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Question 601Question →

A practical nurse (PN) enters a client's room and observes the client coughing forcefully and clutching their chest. The client is receiving continuous enteral nutrition via a nasogastric (NG) tube. The client appears cyanotic around the lips, and the pulse oximeter reads 86% on room air. 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: Turn off the continuous enteral feeding pump, Elevate the head of the bed to a high-Fowler's position, Apply supplemental oxygen, Auscultate the client's bilateral lung sounds, and Notify the supervising registered nurse (RN).
In any acute respiratory emergency involving enteral feeding, the first step is to remove the noxious stimulus by stopping the pump to prevent further aspiration. Following the ABCs (Airway, Breathing, Circulation), the nurse should then position the client to maximize lung expansion and apply oxygen to treat the hypoxia. Once these immediate life-saving measures are applied, the PN should collect focused data (lung sounds) so that a complete and accurate report can be given when notifying the supervising RN.

Step-by-Step Solution

1
Turn off the continuous enteral feeding pump.
The flow of enteral formula is halted immediately.
This is the most critical action to prevent further aspiration of formula into the airway.
2
Elevate the head of the bed to a high-Fowler's position.
The client is placed in an upright position.
This maximizes lung expansion and utilizes gravity to minimize the risk of further reflux.
3
Apply supplemental oxygen per facility emergency protocol.
Oxygen delivery to the lungs is increased.
This treats the immediate hypoxia evidenced by cyanosis and a pulse oximetry reading of 86%.
4
Auscultate the client's bilateral lung sounds.
Clinical data regarding the respiratory status is collected.
The PN must gather baseline data on the extent of the complication (e.g., presence of crackles) before calling for assistance.
5
Notify the supervising registered nurse (RN) of the status change.
The healthcare team is alerted to the client's deterioration.
With the client stabilized and initial data collected, the RN and healthcare provider can evaluate the client for further interventions like chest x-rays or suctioning.

Key Concept

Prioritization of care during an acute aspiration event focuses on airway protection first (stopping the cause), followed by breathing support (positioning and oxygen), data collection, and then escalation.
Question 602Question →

A practical nurse (PN) at a rehabilitation center is caring for a client scheduled for a peripherally inserted central catheter (PICC) placement. The client has already signed the informed consent document but suddenly tells the PN, 'I have decided not to get the line placed.' In what order should the PN perform the following actions? Arrange the steps from first to last.

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Answer

The correct sequence is to first cease preparations, then inquire about the client's reasons, contact the healthcare provider, and finally record the event in the chart.
When a client revokes consent, the nurse's first legal and ethical duty is to respect their autonomy by immediately stopping the procedure or preparations. Next, the nurse should gather data by exploring the client's concerns. This information is then relayed to the healthcare provider, who is responsible for discussing the implications of refusal. Finally, the nurse must document the entire sequence of events to maintain an accurate and legal medical record.

Step-by-Step Solution

1
Identify the immediate priority to protect client rights.
Cease any ongoing preparations for the catheter insertion.
The client has the right to revoke consent at any time. The PN's first action must be to honor this by stopping the procedure process.
2
Gather data regarding the client's change of mind.
Inquire about the client's reasons for deciding against the procedure.
Data collection helps determine if the refusal is due to anxiety, a misunderstanding, or a genuine desire to decline treatment.
3
Communicate the findings to the appropriate authority.
Contact the healthcare provider to report the client's change in decision.
The healthcare provider must be informed so they can evaluate the client, discuss the risks of refusal, and explore alternative therapies.
4
Ensure legal and accurate communication of the event.
Record the client's verbal refusal and the provider notification in the chart.
Documentation provides a legal record that the client revoked consent, the reasons why, and that the provider was informed.

Key Concept

Clients have the right to revoke informed consent at any time; the PN must immediately stop the procedure, assess concerns, notify the provider, and document.
Question 603Question →

Prior to entering the room of a client placed on strict airborne and contact precautions, a practical nurse must apply multiple layers of protective gear. Arrange the following actions in the correct sequence for safely donning the required personal protective equipment (PPE) from first to last.

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Answer

The correct sequence for donning PPE is to perform hand hygiene, put on the isolation gown, apply the N95 respirator, place the face shield or goggles, and finally don the clean gloves.
Following the standard CDC guidelines for donning PPE ensures that a continuous protective barrier is created systematically. Hand hygiene prevents initial contamination. The gown covers the largest surface area and goes on first. The respirator and eyewear protect the face and airway and are applied next. Finally, the gloves are applied last so they can successfully bridge the gap over the gown cuffs, completing the protective seal.

