.
Client safety and autonomy are immediately protected.
When a client revokes consent, all procedure-related interventions must stop immediately to prevent battery and respect their legal rights.
2
Ask the client to elaborate on their decision.
The PN gathers relevant data regarding the refusal.
Understanding the client's fears or concerns helps inform the healthcare team, though the PN must remain within scope and not attempt to explain medical risks themselves.
3
Notify the healthcare provider.
The provider is alerted to intervene.
It is exclusively the provider's scope of practice to explain the medical consequences of refusing the procedure and to formally accept the revoked consent.
4
Document the event in the medical record.
A formal legal record is established.
Accurate, objective documentation of the client's refusal, the time, and the notification of the provider protects both the client and the healthcare facility.

Key Concept

Clients have the right to revoke informed consent at any time; the PN must prioritize withholding interventions and notifying the provider who is responsible for explaining the risks of refusal.
Estimated Time:1m 30s
Question 564Question →

Upon concluding a dressing change for a pediatric client diagnosed with respiratory syncytial virus (RSV), the nurse steps toward the doorway to exit the isolation room. The nurse is wearing a gown, gloves, a surgical mask, and a face shield. Arrange the following actions in the correct chronological sequence for safely removing this personal protective equipment (PPE) according to standard infection control protocols.

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Answer

The correct sequence is: 1) Remove gloves, 2) Remove face shield, 3) Remove gown, 4) Remove mask, 5) Perform hand hygiene.
According to the Centers for Disease Control and Prevention (CDC) guidelines, the standard sequence for removing personal protective equipment is designed to minimize the risk of self-contamination. The most contaminated items, the gloves, are removed first. Eye protection is removed next by handling only the clean headband. The gown is then unfastened and rolled inward. The mask is removed last (prior to hand hygiene) because it protects the airway during the doffing of the other items. Finally, hand hygiene is universally mandated as the concluding step to ensure safety.

Step-by-Step Solution

1
Remove gloves
The most contaminated PPE is safely discarded
Gloves harbor the highest concentration of pathogens and removing them first prevents cross-contamination to the face or hair.
2
Remove face shield
Eye protection is safely removed without touching the contaminated front
Handling only the clean back headband protects the newly ungloved hands from splash contaminants.
3
Remove gown
The gown is folded inward and discarded
Removing the gown after the face shield prevents contamination of the uniform and ensures the mask remains in place during potential aerosolization.
4
Remove mask
The respiratory and droplet barrier is removed
The mask must remain on until all other potentially contaminated PPE is removed to protect the mucous membranes of the nose and mouth.
5
Perform hand hygiene
Hands are completely cleansed of residual pathogens
Hand hygiene is strictly required as the absolute final step before exiting the area or moving to the next client.

Key Concept

Standard and Transmission-Based Precautions: PPE Doffing Sequence
Estimated Time:1m 0s
Question 565Question →

A healthcare provider prescribes knee-high anti-embolism stockings for a client who is currently sitting in a bedside chair. Arrange the following steps for applying the stockings in the correct chronological order.

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Answer

The practical nurse must first assist the client to a supine position for 15 to 30 minutes, measure the leg for correct sizing, turn the stocking inside out to the heel, apply the foot portion, and finally pull the remaining fabric smoothly up the calf.
Applying anti-embolism stockings requires specific preparation to be effective and safe. Because the client has been sitting in a chair, their legs have been in a dependent position, allowing venous blood to pool. The nurse must first assist the client to a supine position for 15 to 30 minutes to promote venous return and resolve dependent edema. Once the legs are rested, accurate measurements of the calf and leg length ensure the correct size is chosen, preventing a tourniquet effect from stockings that are too tight. After obtaining the right size, turning the stocking inside out to the heel allows the nurse to smoothly apply the foot portion first. Finally, pulling the remainder of the stocking up the calf ensures a wrinkle-free fit that effectively supports venous return.

