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Question 581Question →

A practical nurse is assisting a client with the collection of a clean-catch midstream urine specimen for a culture and sensitivity test. Arrange the following steps in the correct chronological order to ensure an uncontaminated specimen is obtained.

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Answer

The correct sequence is: 1) Perform hand hygiene and don clean gloves; 2) Cleanse the perineal area from front to back; 3) Instruct the client to begin voiding into the toilet; 4) Place the sterile specimen container into the active urine stream.
The established sequence for a clean-catch urine collection minimizes the risk of specimen contamination. Hand hygiene and donning gloves form the foundational step of standard precautions. Cleansing the meatus front-to-back prevents the introduction of rectal flora to the urinary tract. Voiding the initial stream into the toilet effectively flushes the distal urethra of resident bacteria. Finally, catching the midstream urine ensures the sample genuinely reflects the microbiological status of the bladder.

Step-by-Step Solution

1
Identify the standard precautions required before the procedure.
Hand hygiene is performed and clean gloves are donned.
To protect the nurse from exposure to body fluids and prevent introducing environmental contaminants to the client's supplies.
2
Determine the correct anatomical cleansing technique.
The perineal area is cleansed with antiseptic wipes from front to back.
This specific motion removes flora from the urinary meatus while preventing the introduction of bacteria from the anal region.
3
Determine the correct timing for starting the collection.
The client is instructed to begin voiding into the toilet before the cup is introduced.
The initial stream of urine serves to mechanically flush out normal resident bacteria present in the distal urethra.
4
Determine the correct method to catch the sterile specimen.
The sterile cup is placed directly into the midstream flow.
The midstream portion most accurately reflects the status of the bladder and kidneys, ensuring the culture results are reliable.

Key Concept

The purpose of a clean-catch midstream urine collection is to obtain a sample that is free from external contamination. This is achieved by anatomically cleansing the meatus and flushing the urethra before capturing the midstream flow.
Question 582Question →

An older adult client with acute confusion is restless and repeatedly attempts to get out of bed without assistance, creating a high risk for falls. In what order should the practical nurse (PN) implement the following safety interventions, from least restrictive to most restrictive?

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Answer

The correct sequence from least to most restrictive is to first address physiological triggers, then relocate the client for better visualization, next activate a bed-exit alarm, and finally apply physical restraints as a last resort.
When managing a client at high risk for falls due to confusion, the nurse must follow the principle of using the least restrictive intervention first. The sequence begins with assessing and treating underlying physiological causes. If agitation persists, environmental modifications like moving the client closer to the nursing station are implemented. Next, technological safety devices such as bed alarms are utilized. Finally, if all non-restrictive alternatives have failed and the client's safety is in immediate jeopardy, physical restraints may be applied with a healthcare provider's prescription.

Step-by-Step Solution

1
Identify and address underlying physiological triggers, such as a full bladder or untreated pain.
Basic physical causes of agitation are resolved.
Addressing foundational physiological needs is the least restrictive and most direct way to resolve confusion-related restlessness.
2
Relocate the client to a room directly across from the nursing station for frequent visual monitoring.
The environment is modified for increased safety.
Environmental surveillance is a non-invasive safety measure that does not physically restrict the client.
3
Activate a bed-exit alarm system to alert nursing staff immediately upon movement.
Staff are notified if the client attempts to exit the bed.
Electronic monitoring is more intrusive than visual checks but is less restrictive than physical restraint.
4
Apply prescribed soft limb restraints as a final measure to prevent injury.
The client is physically prevented from leaving the bed.
Physical restraints are the most restrictive measure and are legally and ethically reserved as an absolute last resort.

Key Concept

Hierarchy of Least Restrictive Interventions for Fall Prevention
Question 583Question →

A practical nurse (PN) is reinforcing teaching with a client about how to use a metered-dose inhaler (MDI) without a spacer. In which order should the PN instruct the client to perform the following steps? Arrange the actions in the correct sequence.

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Answer

The correct sequence is to shake the inhaler, exhale deeply, seal the lips around the mouthpiece, press the canister while inhaling slowly, and finally hold the breath for 10 seconds.
Correct administration of a metered-dose inhaler requires a precise sequence to ensure maximum drug delivery to the lungs. Shaking the inhaler prepares the dose. Exhaling deeply creates room for maximum inhalation. Sealing the lips around the mouthpiece prevents medication loss. Actuating the inhaler while taking a slow, deep breath ensures the drug reaches the lower airways. Finally, holding the breath allows the medication to settle onto the bronchial walls for optimal therapeutic effect.