Step-by-Step Solution

1
Identify the need for hand hygiene as the foundational step.
Hand hygiene is placed first in the sequence.
Touching clean PPE with unwashed hands contaminates the equipment before it is even applied to the body.
2
Select the gown as the first physical piece of PPE to be applied.
The isolation gown is placed second.
The gown is the bulkiest item and protects the nurse's uniform, forming the base layer of the physical barrier.
3
Apply the respiratory protection next.
The N95 respirator is placed third.
Establishing a secure airway barrier is critical for airborne precautions. The mask must be applied before eyewear so the seal is flush against the face.
4
Add the eye protection.
The face shield or goggles are placed fourth.
Eyewear sits over the bridge of the nose and respirator to protect the mucous membranes of the eyes without breaking the respirator's seal.
5
Finish the barrier by applying gloves.
Donning clean gloves is placed last.
Gloves must go on last so the cuffs can be stretched over the sleeves of the gown, ensuring no skin on the wrists is exposed to the hazardous environment.

Key Concept

Standard Sequence for Donning Personal Protective Equipment (PPE)
Question 604Question →

A practical nurse is preparing to administer a combined dose of regular insulin and NPH insulin in a single syringe to a client with diabetes mellitus. Arrange the following steps for preparing this medication in the correct chronological sequence.

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Answer

The correct sequence 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.
When mixing regular (clear) and NPH (cloudy) insulin, the standard safety protocol is 'clear before cloudy'. This prevents the intermediate-acting NPH insulin from contaminating the short-acting regular insulin vial. The sequence of injecting air into the NPH first, then air into the regular, ensures that the needle does not carry regular insulin into the NPH vial during air injection, and prepares the vials for safe withdrawal.

Step-by-Step Solution

1
Roll the NPH insulin vial between the palms.
The cloudy suspension is mixed without creating air bubbles.
Ensures the insulin is evenly distributed before drawing the dose.
2
Inject air into the NPH insulin vial.
Pressure is equalized in the NPH vial.
Prevents a vacuum from forming when fluid is later withdrawn.
3
Inject air into the regular insulin vial.
Pressure is equalized in the regular insulin vial.
Prepares the vial for immediate withdrawal of the clear insulin.
4
Withdraw the regular insulin.
The clear insulin is drawn into the syringe first.
Prevents accidental contamination of the rapid/short-acting insulin with longer-acting insulin.
5
Withdraw the NPH insulin.
The combined dose is now completely drawn into the syringe.
The cloudy insulin is drawn last to complete the mixture safely without pushing regular insulin into the NPH vial.

Key Concept

Insulin Preparation and Administration Sequence
Question 605Question →

A practical nurse is providing morning hygiene for an adult uncircumcised male client who has an indwelling urinary catheter. In what order should the nurse perform the following steps of perineal care? Arrange the actions in the correct sequence.

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Answer

The correct sequence begins with preparation and exposure, followed by cleansing from the cleanest area (meatus) to dirtier areas (catheter tubing, then scrotum), and concludes with replacing the foreskin to prevent injury.
Performing perineal care with an indwelling catheter relies on strict adherence to the principles of medical asepsis. The nurse must clean from the least contaminated area (the urethral meatus) to the most contaminated areas (the surrounding skin). Proper sequence requires initial preparation, exposure of the meatus, cleansing of the meatus, cleansing down the catheter (wiping away from the body), and then washing the surrounding tissue. Finally, replacing the foreskin is an absolute safety requirement to prevent paraphimosis.

Step-by-Step Solution

1
Don gloves and place a waterproof pad.
The environment and nurse are prepared for the procedure.
Standard precautions and bed protection are foundational first steps.
2
Retract the foreskin.
The urethral meatus is fully exposed.
Exposure is necessary to properly clean the anatomical site most at risk for infection.
3
Cleanse the meatus and glans.
The cleanest and most vulnerable area is sanitized.
Medical asepsis requires cleaning from the least contaminated (meatus) to the most contaminated area.
4
Wipe down the catheter tubing away from the meatus.
The proximal section of the catheter is cleaned.
Wiping away from the meatus prevents the mechanical introduction of microorganisms into the urethra (CAUTI prevention).
5
Wash the penile shaft and scrotum.
The surrounding perineal areas are cleansed.
These areas are considered more contaminated than the meatus and are washed last in the genital region.
6
Return the foreskin to its natural position.
The glans is covered and circulation remains uncompromised.
Failure to replace the foreskin can result in paraphimosis, causing severe edema and tissue damage.

Key Concept

Perineal Care and Aseptic Technique
Question 606Question →

A practical nurse is preparing to assist a client from a seated position on the edge of the bed to a standing position using a gait belt. Place the following nursing actions in the correct sequence to ensure safety and proper ergonomics. (Arrange the steps from first to last.)