Step-by-Step Solution

1
Assist the client to lie supine in bed for 15 to 30 minutes.
Dependent edema is reduced and venous return is maximized.
Applying stockings while the client has been in a dependent position can trap pooled venous blood in the lower extremities.
2
Measure the client's calf circumference and leg length.
The correct stocking size is identified.
Stockings that are too tight can restrict arterial blood flow, while those that are too loose fail to promote venous return.
3
Turn the stocking inside out down to the heel pocket.
The foot section is exposed and ready for application.
This technique allows the nurse to apply the stocking over the foot easily without bunching the stiff compression fabric.
4
Slide the foot portion of the stocking evenly over the client's toes and heel.
The stocking is secured over the foot with the heel patch correctly aligned.
Proper alignment over the heel prevents skin breakdown and ensures the compression gradient starts correctly at the ankle.
5
Pull the remaining fabric smoothly up the leg to just below the knee.
The stocking fits snugly and evenly across the calf.
Wrinkles or rolled-down bands can act as a tourniquet, completely occluding circulation and increasing the risk of deep vein thrombosis.

Key Concept

Proper application of anti-embolism stockings to promote venous return
Question 566Question →

A practical nurse is caring for a client with heart failure who is resting supine in bed. The client suddenly becomes restless and reports severe difficulty breathing. In what sequence should the nurse perform the following actions? (Arrange the actions from first to last.)

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Answer

The correct sequence is: assist the client into a high-Fowler's position, obtain vital signs and oxygen saturation, administer supplemental oxygen as prescribed, and finally report the change in condition to the charge nurse.
In any acute respiratory distress scenario, anatomical positioning to open the airway and facilitate lung expansion is the absolute first priority (Airway/Breathing). After the airway is physically optimized, the nurse collects necessary data (vital signs and oxygen saturation) to guide further intervention, administers prescribed physical treatments (oxygen), and finally communicates the status change to the broader healthcare team.

Step-by-Step Solution

1
Identify the immediate threat to the client's stability.
The client is experiencing sudden respiratory distress, making airway and breathing the absolute top priority.
According to the ABCs (Airway, Breathing, Circulation) framework, respiratory compromise must be addressed before other actions.
2
Select the quickest, most direct intervention to improve breathing.
Assisting the client to a high-Fowler's position is chosen as the first action.
Repositioning provides immediate relief for dyspnea by utilizing gravity to pull organs away from the diaphragm, requiring no equipment or orders to initiate.
3
Determine the next priority after optimizing the client's airway.
Obtaining vital signs and oxygen saturation is the second action.
Data collection is necessary to quantify the severity of the distress and guide further clinical decisions within the PN scope of practice.
4
Implement ordered therapies based on the newly collected data.
Administering prescribed supplemental oxygen is the third action.
Oxygen therapy directly treats the underlying hypoxia identified during the assessment phase.
5
Ensure the healthcare team is aware of the acute change.
Reporting to the charge nurse is the final action in this immediate sequence.
Once the client is stabilized and initial interventions are complete, the supervising nurse must be informed for further medical evaluation and potential modification of the care plan.

Key Concept

Prioritization of airway and breathing management during acute respiratory distress
Question 567Question →

A practical nurse is preparing to transfer a client who has limited mobility from a bed to a stretcher using a lateral transfer board (slide board). The nurse has already explained the procedure to the client, gathered an assistant, and performed hand hygiene. Arrange the following steps in the correct order to safely complete the transfer.

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Answer

The correct sequence is to first level and lock the bed and stretcher, turn the client away, position the board under the draw sheet, roll the client supine onto the board, and finally slide them across.
A safe lateral transfer requires a systematic approach to prevent client injury and nurse strain. First, stabilizing and leveling the surfaces (bed and stretcher) is the fundamental safety priority. Next, the client must be turned away from the destination to expose the bed surface, allowing the transfer board to be placed safely under the draw sheet without shearing the skin. The client is then rolled back onto the board to secure their weight, followed by a coordinated slide using the draw sheet to move the client smoothly across the gap.

Step-by-Step Solution

1
Adjust bed and stretcher height and lock wheels.
Both surfaces are level, stable, and secure.
This is the primary safety measure to prevent the bed or stretcher from separating or moving during the transfer.
2
Turn the client away from the stretcher.
The client is in a lateral position.
This exposes the bed surface and allows the nurse to position the board without forcing it roughly under the client.
3
Position the transfer board under the draw sheet.
The board bridges the gap between the bed and stretcher.
Placing it under the draw sheet protects the client's skin from friction and utilizes the sheet for the pulling action.
4
Return the client to a supine position.
The client is centered securely on the transfer board.
This properly distributes the client's weight and prepares their body alignment for the slide.
5
Slide the client across the board.
The client is successfully transferred to the stretcher.
Coordinating the pull with an assistant ensures proper ergonomics for the staff and a smooth, safe transfer for the client.