Step-by-Step Solution

1
Shake the inhaler vigorously for 3 to 5 seconds.
The medication and propellant are thoroughly mixed.
Ensures the correct dose of medication is delivered when actuated.
2
Exhale deeply to empty the lungs completely.
The lungs are emptied of air.
Prepares the lungs to take in a deep breath and draw the medication as deeply as possible into the lower airways.
3
Place the mouthpiece into the mouth and form a tight seal with the lips.
A secure airway connection is established.
Prevents the medication from escaping from the corners of the mouth during administration.
4
Press down firmly on the canister while inhaling slowly and deeply.
The medication is released and drawn into the respiratory tract.
Simultaneous actuation and inhalation carry the aerosolized particles down into the bronchioles.
5
Hold the breath for at least 10 seconds before exhaling slowly.
The medication settles in the lower airways.
Allows time for the medication to deposit onto the walls of the airways rather than being immediately exhaled.

Key Concept

Metered-Dose Inhaler (MDI) Administration Sequence
Question 584Question →

A client with complete paraplegia needs to be transferred from the hospital bed to a bedside chair. The practical nurse and an assistive personnel (AP) are using a mechanical full-body sling lift for the procedure. Arrange the following steps in the correct chronological order to ensure a safe transfer.

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Answer

The correct sequence is to first position the sling under the client, move the lift into position and widen its base, attach the sling to the hanger bar, raise the client clear of the bed, and finally steer the lift to lower the client into the chair.
The correct sequence follows the standard principles of ergonomics and equipment safety: prepare the client, prepare and stabilize the equipment, secure the connection, perform the lift safely, and complete the transfer. Widening the base of the lift before attaching the client is critical for preventing falls and maintaining a low center of gravity.

Step-by-Step Solution

1
Position the sling
The sling is centered under the client's body.
This must be done first before bringing the lift over the bed to provide clearance and safety.
2
Widen the lift base
The lift is stabilized.
Widening the base of support lowers the center of gravity and prevents the lift from tipping over during the transfer.
3
Attach the sling loops
The client is safely connected to the lifting mechanism.
The connections must be checked for security before any lifting force is applied.
4
Elevate the client
The client clears the mattress.
Keeping the client close to the bed surface reduces injury risk if the sling were to fail.
5
Transfer to chair
The client is safely seated.
The final step is completing the transfer to the destination.

Key Concept

Mechanical Lift Safety and Ergonomics
Question 585Question →

A practical nurse is preparing to administer a large-volume tap water cleansing enema to an adult client experiencing constipation. In what order should the nurse perform the following actions? Arrange the steps in the correct chronological sequence from first to last.

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Answer

The correct sequence is to first position the client appropriately, lubricate the tube, insert the tube into the rectum, elevate the container to begin the flow, and finally, monitor the client and adjust the flow if cramping occurs.
Administering a large-volume enema requires a systematic approach to ensure safety, effectiveness, and comfort. The nurse must first place the client in the left lateral Sims' position to align with the anatomy of the descending colon. Once positioned, the nurse lubricates the tube to prevent mucosal trauma. The tube is then gently inserted 3 to 4 inches, following the direction of the umbilicus. After safe placement, the nurse elevates the container 12 to 18 inches above the anus and unclamps it to initiate the flow. Throughout the procedure, the nurse monitors the client's tolerance, lowering the container or clamping the tube if cramping occurs to allow the colon to relax.

Step-by-Step Solution

1
Position the client in the left lateral Sims' position.
The client is anatomically aligned for the procedure.
The left lateral position allows the enema solution to flow downward by gravity into the sigmoid colon.
2
Lubricate the distal end of the rectal tube.
The tube is prepared for safe insertion.
Water-soluble lubricant prevents tissue damage and eases the tube's passage through the anal sphincters.
3
Insert the tube 3 to 4 inches toward the umbilicus.
The tube is securely positioned in the rectum.
This depth and angle follow the natural course of the bowel and prevent perforation.
4
Elevate the container and unclamp the tubing.
The solution begins to instill into the colon.
A height of 12 to 18 inches ensures adequate pressure without causing rapid distention of the bowel.
5
Lower the container if the client experiences cramping.
The instillation rate is reduced or paused.
Stopping the flow temporarily relieves colon spasms and promotes fluid retention.

Key Concept

Safe procedural sequencing for enema administration
Question 586Question →

A practical nurse is assessing a client who is 3 days postoperative following an abdominal laparotomy. The client experiences a vigorous coughing fit and suddenly reports a sensation of something "giving way" in their abdomen. Upon inspection, the nurse observes that the surgical incision has separated and a loop of intestine is protruding. In which order should the nurse perform the following actions? Arrange the steps from first priority to last.

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Answer

The correct sequence prioritizes securing immediate help, reducing physical strain on the wound, protecting the exposed tissue, assessing hemodynamic stability, and preparing for definitive surgical repair.
Wound evisceration is a medical emergency requiring rapid, sequential actions to protect the exposed bowel and stabilize the client. The immediate priority is to get help without leaving the client. Next, mechanical tension on the abdomen must be reduced by flexing the client's knees and elevating the head slightly. After reducing tension, the exposed organs are covered with sterile, moist dressings to prevent necrosis. Once the tissue is protected, assessing vital signs for shock becomes the priority before ultimately preparing the client for emergency surgical repair.