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Answer

The correct sequence is: Verify the bed is locked and footwear is on, secure the gait belt, assume a wide stance, grasp the belt with an underhand grip, and use leg muscles to assist the client to stand.
Safe transfer protocols require a systematic approach emphasizing both environmental safety and proper body mechanics. First, the environment must be secured by locking the bed and applying non-skid footwear to prevent accidents. Second, the gait belt is applied to provide a secure handling mechanism. Third, the nurse must assume an ergonomic stance with a wide base of support before attempting to lift. Fourth, grasping the belt with an underhand grip ensures a secure hold without straining the nurse's wrists. Finally, the actual lifting motion is performed using the strong muscles of the legs while keeping the back straight, which is essential to prevent musculoskeletal injuries.

Step-by-Step Solution

1
Ensure environmental safety
Bed is immobilized and client has traction
Prevents unpredictable movement during the transfer.
2
Apply the assistive device
Gait belt is safely secured around the waist
Provides a safe handle for the nurse to hold during the transfer.
3
Assume an ergonomic stance
Nurse establishes a wide base of support
Lowers the center of gravity and increases physical stability.
4
Hold the equipment correctly
Gait belt is grasped with an underhand grip
Increases control and reduces musculoskeletal strain on the nurse.
5
Execute the transfer
Client is assisted to a standing position safely
Using leg muscles instead of back muscles prevents ergonomic injuries.

Key Concept

Proper body mechanics and safe equipment use during client transfers
Question 607Question →

A practical nurse (PN) is caring for a client with a central venous catheter (CVC). Upon entering the room, the PN discovers that the intravenous tubing has accidentally disconnected from the CVC hub. The client is suddenly dyspneic, coughing, and appears cyanotic. Suspecting a central line air embolism, in what order should the PN implement the following actions? Arrange the steps from first to last.

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Answer

The correct sequence is to first clamp the catheter, position the client in a left lateral Trendelenburg position, activate the rapid response system, administer oxygen, and finally obtain vital signs.
In a suspected central line air embolism, the absolute first step is source control: clamping the catheter to prevent further air entry. Second, the client must be placed in Durant's maneuver (left lateral decubitus with Trendelenburg) to trap the air bubble in the apex of the right ventricle, keeping it away from the pulmonary outflow tract. Third, the nurse must activate the rapid response system to mobilize advanced help. Fourth, administering 100% oxygen treats ischemia and helps reduce the size of the air embolus by promoting nitrogen washout. Finally, obtaining vital signs provides essential baseline data for the arriving emergency team.

Step-by-Step Solution

1
Clamp the exposed central venous catheter immediately.
Stops further air entry into the circulation.
Source control is the absolute top priority to prevent cardiovascular collapse.
2
Place the client on their left side with the head of the bed lowered.
Traps the air bubble in the right ventricle.
This specific position (Durant's maneuver) prevents the embolus from migrating to the pulmonary artery and causing a right ventricular outflow tract obstruction.
3
Activate the facility's rapid response system.
Summons the emergency medical team.
The client requires advanced interventions (e.g., provider aspiration of air) beyond the PN scope, making advanced support critical once immediate physical safeguards are in place.
4
Administer high-flow supplemental oxygen via a non-rebreather mask.
Promotes nitrogen washout and increases blood oxygenation.
High-flow oxygen decreases the size of the air bubble and treats the severe hypoxia caused by the embolism.
5
Obtain a complete set of vital signs and pulse oximetry.
Establishes a hemodynamic baseline.
Allows the arriving rapid response team to immediately assess the severity of shock and evaluate the client's response to the initial interventions.

Key Concept

Emergency Management of a Central Venous Catheter Air Embolism
Question 608Question →

A client in the preoperative holding area of an ambulatory care center is scheduled for an elective lithotripsy. After the surgeon has explained the procedure and left the area, the client tells the practical nurse (PN), "I changed my mind. I am too scared and do not want to go through with this surgery." In what order should the PN perform the following actions? (Arrange from first action to last action)

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Answer

The correct sequence is to first confirm the client's decision, then ensure safety by stopping preoperative preparations, followed by notifying the appropriate providers, and finally documenting the event.
When a client revokes informed consent, the nursing process guides the PN's prioritization. First, the PN must assess and confirm the client's statement to ensure clear communication. Second, the PN must immediately implement safety measures by halting any procedures or medications (such as sedatives) related to the canceled surgery, as administering them would constitute battery. Third, the PN must notify the RN and the surgeon, as it is the provider's responsibility to discuss the risks of refusing the procedure and formally cancel the medical orders. Finally, after all immediate actions and notifications are complete, the PN documents the entire event objectively in the medical record.