Key Concept

Safe client handling and mobility: lateral transfer techniques
Question 568Question →

A licensed practical nurse (LPN) is assisting a healthcare provider with a bedside thoracentesis for a client who has a pleural effusion. In what order should the LPN perform the following actions to reduce the client's risk of potential complications? (Arrange the steps from first to last.)

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Answer

The correct sequence is: Verify identity and consent, position the client upright over a table, instruct the client to remain still, apply a sterile dressing, and finally auscultate breath sounds.
To reduce the risk of complications during a thoracentesis, the practical nurse must follow a logical sequence from pre-procedure preparation to post-procedure monitoring. First, safety protocols require verifying identity and informed consent. Next, optimal positioning is required to safely access the pleural space. Once positioned, instructing the client to remain still prevents accidental lung puncture during the procedure. Immediately after the procedure, a sterile dressing prevents air entry and infection. Finally, the nurse monitors respiratory status to detect complications such as a pneumothorax.

Step-by-Step Solution

1
Verify identity and informed consent.
The correct client is identified and legal permission is confirmed.
This is the primary safety check and must always precede any invasive procedure.
2
Position the client upright and leaning over an overbed table.
The client is in the optimal anatomical position.
This specific position expands the intercostal spaces, allowing safe access to the pleural fluid and reducing the risk of puncturing the lung.
3
Instruct the client to remain still and avoid coughing.
The client understands the critical need for immobility.
Sudden movements or coughing during needle insertion can cause a traumatic pneumothorax or liver/spleen puncture.
4
Apply a sterile dressing to the puncture site.
The puncture site is sealed immediately after needle removal.
This prompt action prevents ambient air from entering the pleural cavity (which could cause a pneumothorax) and reduces infection risk.
5
Auscultate breath sounds and monitor respiratory rate.
The client's post-procedure respiratory status is evaluated.
Continuous monitoring is necessary to detect early clinical signs of a pneumothorax, respiratory distress, or hypoxemia.

Key Concept

Prioritizing nursing actions before, during, and after an invasive procedure to minimize the risk of complications such as organ puncture or pneumothorax.
Question 569Question →

A practical nurse (PN) realizes they have just administered the wrong oral medication to a client. Arrange the following actions in the correct priority order the PN should perform them to ensure client safety.

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Answer

The correct sequence is: Assess the client, notify the provider, implement new orders, document in the chart, and complete the incident report.
In the event of a medication error, the nursing process dictates that assessment is always the first action to ensure client safety. Following assessment, the nurse must communicate the findings to the provider to receive further orders. Once the client is stabilized through new interventions, the nurse completes the legal documentation in the health record. The final step is the administrative task of filing an incident report.

Step-by-Step Solution

1
Assess the client's vital signs and physiological status.
The PN determines the client's baseline condition immediately following the error.
Client safety is the paramount concern. Assessment must always precede communication.
2
Notify the healthcare provider and the charge nurse.
The provider is made aware of the error and the client's current status.
The provider needs this information to determine if any counteractive measures are necessary.
3
Implement any new prescriptions or interventions ordered by the healthcare provider.
The client receives necessary monitoring or treatments.
Prompt execution of medical orders minimizes the potential harm from the medication error.
4
Document the medication administered and the client's response in the health record.
An accurate, legal record of the event is established in the client's chart.
Factual documentation of care provided is a legal nursing responsibility.
5
Complete an institutional incident or variance report.
The facility receives data for quality improvement and risk management.
Incident reports help facilities identify systemic issues, but they do not go in the client's chart and are the lowest clinical priority.

Key Concept

Prioritization of Care Post-Medication Error
Question 570Question →

A practical nurse is preparing to administer a mixed dose of short-acting (Regular) and intermediate-acting (NPH) insulin to a client with type 2 diabetes mellitus. Place the following steps for drawing up the insulins in the correct chronological order.

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Answer

The correct sequence is to roll the intermediate-acting insulin, inject air into the intermediate-acting insulin, inject air into the short-acting insulin, withdraw the short-acting insulin, and finally withdraw the intermediate-acting insulin.
When mixing insulins, the standard safety protocol is 'clear before cloudy' (short-acting before intermediate-acting). This prevents the intermediate-acting insulin from contaminating the short-acting vial. The sequence ensures proper mixing of the suspension (rolling), equalization of pressure in both vials (injecting air into cloudy, then clear), and safe withdrawal (drawing clear, then cloudy).