Step-by-Step Solution

1
Secure help and escalate.
Additional personnel are mobilized to notify the provider and gather supplies.
The primary nurse must not leave the bedside of a client experiencing an acute evisceration.
2
Modify the client's position to low-Fowler's with flexed knees.
Intra-abdominal pressure is significantly reduced.
This prevents further loops of bowel from protruding through the separated incision.
3
Cover the viscera with sterile, saline-moistened dressings.
The exposed bowel is kept moist and protected from environmental contaminants.
Preserves tissue viability and prevents necrosis prior to surgical intervention.
4
Assess a full set of vital signs.
Baseline data during the emergency is established.
Allows for the early identification of hypovolemic shock resulting from fluid shifts and stress.
5
Initiate preoperative preparation protocols.
The client is ready for rapid transport.
Evisceration is a surgical emergency requiring immediate closure in the operating room.

Key Concept

Prioritization of care during wound evisceration
Question 587Question →

A practical nurse (PN) is assisting a client with ambulation in the hallway using a gait belt. The client suddenly reports feeling dizzy, their knees buckle, and they begin to fall. Arrange the following actions the PN should take in the correct chronological order to safely assist the client to the floor.

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Answer

The correct sequence is to establish a base of support, bring the client close, extend a leg for the client to slide down, lower them by bending the knees while protecting the head, and then call for help to assess for injuries.
When a client begins to fall during ambulation, the nurse's priority is to perform a controlled 'assisted fall' to minimize injury. The sequence must begin with the nurse establishing their own stability by taking a wide stance. Next, bringing the client close to the nurse's center of gravity provides control over the descending weight. Extending a leg creates a safe slide path, preventing a rapid drop. Bending at the knees ensures the nurse uses strong leg muscles rather than straining the back, while the nurse actively protects the client's head from impact. Finally, once safely on the floor, the client must remain stationary until a thorough assessment is completed to prevent exacerbating any potential injuries.

Step-by-Step Solution

1
Establish stability.
The nurse takes a wide stance with feet apart.
Creates a broad base of support to prevent the nurse from losing balance when taking on the client's weight.
2
Control the client's weight.
The client is pulled close to the nurse using the gait belt.
Aligns the client with the nurse's center of gravity, providing maximum control and reducing back strain.
3
Create a descent path.
The nurse extends one leg forward.
Provides a physical surface for the client to safely slide down rather than free-falling.
4
Lower the client to the floor.
The nurse bends at the knees and protects the client's head.
Uses strong leg muscles (proper body mechanics) and prevents traumatic head injury upon contact with the floor.
5
Manage post-fall care.
The client is instructed to stay still while the nurse calls for assistance.
Moving a client immediately after a fall can worsen undetected fractures or internal injuries.

Key Concept

Safe Management of an Active Client Fall (Assisted Fall Technique)
Question 588Question →

A practical nurse (PN) is providing care for a client who is receiving a continuous enteral feeding via a nasogastric (NG) tube. The client suddenly develops a severe coughing spell, becomes tachypneic, and appears highly restless.

In what order should the PN perform the following actions? Arrange the actions in sequence from first to last.

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Answer

First, stop the enteral feeding pump. Second, place the client in a high-Fowler's or side-lying position. Third, auscultate lung sounds and measure oxygen saturation. Fourth, report the condition to the registered nurse (RN). Finally, document the event.
When a client receiving an enteral feeding exhibits signs of respiratory distress such as a severe coughing spell and tachypnea, pulmonary aspiration is the primary concern. According to the Airway, Breathing, Circulation (ABC) priority framework, the absolute first step is to remove the immediate threat to the airway by pausing the feeding pump. Next, the airway must be mechanically protected by positioning the client upright or on their side. After the airway is physically safeguarded, the PN collects targeted data (lung sounds, oxygen saturation) to assess the severity of the breathing compromise. This critical data is then rapidly communicated to the RN or provider for advanced medical interventions. Documentation is strictly performed last, once the client is safe and the broader care team is engaged.

Step-by-Step Solution

1
Stop the continuous enteral feeding pump.
The flow of enteral formula is halted immediately.
Continuing the feeding while the client is coughing and tachypneic heavily increases the risk of massive pulmonary aspiration.
2
Place the client in a high-Fowler's or side-lying position.
The client's airway is physically protected.
An upright or side-lying position utilizes gravity to keep residual gastric contents from traveling up the esophagus and allows for maximum lung expansion.
3
Auscultate lung sounds and measure the client's oxygen saturation.
Quantitative and qualitative respiratory data are obtained.
The PN must collect targeted data to evaluate the degree of physiological adaptation and respiratory compromise before calling for help.
4
Report the sudden change in condition to the registered nurse (RN).
The healthcare team is alerted to the adverse event.
The PN operates under the direction of an RN or provider and must communicate critical changes so advanced interventions can be prescribed.
5
Document the clinical event, vital signs, and nursing interventions.
A legal and clinical record of the emergency is created.
Documentation must reflect the exact sequence of events, but it is strictly performed after the client is safe and handoff is complete.