Step-by-Step Solution

1
Confirm the client's decision to withdraw consent.
The PN verifies the client's intent to cancel the surgery.
Assessment is always the first step to ensure an accurate understanding of the client's wishes before taking action.
2
Stop preoperative preparations and withhold sedatives.
The client is protected from receiving unnecessary or mind-altering medications.
Immediate safety actions must be taken once consent is revoked to uphold the client's right to refuse treatment.
3
Notify the surgeon and supervising RN.
The healthcare team is made aware of the change in the client's consent status.
Communicating with the provider is essential because it is their legal scope and responsibility to address the medical consequences of refusing treatment.
4
Document the event in the medical record.
A legal record of the consent revocation and subsequent actions is created.
Accurate and timely documentation is required to maintain the legal and historical record of care.

Key Concept

Informed Consent Revocation and PN Scope of Practice
Question 609Question →

A client who is recovering from abdominal surgery is preparing to move from the bed to a bedside chair for the first time. In what sequence should the nurse perform the following actions to ensure a safe transfer? Arrange the steps in the correct chronological order.

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Answer

The correct sequence begins with preparing the environment (placing and locking the chair), followed by elevating the head of the bed, assisting the client to dangle their legs, monitoring for dizziness, and finally applying a transfer belt before standing.
Safe client mobilization requires a systematic approach. The nurse must first secure the environment by locking the chair in the optimal position. Next, the client is brought upright gradually by elevating the head of the bed and then pivoting to a dangling position. This gradual movement is crucial for post-operative clients to prevent orthostatic hypotension. The nurse must then verify the client's stability by checking for dizziness before applying the gait belt and initiating the weight-bearing phase of the transfer.

Step-by-Step Solution

1
Prepare the environment and equipment.
The destination chair is positioned correctly and secured.
Ensuring the chair is locked and appropriately angled guarantees a safe landing point and prevents the equipment from rolling during the transfer.
2
Raise the head of the bed.
The client is moved into an initial upright position.
Elevating the head minimizes physical exertion for the client and protects the abdominal incision from excess strain while transitioning.
3
Assist the client to a dangling position on the edge of the bed.
The client's legs are dependent, allowing the cardiovascular system to adjust.
Gradual position changes are essential in post-operative care to prevent a sudden drop in blood pressure.
4
Evaluate the client for orthostatic changes.
The nurse confirms the client is stable enough to stand.
Dizziness or syncope can lead to severe injury if the client is allowed to bear weight while hemodynamically unstable.
5
Apply a gait belt and assist with the stand-and-pivot maneuver.
The client is safely moved into the chair.
A transfer belt provides the nurse with a firm, safe hold on the client's center of gravity without pulling on their arms or shoulders.

Key Concept

Safe Client Transfer and Mobility
Question 610Question →

A practical nurse (PN) is caring for a client who is 3 days postoperative following a laparotomy. The client reports a "popping" sensation after a severe bout of coughing. Upon inspection, the PN observes that the surgical incision has opened and bowel loops are protruding. 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 of actions for an abdominal evisceration is to first call for help and stay with the client, then position the client to reduce abdominal tension, next cover the protruding organs with sterile moistened dressings, and finally assess vital signs.
In the event of an evisceration, the primary goal is to protect the exposed organs and prepare for emergency surgery. The nurse must first ensure help is on the way because they cannot leave the client to gather supplies. Immediately positioning the client reduces intra-abdominal pressure to prevent further evisceration. Once the delegated staff brings the sterile supplies, the nurse covers the organs to prevent necrosis. Finally, vital signs are assessed to monitor for shock as the client is prepared for the operating room.

Step-by-Step Solution

1
Call for immediate assistance and remain with the client.
Help is mobilized without leaving the client unattended in an emergency.
Evisceration is a medical emergency requiring sterile supplies and immediate surgical intervention. The nurse must not leave the client alone.
2
Place the client in a low Fowler's position with the knees flexed.
Abdominal muscle tension is reduced.
This specific position relaxes the abdominal wall, which prevents further pushing out of the internal organs.
3
Cover the exposed organs with sterile dressings moistened with sterile 0.9% sodium chloride.
The eviscerated tissue is protected from drying and environmental contaminants.
Exposed bowel can quickly dry out and become necrotic. Sterile saline maintains tissue viability until surgical repair.
4
Assess the client's vital signs.
Baseline hemodynamic status is established.
The client is at high risk for hypovolemic shock due to fluid shifts, bleeding, and stress. Monitoring vitals guides further emergency interventions.

Key Concept

The priority management of an abdominal evisceration involves securing help, reducing abdominal tension, protecting the exposed tissue, and monitoring for shock.
Question 611Question →

During morning rounds, a practical nurse observes that a resident with type 1 diabetes mellitus is pale, sweating profusely, and visibly shaking. The resident is conscious, able to follow commands, and has an intact gag reflex. In what sequence should the practical nurse perform the following actions? Arrange them from the highest priority (first action) to the lowest priority (final action).