Step-by-Step Solution

1
Roll the vial of intermediate-acting insulin between the palms of the hands.
The suspension is mixed evenly.
NPH insulin is a suspension that settles. Rolling mixes it without creating bubbles that could lead to inaccurate dosing.
2
Inject a volume of air equal to the prescribed dose into the intermediate-acting insulin vial.
Pressure is equalized in the NPH vial.
Injecting air prevents a vacuum, making it easier to withdraw the medication later. Doing this first prevents contamination of the needle with clear insulin.
3
Inject a volume of air equal to the prescribed dose into the short-acting insulin vial.
Pressure is equalized in the Regular insulin vial.
Injecting air prepares the vial for withdrawal. Since the needle is already in this vial, the nurse can immediately proceed to the next step.
4
Invert the vial and withdraw the prescribed dose of short-acting insulin.
The clear insulin is drawn into the syringe first.
Drawing clear (short-acting) insulin before cloudy (intermediate-acting) insulin prevents the longer-acting insulin from contaminating the short-acting insulin vial.
5
Insert the syringe into the intermediate-acting insulin vial and withdraw the prescribed dose.
The total mixed dose is now in the syringe.
The cloudy insulin is drawn last to complete the mixture safely.

Key Concept

Safe administration and preparation of mixed insulins (Clear before Cloudy)
Question 571Question →

While assisting a client with a history of seizure disorders during their morning meal, the individual suddenly loses consciousness and begins exhibiting rhythmic, jerking muscle movements while seated in their chair. Arrange the following nursing interventions in the correct order of priority.

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Answer

The correct sequence is: Guide the client safely to the floor, place a pad beneath their head, turn them onto their side, loosen restrictive clothing, and finally note the time of onset and characteristics of the seizure.
In any acute medical emergency, nursing priorities dictate that immediate physical safety and airway protection come first. For a seizing client seated in a chair, the most imminent threat is a fall, requiring the nurse to first lower them to the floor. Once on the floor, the head is vulnerable to trauma from clonic jerking and must be padded. With gross physical safety secured, the priority shifts to airway management by rolling the client onto their side to prevent aspiration, followed by loosening restrictive clothing to optimize breathing. Only after these life-safety measures are established should the nurse focus on observing and timing the seizure.

Step-by-Step Solution

1
Ensure immediate physical safety from falls.
The client is guided from the chair to the floor.
The client has lost consciousness and is at severe risk for a traumatic fall from the chair.
2
Protect the head from traumatic injury.
A soft pad or blanket is placed beneath the head.
Tonic-clonic movements on a hard floor can cause severe head trauma if the head is not adequately cushioned.
3
Protect the airway from aspiration.
The client is turned onto their side.
The lateral position allows saliva and emesis to drain from the mouth, maintaining a patent airway during the event.
4
Remove mechanical restrictions to breathing.
Restrictive clothing around the neck and chest is loosened.
Tight clothing can impede respiratory effort and venous return during the intense physiological stress of a seizure.
5
Monitor and record the event details.
The time of onset and seizure characteristics are noted.
Accurate timing and observation are necessary for post-seizure medical management, but this must follow immediate safety interventions.

Key Concept

Acute Seizure Management and Safety Prioritization
Question 572Question →

A practical nurse is preparing to measure the gastric residual volume for a client who is receiving continuous enteral tube feedings. In what order should the nurse perform the following actions to reduce the risk of aspiration and other clinical complications? Arrange the steps in the correct sequence from first to last.

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Answer

The correct sequence for checking gastric residual volume is: elevate the head of the bed, perform hand hygiene and don gloves, attach the syringe, aspirate and measure the contents, and finally reinstill the contents.
Evaluating gastric residual volume is a critical risk reduction intervention to prevent aspiration in clients receiving enteral feedings. The correct, safe sequence prioritizes airway protection first (elevating the head of the bed), followed by infection control (hand hygiene and gloves). Once safety parameters are set, the nurse attaches the syringe, withdraws the fluid to measure it, and finally reinstills the fluid to prevent dangerous electrolyte and fluid shifts.