Key Concept

Prioritization of emergency interventions during suspected aspiration (Airway-Breathing-Circulation approach).
Question 589Question →

A practical nurse is preparing to change a one-piece ostomy pouching system for a client with an established descending colostomy. In what order should the nurse perform the following actions? Arrange the steps in the correct sequence from first to last.

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Answer

The correct sequence for changing an ostomy pouch is: 1) Remove the used pouch and skin barrier, 2) Cleanse the stoma and peristomal skin with warm water and pat dry, 3) Measure the stoma, 4) Cut the opening on the new skin barrier 1/8 inch larger than the stoma, and 5) Apply the new skin barrier and pouch.
The correct sequence ensures patient comfort, skin protection, and appliance adherence. First, the old pouch must be gently removed to avoid skin trauma. Next, the area is cleansed with warm water (avoiding soaps that leave residue) and dried completely to prepare the skin. Once clean, the stoma is measured accurately, as sizes can fluctuate. The new wafer is then cut 1/8 inch larger than the measurement to prevent stomal constriction while protecting the peristomal skin. Finally, the new appliance is applied and sealed with gentle pressure.

Step-by-Step Solution

1
Remove the used pouch and skin barrier.
The old appliance is safely detached from the skin.
This allows access to the stoma and peristomal skin for assessment and cleaning. Gentle removal prevents skin tears.
2
Cleanse the stoma and peristomal skin with warm tap water and pat dry.
The skin is free of effluent and moisture.
Thorough cleaning prevents infection and skin breakdown. Avoiding soap prevents leaving a residue that impairs adhesion. Drying is critical for the new wafer to stick.
3
Measure the stoma using a measuring guide.
The exact current size of the stoma is determined.
Stomas can swell or shrink. An accurate measurement ensures the new barrier will fit correctly without exposing skin or strangulating the stoma.
4
Cut the opening on the new skin barrier 1/8 inch larger than the stoma.
A custom-sized opening is created in the barrier.
Leaving a 1/8-inch margin prevents the rigid edge of the wafer from rubbing against and cutting the stoma, while still protecting the peristomal skin from fecal contact.
5
Center the new barrier over the stoma and apply pressure.
The new pouching system is securely attached.
Proper alignment and pressure activate the adhesive and create a seal, preventing leaks.

Key Concept

Proper ostomy care requires a sequential approach focused on protecting peristomal skin integrity and ensuring a secure appliance seal.
Question 590Question →

A practical nurse (PN) is preparing to administer 8 units of regular insulin and 14 units of NPH insulin subcutaneously to a client with diabetes mellitus. In which order should the PN perform the following steps to prepare the medication? Arrange the actions in the correct sequence from first to last.

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Answer

The correct sequence for mixing insulins is: roll the NPH vial, inject air into the NPH vial, inject air into the regular insulin vial, withdraw the regular insulin, and finally withdraw the NPH insulin.
To safely mix regular and NPH insulin, the nurse must follow the 'clear before cloudy' sequence to prevent contaminating the rapid-acting regular insulin with the longer-acting NPH insulin. The sequence involves preparing the suspension, pressurizing both vials (starting with NPH), and then withdrawing the insulins (starting with regular).

Step-by-Step Solution

1
Roll the NPH insulin vial gently between the palms.
The suspension is evenly mixed without creating air bubbles.
NPH insulin settles when standing and must be resuspended to ensure an accurate dose.
2
Inject air equal to the prescribed dose into the NPH insulin vial.
The NPH vial is pressurized.
Injecting air prevents a vacuum. This is done first so the needle does not carry regular insulin into the NPH vial.
3
Inject air equal to the prescribed dose into the regular insulin vial.
The regular insulin vial is pressurized.
This prepares the vial for immediate withdrawal of the medication without creating a vacuum.
4
Withdraw the prescribed dose of regular insulin from its vial.
The regular insulin is drawn into the syringe.
Regular insulin (clear) is drawn first to prevent it from being contaminated by the NPH insulin (cloudy).
5
Withdraw the prescribed dose of NPH insulin from its vial.
Both insulins are accurately mixed in the syringe.
NPH is drawn last because any excess cannot be injected back into the vial without contaminating it with regular insulin.

Key Concept

Safe medication preparation: mixing clear (regular) and cloudy (NPH) insulins in a single syringe.
Question 591Question →

A practical nurse (PN) is preparing to perform tracheostomy suctioning for a pediatric client diagnosed with Respiratory Syncytial Virus (RSV). The facility's infection control protocol requires full personal protective equipment (PPE) due to contact and droplet precautions, as well as the high risk of splashing respiratory secretions. Arrange the steps for donning the necessary PPE in the correct sequence according to the Centers for Disease Control and Prevention (CDC).