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Answer

The correct sequence follows the standard 15-15 rule for conscious hypoglycemia: verify the glucose level first, treat immediately with a simple carbohydrate, evaluate the response in 15 minutes, stabilize the client with a complex snack, and document the event last.
This sequence strictly adheres to the standard physiological adaptation protocol for acute, conscious hypoglycemia. The nurse must first verify the condition with data (blood glucose check), immediately intervene with rapidly absorbed glucose (apple juice), evaluate the intervention (recheck in 15 minutes), provide long-term physiological support (complex snack), and conclude with accurate documentation.

Step-by-Step Solution

1
Obtain a capillary blood glucose reading.
Confirms the physiological presence of hypoglycemia.
Assessment is the primary step in the nursing process to ensure the correct protocol is initiated before administering treatments.
2
Administer a fast-acting simple carbohydrate.
Begins the rapid correction of the low blood sugar.
Immediate treatment is necessary to prevent severe neurological complications such as seizures or coma.
3
Recheck the capillary blood glucose level in 15 minutes.
Determines if the blood glucose has risen appropriately.
Follows the evidence-based 15-15 rule for hypoglycemia management to ensure the intervention was effective and the client is safe.
4
Provide a complex carbohydrate and protein snack.
Sustains the blood glucose levels over a longer duration.
Prevents a rebound hypoglycemic event once the rapidly absorbed simple sugars have metabolized.
5
Document the event and interventions.
Creates a permanent legal and medical record of the client's status change.
Completes the nursing process after client safety and physiological stability are fully secured.

Key Concept

Management of acute conscious hypoglycemia using the 15-15 protocol.
Question 612Question →

A practical nurse (PN) is preparing to administer a scheduled transdermal nitroglycerin patch to a client with a history of stable angina. The client currently has an active patch on their right upper chest. In what order should the PN perform the following actions to ensure safe medication administration?

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Answer

The correct sequence for applying a transdermal medication patch is: 1) Don gloves, 2) Remove the old patch, 3) Clean the new site, 4) Label the new patch, and 5) Apply the new patch.
Safe application of a transdermal nitroglycerin patch requires a strict chronological sequence to protect both the client and the nurse. The nurse must first don gloves to prevent self-absorption of the vasoactive medication. Removing the old patch is the immediate next step to prevent medication toxicity (double-dosing). The new site must then be prepared to ensure proper absorption. The new patch should always be labeled prior to application so that the pressure of writing does not inadvertently push a bolus of the drug into the client's skin. Finally, the patch is applied securely.

Step-by-Step Solution

1
Perform hand hygiene and put on a pair of clean gloves.
The nurse's skin is protected from accidental medication exposure.
Nitroglycerin is readily absorbed through the skin and can cause systemic adverse effects in the nurse.
2
Remove the existing nitroglycerin patch and fold it in half with the adhesive sides together.
The source of the previous medication dose is eliminated.
Leaving the old patch in place while applying a new one can result in an overdose and severe hypotension.
3
Cleanse a newly selected, hairless application site on the upper body and allow it to air dry.
A clean, dry surface is prepared for the new patch.
Rotating sites prevents skin breakdown, and a clean surface is required for optimal adhesive function.
4
Write the current date, time, and nurse's initials on the outer backing of the new patch.
The patch is properly identified for future shifts.
Labeling must occur before application; using a pen on an applied patch can squeeze out excess medication.
5
Remove the protective liner and apply the new patch, pressing firmly with the palm of the hand.
The medication is safely administered to the client.
Firm pressure ensures the patch is secure. Avoiding touching the adhesive maintains stickiness and protects the nurse.

Key Concept

Safe Administration of Transdermal Medications
Question 613Question →

During a routine wound assessment, a licensed practical nurse discovers that a postoperative client's abdominal incision has completely opened, and loops of bowel are visible outside the body cavity. Arrange the following emergency interventions in the correct chronological sequence to mitigate physiological risk.

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Answer

First call for help while staying with the client, then place the client in a low Fowler's position with flexed knees, followed by covering the exposed bowel with moist sterile dressings, and finally obtain vital signs.
The management of an abdominal evisceration requires immediate prioritized action to prevent further structural damage and physiological shock. The nurse must first secure help without abandoning the client. Next, mechanical tension on the abdomen is relieved by positioning. Once tension is reduced, the exposed organs are protected with moist sterile dressings to prevent necrosis. Finally, systemic perfusion is evaluated by measuring vital signs while awaiting surgical intervention.

