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Question 741Question →

A practical nurse (PN) working in a long-term care facility witnesses another staff member aggressively grabbing a resident's arm and shouting at them. Arrange the following actions the PN should take in the correct chronological order.

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Answer

The correct sequence is to first intervene to ensure safety, assess the resident for injuries, notify management to remove the staff member, and finally document the event.
In any scenario involving active harm, the nursing process dictates that immediate safety intervention is the first priority. This is followed by assessment of the client, notifying the chain of command to manage the offending staff member and initiate legal reporting, and finally creating an objective medical record of the event.

Step-by-Step Solution

1
Intervene immediately to separate the staff member from the resident.
The resident is protected from further physical or emotional harm.
According to the hierarchy of nursing actions, immediate client safety and preventing further injury always takes absolute precedence.
2
Assess the resident for any physical injuries and provide necessary care.
The resident's clinical status is determined.
After securing the environment, the nurse must evaluate the resident to treat any injuries sustained during the incident.
3
Notify the nursing supervisor about the witnessed incident.
The chain of command is activated.
The supervisor must be alerted to remove the accused staff member from the premises and to fulfill the facility's legal obligation for mandatory reporting.
4
Document the objective, factual details of the event in the medical record.
A legal record of the incident is created.
Accurate, objective documentation is required for the client's health record and for the inevitable investigation by adult protective services.

Key Concept

Procedural escalation for suspected client abuse and prioritizing client safety.
Question 742Question →

An older adult client is admitted to the medical-surgical unit and is scheduled for a complex diagnostic biopsy. The client is alert and oriented. Which interventions should the practical nurse implement to uphold this client's rights and maintain a safe care environment? (Select all that apply.)

Select all that apply

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Answer: Close the electronic health record on the in-room computer monitor when stepping away from the bedside.; Notify the primary healthcare provider promptly if the client decides to withdraw agreement to undergo the biopsy.; Confirm that the client is signing the procedure authorization voluntarily and without pressure from family members.

Answer

The correct interventions are closing the electronic health record when stepping away, notifying the provider if the client withdraws agreement for the procedure, and confirming that the client is signing the authorization voluntarily.
The correct actions demonstrate appropriate advocacy, confidentiality, and an understanding of the practical nurse's scope of practice. Securing the electronic health record protects the client's right to privacy. Notifying the provider if the client withdraws consent upholds their right to refuse treatment. Confirming that the signature on the consent form is voluntary fulfills the nurse's ethical and legal role as a witness.

Step-by-Step Solution

1
Analyze the practical nurse's role in informed consent and client advocacy.
The nurse acts as a witness to ensure a voluntary signature and advocates for the client if they wish to refuse treatment. The nurse does not provide primary explanations of surgical risks.
To correctly differentiate between the healthcare provider's responsibilities and the nursing scope of practice regarding consent.
2
Evaluate the requirement for client privacy and confidentiality.
The nurse must secure electronic records and restrict medical information sharing to authorized individuals only.
To comply with federal privacy regulations and protect the client's legal right to medical confidentiality.
3
Assess the protocol for maintaining a safe environment regarding physical restraints.
Less restrictive measures, such as diversion tactics, must always be attempted and documented before applying any physical restraints.
To uphold the client's right to be free from unnecessary physical restraints and ensure a safe, least-restrictive care environment.

Key Concept

Client Rights and Advocacy
Question 743Question →

A client who adheres to the Jehovah's Witness faith is admitted to the medical-surgical unit with severe symptomatic anemia following a gastrointestinal hemorrhage. The provider has prescribed a treatment plan to manage the acute blood loss. Identify the appropriate nursing actions the licensed practical nurse (LPN/LVN) should take to support this client's physiological needs while respecting their spiritual beliefs. Select all that apply.

Select all that apply

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Answer: Administer prescribed subcutaneous epoetin alfa to stimulate endogenous red blood cell production.; Inquire privately if the client's personal conscience permits the administration of a prescribed human albumin infusion.; Document the client's choice and immediately notify the registered nurse (RN) if the client declines a prescribed intravenous iron infusion.

Answer

The appropriate actions include administering subcutaneous epoetin alfa, inquiring if the client's conscience permits human albumin, and reporting the refusal of an iron infusion.
The correct actions demonstrate cultural competence, respect for client autonomy, and strict adherence to the LPN/LVN scope of practice. Administering subcutaneous epoetin alfa is within scope and widely accepted in bloodless medicine as it contains no blood components. Human albumin is a minor blood fraction; therefore, accepting it is a matter of personal conscience for Jehovah's Witnesses, making it appropriate for the nurse to respectfully inquire about the client's preference. Finally, documenting and reporting a client's refusal of any treatment ensures proper continuity of care and protects the client's legal right to self-determination.