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Answer

The correct sequence for donning PPE is: perform hand hygiene, put on the isolation gown, apply the surgical mask, place the goggles or face shield, and finally don the examination gloves.
According to the Centers for Disease Control and Prevention (CDC), the standard sequence for donning personal protective equipment (PPE) maintains the cleanliness of the equipment and ensures a continuous protective barrier. Hand hygiene must always be performed first. The gown is donned next as it covers the largest area. The mask is applied to protect the airway, followed by eye protection which often rests slightly over the top of the mask. Finally, gloves are donned last and must be pulled completely over the gown cuffs to ensure no skin is exposed at the wrists.

Step-by-Step Solution

1
Perform hand hygiene using an alcohol-based hand rub or antimicrobial soap.
Hands are clean and ready to handle clean PPE without transferring pathogens.
Hand hygiene removes surface microorganisms before touching clean equipment.
2
Put on the isolation gown and fasten the ties securely at the neck and back.
The torso and arms are protected with a barrier.
The gown is the largest piece of equipment and must be placed first so gloves can later overlap its cuffs.
3
Apply a surgical mask and fit the flexible band securely to the bridge of the nose.
The nose and mouth are protected from infectious droplets.
The mask must be secured directly to the face for a proper fit before eye protection is added.
4
Place goggles or a face shield comfortably over the eyes and face.
The mucous membranes of the eyes are protected from potential splashes.
Eye protection rests over the edges of the mask, so it must be applied after the mask.
5
Don clean examination gloves, ensuring they extend over the cuffs of the gown.
The hands are protected and a continuous barrier is formed at the wrists.
Gloves are donned last to keep them clean for client contact and must cover the gown cuffs to prevent skin exposure.

Key Concept

The Centers for Disease Control and Prevention (CDC) sequence for donning personal protective equipment is designed to ensure maximum protection and prevent contamination of the equipment before providing care.
Question 592Question →

A practical nurse (PN) discovers a client with type 1 diabetes mellitus unresponsive in bed. The client is profusely diaphoretic, and a stat capillary blood glucose reading is 34 mg/dL34 \text{ mg/dL} (1.9 mmol/L1.9 \text{ mmol/L}). The client does not have established intravenous (IV) access. Arrange the following emergency interventions in the safest priority sequence from first to last.

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Answer

The correct sequence is to first administer IM glucagon, immediately position the client on their side to protect the airway, recheck the glucose in 15 minutes, assess the gag reflex upon awakening, and finally provide an oral snack once safe swallowing is confirmed.
In severe hypoglycemia where the client is unresponsive and lacks IV access, the immediate priority is raising the blood glucose using IM glucagon. Because glucagon frequently causes nausea and vomiting, the client must be immediately turned to a lateral side-lying position to prevent aspiration while they remain unconscious. Once the airway is physically protected, the PN follows the 'rule of 15' by rechecking the capillary blood glucose 15 minutes post-intervention. As the client regains consciousness, the PN must assess their gag reflex and swallowing ability to ensure oral intake is physically safe. Finally, providing a complex carbohydrate and protein snack is necessary to replenish hepatic glycogen stores and prevent a subsequent drop in blood glucose, as glucagon's metabolic effects are short-lived.

Step-by-Step Solution

1
Treat the immediate life-threatening physiological deficit.
Administer the prescribed IM glucagon.
The client is unresponsive without IV access, making oral glucose contraindicated and IV dextrose impossible. IM glucagon is the fastest available and safest treatment method.
2
Anticipate adverse effects and protect the airway.
Place the client in a lateral side-lying position.
A frequent and dangerous adverse effect of glucagon is emesis. The recovery position prevents aspiration if vomiting occurs while the client is still unresponsive.
3
Evaluate the clinical response to the intervention.
Recheck the capillary blood glucose level in 1515 minutes.
Standard hypoglycemia protocols require reassessment 15 minutes after treatment to ensure the blood glucose is trending upward toward a safe range.
4
Assess readiness for safe oral intake.
Verify the gag reflex and swallowing ability.
Before providing sustained nutritional support by mouth, the nurse must ensure the client is alert enough to eat and will not aspirate the intake.
5
Prevent rebound physiological instability.
Provide a complex carbohydrate and protein snack.
Glucagon has a short duration of action. A mixed macronutrient snack provides sustained glucose release to prevent a secondary hypoglycemic event.

Key Concept

Management of severe hypoglycemia with IM glucagon requires immediate airway protection due to the high risk of treatment-induced emesis, followed by strict protocol reassessment.
Question 593Question →

A practical nurse (PN) has finished providing care for a client on Airborne and Contact precautions for disseminated herpes zoster. Arrange the following actions for removing personal protective equipment (PPE) in the correct chronological sequence to prevent self-contamination.

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Answer

The correct sequence is to first remove the gown and gloves together, then remove the face shield, exit the isolation room, remove the N95 respirator in the hallway, and finally perform hand hygiene.
Proper removal (doffing) of PPE is critical to prevent self-contamination and the spread of pathogens. According to standard guidelines for combined Airborne and Contact precautions, the nurse must first remove the most highly contaminated items (the gown and gloves) inside the client's room by peeling them off and rolling them inside-out. Next, the face shield is removed by touching only the clean back straps. Crucially, because the client requires Airborne precautions, the nurse must keep the N95 respirator on until they have completely exited the negative-pressure room and closed the door. Once in the hallway or anteroom, the N95 respirator is removed by the elastic straps to avoid touching the contaminated front. Finally, hand hygiene is performed as the absolute last step to eradicate any residual pathogens picked up during the doffing process.