Step-by-Step Solution

1
Remain at the bedside and call for help.
Additional staff is secured to notify the provider and gather supplies.
Client safety mandates that the nurse does not leave a critically unstable client alone.
2
Position the client with the head of the bed slightly elevated and knees bent.
Abdominal muscle tension is minimized.
Reducing intra-abdominal pressure is the fastest mechanical way to prevent further organs from eviscerating while waiting for supplies.
3
Cover the bowel with sterile, saline-soaked gauze.
The exposed viscera are kept moist and protected from airborne contaminants.
Bowel tissue can quickly become ischemic and necrotic if allowed to dry out; sterile saline maintains tissue viability.
4
Obtain baseline vital signs.
The client's hemodynamic status is documented.
Evisceration causes massive fluid shifts and stress, putting the client at high risk for shock, which must be monitored immediately after the tissue is secured.

Key Concept

Emergency Management of Wound Evisceration
Question 614Question →

A practical nurse (PN) is caring for a conscious client with diabetes mellitus who suddenly reports feeling shaky and appears diaphoretic. Arrange the following nursing actions in the correct priority sequence to manage this situation and reduce the risk of severe complications. All options must be used.

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Answer

The correct sequence is to first check the blood glucose, administer a fast-acting carbohydrate, recheck in 15 minutes, provide a stabilizing snack, and finally document the event.
The correct sequence follows the standard 'Rule of 15' for hypoglycemia management combined with the nursing process. Assessment (checking blood glucose) must precede intervention. The immediate intervention is a simple carbohydrate to rapidly raise blood sugar. Evaluation (rechecking in 15 minutes) determines if further acute treatment is needed. Once stable, a complex snack prevents recurrence, and final documentation records the resolved incident.

Step-by-Step Solution

1
Obtain a capillary blood glucose reading.
Confirms if the client's symptoms are due to hypoglycemia.
Assessment is always the first step in the nursing process to ensure interventions are appropriate.
2
Administer 4 ounces (120 mL) of a fast-acting carbohydrate.
Rapidly increases the client's blood glucose level.
This follows the 'Rule of 15' for treating symptomatic hypoglycemia in a conscious client.
3
Wait 15 minutes and reassess the capillary blood glucose level.
Evaluates the client's response to the simple carbohydrate.
It takes approximately 15 minutes for the simple carbohydrate to absorb and affect the capillary glucose level. If it remains low, the treatment must be repeated.
4
Provide a complex carbohydrate and protein snack.
Maintains the blood glucose level over a longer period.
Simple carbohydrates cause a rapid spike and subsequent drop; complex carbohydrates and protein stabilize the level until the next meal.
5
Document the client's symptoms, interventions, and blood glucose results.
Provides an accurate legal and medical record of the event.
Documentation occurs after patient care is completed and the client is stable.

Key Concept

Management of Hypoglycemia (Rule of 15)
Question 615Question →

A practical nurse (PN) is preparing to mix and administer 5 units of regular insulin and 15 units of NPH insulin in a single syringe for a client with diabetes mellitus. In what order should the PN perform the following steps to prepare the medication? Arrange the actions from first to last.

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Answer

The correct sequence is to roll the NPH vial, inject air into the NPH vial, inject air into the regular insulin vial, withdraw the regular insulin, and finally withdraw the NPH insulin.
The standard procedure for mixing insulins involves drawing up the clear (regular) insulin before the cloudy (NPH) insulin. This 'clear before cloudy' sequence prevents the intermediate-acting NPH insulin from inadvertently mixing into and modifying the action of the short-acting regular insulin vial. Air is injected into both vials beforehand to equalize pressure and facilitate withdrawal.

Step-by-Step Solution

1
Identify the need to mix a suspension (NPH) and a solution (regular insulin).
The NPH vial is gently rolled.
Rolling resuspends the particles without introducing air bubbles.
2
Pressurize the vials by injecting air.
Inject 15 units of air into the NPH vial, then 5 units of air into the regular insulin vial.
Injecting air prevents a vacuum. The cloudy insulin is pressurized first to avoid contaminating the clear insulin later.
3
Withdraw the insulin doses.
Withdraw 5 units of regular insulin, then 15 units of NPH insulin.
Drawing clear before cloudy prevents intermediate-acting insulin from inadvertently mixing into the short-acting insulin vial.

Key Concept

Mixing Insulins (Clear Before Cloudy)
Question 616Question →

A practical nurse (PN) and an unlicensed assistive personnel (UAP) are preparing to move an alert, partially mobile client up in bed using a draw sheet. In what order should the team perform the following actions to ensure client safety and maintain proper body mechanics? Arrange the actions in the correct sequence.