Step-by-Step Solution

1
Elevate the head of the client's bed to at least 30 degrees.
The client is placed in a semi-Fowler's or higher position.
This utilizes gravity to keep gastric contents in the stomach, directly reducing the risk of aspiration when the tube is accessed.
2
Perform hand hygiene and put on clean gloves.
The nurse's hands are sanitized and protected.
Standard infection control practices must be established before touching the client's lines or equipment.
3
Attach a large-volume syringe to the port of the feeding tube.
The syringe is secured to the enteral access point.
A closed system must be created with the syringe to safely draw out the fluid without leakage.
4
Pull back on the syringe plunger gently to withdraw and measure the fluid.
Gastric contents are pulled into the syringe barrel and quantified.
Measuring the volume identifies whether the client is digesting the feeding properly or is at risk for regurgitation due to delayed emptying.
5
Reinstill the aspirated gastric contents back into the client's stomach.
The fluid is safely returned to the gastrointestinal tract.
Gastric aspirate contains essential electrolytes and digestive enzymes; discarding it can rapidly lead to metabolic alkalosis and fluid deficits.

Key Concept

Enteral Tube Feeding Safety and Complication Prevention
Estimated Time:1m 0s
Question 573Question →

Before entering the isolation room of a client diagnosed with measles (rubeola) who also has a heavily draining leg wound, a nurse must apply full personal protective equipment (PPE) due to the combination of precautions required. Place the following steps for preparing and donning the required PPE in the correct sequential order.

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Answer

The correct sequence for donning full personal protective equipment is to first perform hand hygiene, then don the isolation gown, followed by the N95 respirator, then the face shield or goggles, and finally the clean gloves.
According to standard infection control guidelines provided by the Centers for Disease Control and Prevention (CDC), the sequence for donning full personal protective equipment is strict to minimize contamination risk. The nurse must begin with hand hygiene to ensure clean hands. The gown is put on first to cover the torso and arms. Next, the mask or N95 respirator is applied to protect the respiratory tract and establish a face seal, followed by goggles or a face shield for eye protection. Finally, gloves are donned last and pulled directly over the gown cuffs to establish a continuous, unbroken barrier against infectious agents.

Step-by-Step Solution

1
Perform hand hygiene using an alcohol-based hand sanitizer or soap and water.
Hands are clean and ready to handle uncontaminated PPE.
Hand hygiene is the foundational step to prevent the transfer of pathogens to the clean equipment being donned.
2
Fasten the isolation gown securely at the neck and waist.
The torso, arms, and uniform are covered and protected.
The gown is the first article of PPE donned to provide the largest surface area of protection before applying facial gear.
3
Apply an N95 respirator and perform a user seal check.
The respiratory tract is protected with a secure seal against airborne pathogens.
The respirator is applied prior to eye protection to ensure a tight, unimpeded seal against the face.
4
Position the face shield or goggles over the eyes.
The mucous membranes of the eyes are protected from exudate or respiratory secretions.
Eye protection is placed over the respirator straps to guard against potential splashes or sprays of infectious material.
5
Don clean gloves, extending them over the cuffs of the gown.
A continuous protective barrier is created over the hands and wrists.
Gloves must be donned last so they can cover and overlap the gown cuffs, preventing any exposure of the wrists during client care.

Key Concept

Standard donning sequence for personal protective equipment (PPE)
Question 574Question →

A licensed practical nurse (LPN) is preparing to collect an aerobic wound culture from a client's purulent abdominal surgical incision. In what order should the LPN perform the following steps to ensure an accurate specimen? Arrange the actions in the correct chronological sequence.

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Answer

The correct sequence is to remove the soiled dressing, cleanse the wound with sterile normal saline, rotate the swab over clean granulation tissue, place the swab into the culture tube, and apply a new sterile dressing.
To collect an accurate wound culture that directs appropriate antibiotic therapy, the nurse must first remove the old dressing. Crucially, the wound must then be cleansed with sterile normal saline. Culturing uncleansed purulent drainage often yields resident skin flora or dead organisms, leading to inaccurate results. After cleansing, a sterile swab is rotated over clean, viable granulation tissue. The swab is then immediately placed into the sterile transport tube to prevent contamination, and finally, a new sterile dressing is applied to protect the wound.

Step-by-Step Solution

1
Remove the soiled dressing and assess the appearance of the wound bed.
The wound is exposed and ready for evaluation.
The old dressing must be removed to access the site and determine where the culture should be taken.
2
Cleanse the wound bed with sterile normal saline.
Surface exudate, pus, and resident skin flora are washed away.
Culturing uncleansed surface pus yields inaccurate results; the goal is to identify the pathogen actively invading the tissue, not surface colonizers.
3
Rotate a sterile culture swab over an area of clean granulation tissue.
The pathogen causing the deep infection is collected.
Actively growing pathogens are concentrated in viable granulation tissue, providing the most accurate diagnostic specimen.
4
Place the swab securely into the sterile culture tube.
The specimen is secured in its transport medium.
Immediate placement prevents environmental contamination of the swab and protects the nurse from exposure.
5
Apply a new sterile dressing over the abdominal incision.
The wound is protected from the external environment.
Restoring the protective barrier is the final step after the procedure is complete.