Step-by-Step Solution

1
Remove the gown and gloves.
The most contaminated outer layers of PPE are safely discarded inside the room.
Gloves and gowns carry the highest bioburden; rolling them inside-out together contains the pathogens and protects the nurse's uniform.
2
Remove the face shield.
Eye protection is removed without touching the contaminated front.
Handling only the back straps prevents direct transmission of pathogens to the nurse's bare hands.
3
Exit the isolation room.
The nurse leaves the airborne-contaminated environment while still wearing respiratory protection.
The N95 respirator must remain sealed to the face until outside the negative-pressure room to prevent inhalation of suspended infectious particles.
4
Remove the N95 respirator.
The respirator is discarded in a safe area outside the room.
Removing the mask by its straps in the hallway prevents exposure to the airborne pathogen.
5
Perform hand hygiene.
Any residual pathogens on the hands are destroyed.
This is the universal final step to ensure safety and prevent cross-contamination to other clients, staff, or the environment.

Key Concept

The correct doffing sequence for Airborne and Contact precautions requires removing the most contaminated items (gown, gloves, face shield) inside the room, while retaining the N95 respirator until safely outside the negative-pressure environment.
Question 594Question →

A practical nurse (PN) is caring for a client who suddenly develops acute respiratory distress. The PN prepares to contact the covering healthcare provider using the ISBAR (Identify, Situation, Background, Assessment, Recommendation) communication framework. Place the following statements in the correct order the PN should deliver them.

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Answer

The correct sequence follows the ISBAR framework: Identify, Situation, Background, Assessment, and Recommendation.
Effective interprofessional collaboration requires standardized communication to ensure client safety and prevent errors. The ISBAR framework organizes critical information logically. The nurse first identifies themselves and the client. Next, the acute situation (chest pain and dyspnea) is reported to immediately establish urgency. This is followed by the relevant background (DVT and heparin) to provide context. Then, the nurse shares their assessment data (vital signs and clinical impression). Finally, the nurse makes a specific recommendation or request (immediate evaluation) to ensure the client receives timely medical intervention.

Step-by-Step Solution

1
Identify the communication framework required by the scenario.
The scenario requires the ISBAR format.
ISBAR is the standard evidence-based tool for safe and effective interprofessional collaboration.
2
Select the 'Identify' statement.
The statement introducing the nurse and the client's location.
The receiver must first know who is calling and which client is being discussed to access the correct medical record.
3
Select the 'Situation' statement.
The statement describing the acute chest pain and shortness of breath.
The immediate reason for the call must be stated promptly to capture the receiver's attention and establish urgency.
4
Select the 'Background' statement.
The statement detailing the admission for deep vein thrombosis and current heparin therapy.
Contextual history provides essential information for interpreting the acute situation without providing unnecessary details.
5
Select the 'Assessment' statement.
The statement providing the oxygen saturation data and the suspicion of a pulmonary embolism.
Objective data and the nurse's clinical judgment help quantify the severity of the problem for the provider.
6
Select the 'Recommendation' statement.
The statement requesting an immediate evaluation and potential orders.
The communication must conclude with a clear request for action to ensure immediate client safety and care.

Key Concept

ISBAR Communication Framework
Question 595Question →

A practical nurse (PN) is assigned to collect a sterile urine specimen for culture and sensitivity from a client who has a continuous indwelling urinary catheter. Arrange the following nursing actions in the correct chronological order to safely collect the specimen and minimize the risk of complications.

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Answer

The correct sequence is to first clamp the tubing to collect fresh urine, then disinfect the port, aspirate the sample with a syringe, transfer it to a sterile container, and finally unclamp the tubing to prevent bladder distension.
Safe and effective collection of a sterile urine specimen requires a logical sequence that prioritizes both infection control and client safety. The tubing is clamped first to gather fresh urine. The port is then sanitized to maintain a sterile barrier. The sample is aspirated and secured in a sterile container. Finally, unclamping the tube immediately after the procedure is a critical risk-reduction step to prevent urinary retention and potential renal injury.

Step-by-Step Solution

1
Clamp the drainage tubing below the port.
Fresh urine accumulates near the sampling port.
Urine in the drainage bag is stagnant and not suitable for an accurate culture. Clamping ensures fresh urine from the bladder is collected.
2
Disinfect the sampling port with an antiseptic wipe.
The surface of the port is free of microorganisms.
Maintaining the sterile integrity of the closed urinary system is essential to prevent a catheter-associated urinary tract infection (CAUTI).
3
Aspirate urine using a sterile syringe.
The necessary volume of uncontaminated urine is collected.
Using a sterile syringe prevents the introduction of bacteria while safely extracting the sample.
4
Transfer the specimen to a sterile cup.
The sample is safely housed for transport to the laboratory.
The inside of the cup and lid must remain sterile to ensure laboratory results reflect the client's actual flora rather than environmental contaminants.
5
Unclamp the catheter tubing.
Continuous urinary drainage is restored.
Leaving the catheter clamped is a major safety risk that can lead to acute urinary retention, bladder trauma, or kidney damage.