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Answer

The correct sequence is: Adjust the bed height and position, place a pillow at the headboard, position the client's arms and legs, roll the draw sheet close to the client, and finally shift weight to move the client.
The correct sequence prioritizes environmental preparation and staff ergonomics first, followed by client safety and positioning, and concludes with the physical transfer using proper body mechanics. By flattening and raising the bed, nurses avoid working against gravity and bending over. Padding the headboard protects the client from injury. Having the client bend their knees allows them to assist, significantly reducing the physical load. Finally, securing the draw sheet close to the body and shifting weight ensures the use of strong leg muscles instead of the vulnerable back muscles.

Step-by-Step Solution

1
Prepare the physical environment by adjusting the bed.
The bed is flat and raised to the nurses' waist height.
Flattening the bed reduces gravity resistance. Raising the bed to waist height maintains the nurses' center of gravity and prevents back strain.
2
Protect the client's head by relocating the pillow.
A pillow is positioned vertically against the headboard.
This prevents the client's head from accidentally striking the hard headboard surface during the upward movement.
3
Prepare the client for the movement.
The client crosses their arms and bends their knees, placing their feet flat on the mattress.
Crossing the arms reduces surface friction. Bending the knees allows the client to push down with their feet, assisting the nurses and reducing the physical load.
4
Establish a secure, ergonomic grip.
The draw sheet is rolled tightly against both sides of the client's body.
A close grip keeps the weight of the client near the nurses' center of gravity, significantly reducing strain on the lower back.
5
Execute the movement using large muscle groups.
The nurses shift their weight from their back leg to their front leg, gliding the client up the bed.
Using a weight-shifting rocking motion employs the strong muscles of the thighs and legs rather than the weaker back muscles.

Key Concept

Proper body mechanics and safe client handling techniques
Estimated Time:1m 30s
Question 617Question →

While assisting a client who has left-sided hemiparesis to move from the bed to a wheelchair, a practical nurse must ensure proper mechanics and safety. 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 to first position the wheelchair on the strong side and lock it, assist the client to a sitting position on the edge of the bed, apply a transfer belt, instruct the client to pivot on their strong leg, and finally have them lower into the chair using the armrests.
Transferring a client with hemiparesis requires maximizing the use of their strong side to maintain stability and prevent falls. The wheelchair must first be secured on the strong side. The client is then brought to a sitting position to prevent orthostatic hypotension and ensure balance. A transfer belt is applied for safety before any weight-bearing occurs. The client then pivots on their strong leg and carefully lowers into the chair using the armrests for support.

Step-by-Step Solution

1
Determine the correct placement of the wheelchair.
The wheelchair is placed on the client's right (strong) side at a 45-degree angle and the brakes are locked.
Placing the chair on the unaffected side allows the client to use their strong arm and leg to assist with the transfer, and locking the brakes prevents the chair from sliding.
2
Prepare the client for standing.
The client is assisted to a sitting position on the edge of the bed with feet flat on the floor.
Sitting on the edge of the bed allows the client to stabilize their blood pressure (preventing orthostatic hypotension) and gain balance before standing.
3
Apply safety equipment.
A transfer belt is placed securely around the client's waist.
The transfer belt provides the nurse with a safe way to support the client's center of gravity during the transfer without pulling on the client's limbs.
4
Execute the transfer movement.
The client stands, bearing weight on the right leg, and pivots toward the wheelchair.
Pivoting on the strong leg ensures stability and allows the client to move safely toward the seat.
5
Complete the transfer.
The client reaches for the armrests and lowers into the chair.
Using the armrests provides upper body support and control while lowering into the chair.

Key Concept

Safe transfer techniques and mobility assistance for clients with hemiparesis
Question 618Question →

A practical nurse (PN) is preparing to administer a prescribed dose of inhaled fluticasone via a metered-dose inhaler (MDI) with a spacer to a client with chronic asthma. Arrange the following steps for administering this medication in the correct chronological order.

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Answer

The correct sequence is: shake and attach the inhaler, instruct the client to exhale completely, seal the lips tightly around the spacer mouthpiece, depress the canister to release medication, have the client inhale slowly and hold their breath, and finally, rinse the mouth and spit.
Administering a corticosteroid via an MDI with a spacer requires a precise sequence to ensure maximum medication delivery to the lungs and to minimize local adverse effects. The sequence begins with device preparation (shaking and attaching). Next, the client must be prepared by exhaling completely to allow for a maximal inspiratory volume. Once the lungs are emptied, a tight seal is made around the mouthpiece to prevent leakage. Only then is the canister depressed to suspend the medication in the spacer. The client then inhales slowly and holds their breath for 10 seconds, allowing the particles to settle deeply in the bronchioles. Because fluticasone is a corticosteroid, the final and mandatory step is rinsing the mouth and spitting to prevent oral candidiasis.