Step-by-Step Solution

1
Identify the client's spiritual affiliation and core prohibitions.
The client is a Jehovah's Witness, a faith that strictly prohibits the intake or transfusion of whole blood and its primary components (red cells, white cells, plasma, and platelets).
Establishing the absolute spiritual restrictions directs the baseline for both physiological and dietary interventions.
2
Differentiate between primary blood components and minor blood fractions.
Plasma is universally prohibited, whereas albumin is a minor fraction and its acceptance is left to the individual's personal conscience.
Ensures the nurse does not administer forbidden treatments while still advocating for and offering permitted medical options.
3
Evaluate the cultural dietary implications of the prescribed care.
Foods containing animal blood, such as black pudding, must be strictly avoided.
Prevents a severe breach of the client's spiritual dietary laws when attempting to correct nutritional deficits like low iron.
4
Assess the scope of practice and communication standards for the LPN/LVN.
The LPN/LVN can administer subcutaneous medications, must avoid non-therapeutic 'why' questions, and cannot initiate blood products.
Guarantees that care is legally compliant, safe, and culturally sensitive.

Key Concept

Cultural competence for Jehovah's Witness clients regarding blood products, dietary restrictions, and therapeutic communication within the LPN/LVN scope of practice.
Estimated Time:2m 0s
Question 744Question →

A practical nurse (PN) is preparing to delegate the routine task of obtaining morning vital signs on a stable adult client to an assistive personnel (AP). Arrange the steps of the delegation process in the correct chronological sequence.

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Answer

The correct sequence follows the standard delegation process: first assessing the client's stability (Right Circumstance/Task), then verifying the AP's competence (Right Person), followed by giving clear instructions (Right Direction/Communication), and finally evaluating the outcome (Right Supervision/Evaluation).
The NCSBN delegation model requires a systematic approach. The nurse must first assess the client and the appropriateness of the task, then ensure the right person is selected. Only after these factors are confirmed can the nurse provide specific directions. Finally, the nurse must supervise and evaluate the outcome, as accountability for the task's outcome always remains with the delegating nurse.

Step-by-Step Solution

1
Determine task appropriateness.
The PN verifies the client is stable.
Delegation requires a stable client and a routine, predictable task to ensure safety.
2
Verify competence.
The PN selects an AP who is trained for the specific task.
The delegatee must be legally permitted and individually competent to perform the skill.
3
Provide instructions.
The PN tells the AP exactly what to do and when to report.
Clear, specific, two-way communication prevents errors and ensures the AP knows when to escalate concerns.
4
Supervise and evaluate.
The PN checks the vital signs and follows up with the AP.
The PN retains ultimate accountability for the task's outcome and must ensure it was completed properly.

Key Concept

Five Rights of Delegation in Nursing Practice
Question 745Question →

A practical nurse is changing the abdominal dressing of a client who is four days postoperative from an exploratory laparotomy. When the client forcefully coughs, the nurse observes internal organs protruding through the opened incision line. In which sequential order should the practical nurse prioritize the following interventions? Arrange the actions from first to last.

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Answer

The correct sequence of actions is to first call for help while staying with the client, position the client to reduce abdominal tension, cover the exposed organs with moist sterile dressings, assess vital signs for shock, and maintain NPO status for emergency surgery.
In an acute evisceration, the practical nurse must prioritize actions that protect the client and the exposed organs while expediting emergency medical intervention. First, the nurse must never leave the client; activating the emergency system brings necessary personnel and sterile supplies to the bedside. Next, positioning the client in a low-Fowler's position with flexed knees is a critical mechanical intervention that instantly reduces intra-abdominal pressure and prevents further protrusion of the bowel. Once sterile supplies are available, the nurse must cover the exposed viscera with sterile, saline-moistened dressings to prevent tissue necrosis and severe infection. After the site is physically protected, obtaining vital signs is essential to monitor for hypovolemic shock, a major systemic complication of evisceration. Finally, because evisceration requires immediate operative repair, the nurse must ensure the client is kept strictly NPO to prevent aspiration during anesthesia.

Step-by-Step Solution

1
Activate the emergency response while staying with the client.
Ensures the client remains safe while necessary sterile supplies and personnel are brought to the bedside.
The practical nurse must not leave an unstable client; leaving could lead to further injury or severe complications.
2
Place the client in a low-Fowler's position with knees flexed.
Minimizes intra-abdominal pressure.
Relieving tension on the abdominal wall physically prevents further evisceration of internal organs.
3
Apply sterile, saline-moistened dressings over the evisceration.
Protects the exposed bowel from the external environment.
Exposed viscera are highly susceptible to drying and infection, which can cause tissue necrosis. Sterile normal saline maintains moisture safely.
4
Assess and document the client's vital signs.
Provides baseline hemodynamic data.
Evisceration can trigger a massive stress response and fluid shifts, leading to hypovolemic shock. Tachycardia and hypotension require immediate medical intervention.
5
Reinforce NPO status and prepare for surgery.
Prevents aspiration during future anesthesia.
Wound evisceration is a surgical emergency requiring operative closure. Maintaining strict NPO status is critical for safe intubation.