Key Concept

Sterile Specimen Collection and CAUTI Prevention
Estimated Time:1m 30s
Question 596Question →

An LPN/VN is preparing to transfer a client who recently underwent an exploratory laparotomy from the bed to a resting chair. To promote comfort and safety, in what order should the nurse execute these steps?

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Answer

The correct sequence prioritizes positional adjustment, incisional support, hemodynamic stability, mechanical safety, and finally the physical transfer.
When transferring a postoperative abdominal surgery client, the nurse must first elevate the bed to reduce the effort of moving. Next, splinting the incision is required to protect the wound during the exertion of sitting up. Once supported, the client sits on the edge of the bed to allow their blood pressure to stabilize (preventing orthostatic hypotension). After stability is confirmed, the nurse applies the gait belt for a secure grip before finally assisting the client to stand and pivot into the chair.

Step-by-Step Solution

1
Elevate the head of the bed.
The client is moved into an upright position.
Decreases the physical work of moving against gravity from a flat position.
2
Have the client splint the incision.
The abdominal wound is supported.
Prevents wound dehiscence and manages pain before the core is stressed.
3
Assist to sit and dangle legs.
The client sits safely on the edge of the bed.
Prevents orthostatic hypotension after periods of bed rest.
4
Apply the transfer gait belt.
Safety equipment is in place.
Provides a secure hold for the nurse once the client is upright and stable.
5
Stand, pivot, and sit in the chair.
The transfer is completed safely.
Moves the client to the destination while minimizing fall risk.

Key Concept

Safe postoperative mobility transfers and incisional care
Question 597Question →

A practical nurse (PN) is assisting in the preoperative staging area. A client scheduled for an elective cholecystectomy has already signed the surgical consent form. While the PN is taking vital signs, the client states, 'I cannot do this. I have decided to cancel the surgery.' Arrange the following actions in the chronological order the PN should perform them.

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Answer

The correct sequence is to first assess and clarify the client's intent, then halt the preoperative preparation, subsequently notify the surgeon and RN, and finally document the event in the medical record.
When a client revokes consent, the practical nurse must follow the nursing process. Assessment comes first to clarify the client's statement and ensure they mean to cancel. Next, implementation ensures immediate safety by stopping all preparations and holding sedatives. Then, communication ensures the provider is aware, as the surgeon must speak with the client. Finally, accurate documentation provides a permanent legal record of the client's decision.

Step-by-Step Solution

1
Clarify the client's intent using open-ended questions.
The nurse confirms whether the client is formally withdrawing consent or simply expressing anxiety.
Assessment is always the foundational first step in the nursing process before any intervention occurs.
2
Halt preparation and withhold preoperative sedatives.
The client's safety and autonomy are maintained.
Administering a preoperative sedative to a client who has stated they do not want the surgery violates their right to refuse treatment.
3
Notify the surgeon and the supervising RN.
The chain of command and the responsible healthcare provider are informed.
The surgeon owns the informed consent process and is legally responsible for discussing the risks of refusing the procedure with the client.
4
Document the event in the medical record.
A chronological, legal record is established.
Objective documentation protects the client's rights and the facility from liability by proving that the refusal was properly handled.

Key Concept

A competent client has the right to revoke informed consent at any time; the nurse must assess the refusal, ensure client safety, notify the provider, and document the event.
Question 598Question →

A client with a history of epilepsy is sitting in a chair at the bedside when they suddenly lose consciousness and begin experiencing generalized tonic-clonic muscle jerking. In what order should the practical nurse (PN) implement the following interventions? Arrange the actions in the correct sequential order.

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Answer

The correct sequence prioritizes immediate physical safety (moving to the floor), followed by airway management (turning to the side), breathing support (loosening clothing), continuous observation, and final reporting.
The correct order follows the foundational nursing principles of safety and the ABCs (Airway, Breathing, Circulation). When a client begins seizing in a chair, the most imminent threat is a traumatic fall; therefore, easing them to the floor and padding the head is the absolute first step. Once on the floor, the airway becomes the primary concern, requiring the nurse to turn the client to the side to prevent aspiration. Loosening tight clothing further supports breathing. After safety and ABCs are managed, the nurse observes the seizure's duration and characteristics. Finally, reporting and documentation occur after the acute phase has resolved.