Step-by-Step Solution

1
Shake the metered-dose inhaler vigorously and insert it into the end of the spacer.
The medication is uniformly mixed and the device is assembled.
Inhaled suspensions can separate; shaking ensures the client receives an accurate, measured dose.
2
Instruct the client to exhale completely to empty the lungs.
The client's lungs are emptied of residual volume.
Starting with empty lungs maximizes the volume of the subsequent inhalation, drawing the medication deeper into the respiratory tract.
3
Place the spacer mouthpiece into the client's mouth and ensure the lips are sealed tightly around it.
A closed system is created between the spacer and the client's airway.
A tight seal prevents the aerosolized medication from escaping out of the mouth during release.
4
Depress the inhaler canister once to release the medication into the spacer chamber.
One dose of medication is suspended inside the spacer.
The spacer holds the medication in a fine cloud, removing the need for the client to perfectly coordinate pressing the canister with inhaling.
5
Instruct the client to inhale slowly and deeply, then hold their breath for 10 seconds.
The medication travels to the lower airways and settles.
Slow inhalation prevents turbulent airflow from depositing medication in the back of the throat. Holding the breath maximizes absorption in the lungs.
6
Assist the client to rinse their mouth with water and spit it out.
Residual medication is cleared from the oropharynx.
Fluticasone is an inhaled corticosteroid. Leaving residue in the mouth increases the risk of oral fungal infections (candidiasis) and systemic absorption.

Key Concept

Safe Administration Sequence for Inhaled Corticosteroids via MDI with Spacer
Question 619Question →

A practical nurse (PN) is preparing to enter the room of a client placed on airborne and contact precautions for disseminated herpes zoster. The PN has gathered the necessary personal protective equipment (PPE). Arrange the following steps for donning the PPE in the correct sequential order.

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Answer

The correct donning sequence is: Hand hygiene, Isolation gown, N95 respirator, Face shield, and finally Gloves.
According to standard infection control guidelines, personal protective equipment (PPE) must be donned in a specific sequence to maximize protection. The sequence begins with hand hygiene to ensure clean hands are used to handle the equipment. Next, the gown is applied to protect the body, followed by the respirator (which requires a direct seal to the face). Eye protection is added over the respirator. Finally, gloves are donned last so they can be pulled up over the cuffs of the gown, ensuring no skin is exposed.

Step-by-Step Solution

1
Perform hand hygiene.
Hands are clean before touching any equipment.
Prevents the transfer of pathogens to the clean PPE.
2
Put on the isolation gown.
The nurse's torso and clothing are fully covered.
Provides a primary body barrier against contact contaminants.
3
Don the N95 respirator.
The respiratory tract is protected with a secure seal.
Filters airborne particles; applying it before eye protection ensures the straps do not compromise the seal.
4
Place the face shield.
The eyes and upper face are shielded.
Protects mucous membranes from splashes and droplets without interfering with the respirator.
5
Put on clean gloves.
Hands and wrists are completely covered.
Applying gloves last allows them to be pulled over the gown cuffs, completing the protective barrier.

Key Concept

Personal Protective Equipment (PPE) Donning Sequence
Question 620Question →

A practical nurse is preparing to enter the room of an infant diagnosed with respiratory syncytial virus (RSV). The facility policy requires both contact and droplet precautions. Arrange the steps for donning the required personal protective equipment (PPE) in the correct sequence.

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Answer

The correct sequence for donning PPE is: Gown, Mask, Goggles/Face Shield, and then Gloves.
The Centers for Disease Control and Prevention (CDC) sequence for donning PPE is designed to maximize protection and minimize the risk of self-contamination during the process. The correct order is gown, mask or respirator, goggles or face shield, and finally gloves. The gown is applied first to cover the torso and arms. The mask is applied next to protect the respiratory system. Eye protection is then added. Gloves are always donned last so they can be securely pulled over the cuffs of the gown, completing the continuous barrier.

Step-by-Step Solution

1
Don the isolation gown.
The nurse's torso, arms, and clothing are covered.
Applying the gown first prevents contamination of the uniform and allows for unrestricted movement when securing the remaining PPE.
2
Don the surgical mask.
The respiratory tract is protected from large respiratory droplets.
The mask must be secured before eye protection to ensure a proper fit over the nose bridge.
3
Don goggles or a face shield.
The eyes are protected from potential splashes or respiratory secretions.
Eye protection rests over the upper edge of the mask to provide complete facial coverage.
4
Don procedure gloves.
The hands are protected and the gown cuffs are sealed tightly.
Gloves must be placed last so they can be pulled up and over the cuffs of the gown, preventing any exposed skin at the wrists.

Key Concept

Standard and Transmission-Based Precautions
Estimated Time:1m 0s
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