Key Concept

Accurate wound culture collection requires cleansing the wound with sterile saline prior to swabbing to avoid capturing surface colonizers or old exudate.
Question 575Question →

A practical nurse (PN) is providing care for an older adult resident in a skilled nursing facility. The resident, who currently has a "Do Not Resuscitate" (DNR) order in their medical record, states, "I have changed my mind. If my heart stops, I want you to do everything possible to save me." In what order should the PN perform the following actions? Arrange the actions from first to last.

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Answer

The correct sequence is to first ask the resident to elaborate on their decision, then report the request to the charge nurse and provider, document the conversation in the medical record, confirm the provider has canceled the order, and finally change the resident's code status identifiers.
When a client requests a change to their advance directive, the practical nurse must first assess the client's understanding and intent. Because the practical nurse cannot independently alter medical orders, the request must be escalated to the registered nurse and provider. Documentation follows immediately to create a legal record of the client's verbal revocation. The practical nurse must then wait for the provider to officially cancel the order in the chart before physically changing the client's care plan and identification tools to reflect a 'Full Code'.

Step-by-Step Solution

1
Collect data by exploring the resident's request.
The practical nurse understands the resident's intent and ensures the request is voluntary.
Data collection is the necessary first step of the nursing process before taking any further action.
2
Notify the charge nurse and healthcare provider.
The individuals with the authority to legally alter the medical order are informed.
A practical nurse cannot independently cancel a legal advance directive such as a DNR order.
3
Document the interaction and notifications.
A formal legal record of the resident's wishes and the nurse's actions is established.
Timely documentation is required to protect client rights and maintain accurate medical records.
4
Verify the new medical prescription.
The practical nurse confirms the DNR order has been legally discontinued by the provider.
Nursing interventions regarding code status must be based on a valid, updated provider prescription.
5
Update the care plan and client identifiers.
The interdisciplinary team is made aware of the resident's new 'Full Code' status.
Updating physical identifiers and the care plan ensures that all staff will perform life-saving measures if a cardiac event occurs.

Key Concept

A competent client has the right to revoke an advance directive, such as a DNR order, at any time. The practical nurse's role is to gather information, escalate the request to the provider for a legal order change, document the event, and update care identifiers only after the new order is verified.
Question 576Question →

A practical nurse is preparing to transfer a client who has right-sided hemiparesis from the bed to a wheelchair using a stand-and-pivot technique. In what order should the nurse perform the following actions to maintain proper ergonomics and client safety? Arrange the steps in the correct chronological sequence.

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Answer

The correct sequence begins with equipment setup on the strong side, followed by preparing the client, applying the safety device, using proper nurse body mechanics, and finally executing the pivot transfer.
Safe transfer protocols require a structured approach to minimize injury risk for both the client and the nurse. First, the environment must be prepared by placing the wheelchair on the client's strong (left) side and locking the wheels. Next, the client is brought to a sitting position and provided with non-skid footwear to prevent slipping. A gait belt is then applied to give the nurse a secure handling point. The nurse then adopts a wide base of support and braces the client's weak (right) leg to prevent buckling. Finally, the client pivots on their strong leg to safely lower themselves into the wheelchair.

Step-by-Step Solution

1
Position the wheelchair on the client's left side at a 45-degree angle and lock the wheels.
The equipment is safely secured on the client's strong side.
Preparing the destination environment is always the first priority to ensure safety before mobilizing the client.
2
Assist the client to sit on the edge of the bed and apply non-skid footwear.
The client is sitting securely with appropriate traction.
Dangling allows for cardiovascular adjustment, and non-skid footwear prevents slipping during the pivot.
3
Apply a transfer gait belt securely around the client's waist over their clothing.
The nurse has a safe handling mechanism to control the client's center of gravity.
Using a gait belt prevents joint injuries and skin shearing that can occur if lifting by the arms.
4
Face the client, maintain a wide base of support, and brace the client's right knee.
The nurse's body is ergonomically positioned, and the client's weak leg is stabilized.
A wide base lowers the nurse's center of gravity, and bracing the hemiparetic limb prevents it from buckling when bearing weight.
5
Instruct the client to push up from the bed, pivot on the left leg, and reach for the wheelchair armrest.
The client safely transitions from the bed to the wheelchair.
Utilizing the client's unaffected side maximizes their independence and reduces physical strain on the nurse.