Step-by-Step Solution

1
Ease the client to the floor and place a soft pad under their head.
The client is protected from sustaining blunt force trauma or fractures from falling out of the chair.
Immediate physical safety is the primary concern when a client loses consciousness in an upright position.
2
Turn the client onto their side.
The airway is protected from obstruction by the tongue, and oral secretions can drain freely.
Following the ABCs (Airway, Breathing, Circulation), securing a patent airway prevents aspiration and hypoxia.
3
Loosen any restrictive clothing around the client's neck and chest.
Chest expansion is optimized, and venous return from the head is unhindered.
Removing mechanical restrictions supports the 'Breathing' and 'Circulation' components of emergency care.
4
Note the exact time the seizure began and observe the characteristics of the movements.
Accurate clinical data regarding the seizure is collected for later medical evaluation.
Careful observation dictates future pharmacological interventions, but it must not delay life-saving safety measures.
5
Document the seizure event and report the findings to the registered nurse (RN).
The healthcare team is informed, and the legal medical record is updated.
Reporting and charting are vital administrative and collaborative steps performed after the client is stabilized.

Key Concept

During a seizure, nursing priorities are strictly ordered: immediate physical safety (preventing falls/trauma), airway maintenance (side-lying position), breathing support (loosening clothing), continuous assessment, and post-event documentation.
Question 599Question →

After assisting a healthcare provider with a bedside procedure for a client on droplet and contact precautions, a licensed practical nurse (LPN) is ready to exit the isolation room. The LPN is currently wearing gloves, an isolation gown, a face shield, and a surgical mask. In what order should the LPN remove the personal protective equipment (PPE) to prevent self-contamination? Arrange the actions in the correct chronological sequence from first to last.

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Answer

The correct sequence for removing personal protective equipment is: first remove the gloves, then the face shield, followed by the isolation gown, then the surgical mask, and finally perform hand hygiene.
According to standard Centers for Disease Control and Prevention (CDC) infection control guidelines, the most contaminated items should be removed first. Gloves are removed first, followed by the face shield or goggles handled by their clean back straps. The gown is then removed by pulling it away from the body and rolling it inside out. The mask is removed last, touching only the ties or ear loops, to maintain respiratory and mucous membrane protection until all other contaminated items are discarded. Hand hygiene must always be the final step after all PPE has been removed.

Step-by-Step Solution

1
Remove gloves
Hands are freed from the most heavily contaminated item.
Gloves touch the client and environment directly, carrying the highest pathogen load.
2
Remove face shield
Eye protection is safely removed without contaminating the face.
The outside of the shield is contaminated; handling it by the clean back strap protects the nurse.
3
Remove gown
The gown is safely bundled and discarded.
The gown front and sleeves are contaminated; pulling it inside out traps pathogens inside the bundle.
4
Remove surgical mask
Respiratory protection is safely removed.
The mask protects the mucous membranes during the removal of other items and is removed last.
5
Perform hand hygiene
Any residual pathogens on the hands are destroyed or washed away.
Hand hygiene is the crucial final step to ensure hands are safe before touching anything outside the isolation area.

Key Concept

Standard and Transmission-Based Precautions: PPE Doffing Sequence
Question 600Question →

A practical nurse is preparing to administer a large-volume cleansing enema to an adult client who is experiencing constipation. In what order should the nurse perform the following actions? (Arrange from first to last)

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Answer

The correct sequence is to first position the client, lubricate the tubing, insert it into the rectum, elevate the container to start the flow, and monitor the client by clamping the tube if cramping occurs.
Administering a cleansing enema requires a systematic approach to ensure safety and comfort. The client must first be positioned correctly in the left lateral Sims' position to allow gravity to assist the fluid flow into the sigmoid colon. Next, the nurse lubricates the tubing to prevent mucosal injury and gently inserts it safely into the rectum. Once the tube is securely in place, the container is elevated to the proper height to control the fluid's hydrostatic pressure. Finally, the nurse monitors the client continuously during instillation and clamps the tubing if cramping occurs to allow the colon to relax.

Step-by-Step Solution

1
Position the client in the left lateral Sims' position.
The client is properly aligned to facilitate fluid flow.
Gravity aids the flow of solution into the sigmoid colon and descending colon.
2
Lubricate the tip of the rectal tube with water-soluble jelly.
The tube is ready for smooth insertion.
Lubrication minimizes friction, preventing tissue injury and discomfort.
3
Gently insert the tubing 3 to 4 inches (7.5 to 10 cm) into the rectum.
The tube passes the internal sphincter and enters the rectum safely.
This depth ensures the fluid is delivered past the sphincter without risking intestinal perforation.
4
Elevate the enema container 12 to 18 inches (30 to 45 cm) above the anus.
Fluid begins to instill at a safe, controlled rate.
The height determines the fluid pressure. Staying within this range prevents rapid distention and mucosal injury.
5
Clamp the tubing temporarily if the client reports abdominal cramping.
The flow of fluid stops, relieving client discomfort.
Stopping the flow allows bowel spasms to subside before resuming the enema at a slower rate.

Key Concept

The procedural steps for administering a large-volume cleansing enema prioritize anatomical alignment, safety, and client comfort.
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