Key Concept

Safe Patient Transfer and Ergonomics
Question 577Question →

A client who recently received intravenous antineoplastic medications accidentally drops a urinal, spilling contaminated urine on the floor. Arrange the following actions in the priority order the practical nurse should perform them to safely manage the biohazardous spill.

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Answer

The correct sequence prioritizes nurse safety, spill containment, decontamination, safe disposal, and final hand hygiene.
Safe management of a cytotoxic spill requires a strict chronological approach. First, the nurse must protect themselves by donning appropriate PPE (gown and double gloves). Second, the spill must be immediately contained using absorbent pads to prevent spreading. Third, the area is cleaned with an approved detergent to eliminate residue. Fourth, all contaminated materials are isolated in a designated chemotherapy waste receptacle. Finally, PPE is removed and hand hygiene is performed to ensure no trace hazardous materials remain on the nurse.

Step-by-Step Solution

1
Don appropriate personal protective equipment (gown and double gloves).
The nurse is protected from direct contact with cytotoxic fluids.
Antineoplastic agents are hazardous and require protective barriers before any intervention.
2
Cover the spill with absorbent pads.
The fluid is contained and prevented from spreading.
Immediate containment minimizes the surface area of contamination and prevents aerosolization.
3
Clean the surface with an approved detergent.
Chemical residues are neutralized and removed from the floor.
Thorough decontamination is required to ensure the environment is safe for clients and staff.
4
Dispose of materials in a chemotherapy waste receptacle.
Hazardous waste is isolated in a leak-proof, highly visible container.
Proper disposal prevents secondary exposure to environmental services and other healthcare workers.
5
Remove PPE and wash hands with soap and water.
The nurse is free of any trace contaminants.
Hand hygiene mechanically removes any microscopic chemical traces that might have penetrated the gloves.

Key Concept

Management of Hazardous Medication Spills (Antineoplastic Precautions)
Question 578Question →

After completing morning care for a client placed in a negative-pressure isolation room due to a primary varicella-zoster infection, a practical nurse (PN) prepares to leave the room. The PN is currently wearing disposable gloves, a protective gown, and an N95 respirator. Place the following steps for removing personal protective equipment (PPE) and exiting the area in the correct chronological order.

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Answer

The correct sequence for doffing PPE in airborne precautions is: remove gloves, remove gown, exit the isolation room, remove the N95 respirator, and perform hand hygiene.
The Centers for Disease Control and Prevention (CDC) strictly mandates that PPE be removed in a specific sequence to prevent self-contamination. The most contaminated items (gloves) are removed first, followed by the gown. Because the client has an airborne illness (primary varicella-zoster), the N95 respirator must remain on until the nurse has exited the negative-pressure room and closed the door. Finally, hand hygiene is always the last step to ensure any accidentally transferred pathogens are eliminated.

Step-by-Step Solution

1
Identify the type of isolation precautions required for the client's condition.
Primary varicella-zoster (chickenpox) requires Airborne and Contact Precautions.
Understanding the required precautions dictates the specific PPE worn and the strict sequence for safe removal.
2
Determine the order of removal for PPE inside the isolation room.
Gloves are removed first, followed by the gown.
The most contaminated items are removed first. Gloves harbor the highest concentration of pathogens. The gown is removed next, rolling it inside out.
3
Identify the location for respirator removal.
The nurse must exit the negative-pressure room and close the door before removing the N95 respirator.
Removing the respirator inside the room would expose the nurse's respiratory tract to airborne droplet nuclei (varicella virus).
4
Determine the safe method for removing the respirator.
The bottom strap is removed first, followed by the top strap.
This technique prevents the contaminated front of the respirator from flipping forward and touching the nurse's face.
5
Determine the final step of the doffing sequence.
Hand hygiene is performed immediately after removing the respirator.
Hand hygiene removes any transient flora or pathogens that may have contacted the hands during the PPE removal process.

Key Concept

Standard sequence for PPE removal (doffing) in Airborne and Contact Precautions
Question 579Question →

A practical nurse (PN) is administering an intramuscular (IM) injection of iron dextran, a medication known to cause severe skin irritation and staining, to an adult client. The PN will utilize the Z-track method. Arrange the following steps of this procedure in the correct chronological order.

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Answer

The correct chronological order is: Prepare the site and don gloves; pull the skin laterally; insert the needle and inject slowly; wait 10 seconds; withdraw the needle and release the skin; and finally, apply light pressure without massaging.
The Z-track method requires strict adherence to a specific chronological sequence to prevent medication leakage. The site must first be prepared. Then, tissue displacement occurs to misalign the layers. The injection is given, followed by a mandatory 10-second wait to allow dispersion. Crucially, the needle withdrawal and tissue release must happen simultaneously to break the track. Finally, gentle pressure is applied, but the site must never be massaged to avoid pushing the medication out of the muscle.

Step-by-Step Solution

1
Select site and apply standard precautions.
The ventrogluteal site is prepared, minimizing the risk of infection.
Hand hygiene, gloving, and site identification are universal prerequisites for any parenteral administration.
2
Displace the skin and tissue laterally by 1 to 1.5 inches.
The skin and subcutaneous layers are shifted out of their normal alignment with the underlying muscle.
This is the foundational step of the Z-track method, preparing the offset track that will seal the medication.
3
Insert the needle at a 90-degree angle and inject slowly.
The medication is delivered deep into the ventrogluteal muscle.
A 90-degree angle ensures intramuscular delivery, and a slow injection rate minimizes pain and tissue trauma.
4
Wait 10 seconds before removing the needle.
The medication disperses into the muscle belly.
Allowing time for dispersion reduces the risk of the medication tracking back up the needle pathway upon withdrawal.
5
Withdraw the needle and simultaneously release the displaced skin.
The tissue layers slide back into their original anatomical positions.
This breaks the needle track alignment (creating the 'Z' shape), physically sealing the irritating medication inside the muscle layer and preventing seepage.
6
Apply gentle pressure without massaging.
The site is secured without disrupting the trapped medication.
Massage is strictly contraindicated because it can force the medication out of the muscle and into the subcutaneous tissue, causing the severe irritation or staining that the Z-track method is designed to prevent.

Key Concept

The Z-track intramuscular injection method is utilized to administer highly irritating or staining medications, sealing the drug deep within the muscle tissue to protect superficial layers.
Estimated Time:2m 0s
Question 580Question →

A practical nurse (PN) is caring for a client who is receiving continuous enteral tube feedings. The client suddenly begins to cough forcefully and expel vomitus. In which order should the PN perform the following actions? Arrange the actions from first to last.

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Answer

The correct sequence is to first stop the enteral feeding, turn the client onto their side, clear the airway using oral suctioning, measure oxygen saturation and respiratory rate, and finally notify the registered nurse.
In any acute clinical emergency, the practical nurse must prioritize actions based on the Airway, Breathing, and Circulation (ABC) framework. When a client receiving tube feedings begins to vomit, the airway is immediately threatened. The very first action must be to stop the cause (the feeding pump) to prevent more volume from entering the stomach. The second action is to use gravity to clear the airway by turning the client to the side. The third action is to use equipment (suction) to clear any remaining fluid. Once the airway is physically secured, the nurse assesses breathing (oxygen saturation, respiratory rate) to evaluate the impact of the event. Finally, the nurse communicates the findings and actions to the registered nurse.

Step-by-Step Solution

1
Stop the continuous enteral feeding pump.
Prevents additional formula from entering the gastrointestinal tract.
Eliminates the ongoing source of potential aspiration, which is the most critical first action.
2
Turn the client onto their side.
Allows emesis to drain from the mouth via gravity.
Protects the airway from immediate occlusion and further aspiration of the expelled vomitus.
3
Clear the client's airway using oral suctioning.
Removes residual fluids and secretions from the oropharynx.
Actively secures a patent airway after gross decontamination by gravity.
4
Measure the client's oxygen saturation and respiratory rate.
Provides objective data on the client's current respiratory function.
Assessment follows life-saving interventions to evaluate if the aspiration caused hypoxia or respiratory distress.
5
Notify the registered nurse of the client's status change.
Communicates the acute change in condition to the healthcare team.
Ensures the client receives advanced evaluation and potential medical orders after initial stabilization.

Key Concept

Prioritization of Airway, Breathing, and Circulation (ABC) during an acute aspiration event.
Estimated Time:1m 30s
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