Key Concept

Wound Evisceration Emergency Management
Question 746Question →

A practical nurse (PN) is monitoring a client who is receiving a continuous infusion of packed red blood cells (PRBCs). Fifteen minutes after the transfusion begins, the client suddenly reports severe lower back pain, chills, and shortness of breath. Arrange the PN's interventions in the correct order of priority.

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Answer

The correct priority sequence for a suspected hemolytic transfusion reaction is to first stop the transfusion, secure the IV line with normal saline using new tubing, notify the supervising RN, assess vital signs, and finally send the blood product to the blood bank.
In the event of a blood transfusion reaction, the immediate priority is to stop the cause of the reaction (following Airway, Breathing, Circulation principles by stopping the harmful agent first). Next, IV access must be maintained for potential emergency drug administration, which requires entirely new tubing primed with normal saline. Following this, the PN must notify the RN to escalate the emergency. Assessing vital signs is the next priority to monitor for shock and respiratory distress. Finally, administrative and diagnostic steps, such as returning the blood to the lab, are completed.

Step-by-Step Solution

1
Stop the blood transfusion immediately.
The infusion of the potentially incompatible blood product is halted.
This is the most critical first step to minimize the volume of reactive blood entering the client's circulation.
2
Connect new tubing primed with 0.9% normal saline.
Intravenous access is maintained without infusing residual blood.
Emergency medications may be needed, so the IV site must be kept open, but flushing the old tubing would worsen the reaction.
3
Notify the supervising RN.
The healthcare team is alerted to the medical emergency.
The RN will contact the healthcare provider for emergency orders and assist with advanced assessments.
4
Assess vital signs and respiratory status.
Objective data regarding the client's hemodynamic stability is collected.
Vital signs help determine the severity of the reaction and guide further therapeutic interventions.
5
Return the blood bag and tubing to the blood bank.
The blood and tubing are sent for laboratory analysis.
This administrative step allows the facility to investigate the cause of the reaction, but it only occurs after the client is stable.

Key Concept

Management of acute blood transfusion reactions.
Estimated Time:1m 30s
Question 747Question →

During morning care on a palliative unit, a client who previously finalized a do-not-resuscitate order and verbalized readiness for death suddenly shows the practical nurse an article about an unapproved experimental treatment. The client states, 'I am going to discharge myself today because this overseas clinic promises they can cure me completely.' Which response by the nurse is most appropriate?

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Answer: This information has clearly caught your attention. Can you share more about what you are hoping for right now?

Answer

The most appropriate response is the one that acknowledges the client's interest and uses an open-ended question to explore their feelings and hopes without confronting their denial.
In end-of-life care, denial frequently acts as a protective psychological coping mechanism against overwhelming existential distress. Clients often cycle back and forth through different stages of grief; reaching 'acceptance' does not permanently prevent a return to 'denial'. The nurse's role is to facilitate the expression of these feelings. The correct response uses a therapeutic, open-ended question to validate the client's interest and gently explore their underlying feelings without abruptly destroying their hope or arguing about the facts of their diagnosis.

Step-by-Step Solution

1
Analyze the client's statement and current emotional state.
The client is exhibiting signs of denial and profound hope for a cure, despite having previously accepted the terminal nature of their diagnosis.
Recognizing that grief and coping are non-linear processes is essential; clients frequently cycle back into denial as a protective psychological mechanism against overwhelming anxiety or sadness.
2
Evaluate the nurse's role in facilitating therapeutic communication.
The nurse must support the client's emotional expression without arguing, offering false reassurance, or aggressively forcing reality orientation.
Confronting denial directly can destroy the client's coping mechanism and damage the therapeutic relationship, while exploring the emotion allows the client to process their feelings safely.
3
Select the response that best applies therapeutic communication principles.
The option that asks the client to share more about what they are hoping for is chosen.
This response validates the client's current emotional state and opens the door for further therapeutic dialogue without agreeing that the unproven treatment will work.

Key Concept

Non-linear grief process and therapeutic communication in end-of-life care
Question 748Question →

After receiving the morning handoff report, a practical nurse reviews the clinical data for four assigned clients. Which client situation presents the greatest risk for a severe complication and requires immediate communication with the registered nurse?

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Answer: A client taking warfarin for atrial fibrillation who has an International Normalized Ratio (INR) of 5.2

Answer

The client taking warfarin who has an International Normalized Ratio (INR) of 5.2.
An International Normalized Ratio (INR) of 5.2 is critically elevated beyond the standard therapeutic target of 2.0 to 3.0 for a client with atrial fibrillation. This places the client at imminent risk for spontaneous, severe hemorrhage. The practical nurse must immediately report this finding to the registered nurse so that anticoagulant medications can be withheld and the provider can determine if an antidote or dosage adjustment is necessary.

Step-by-Step Solution

1
Analyze each client situation to distinguish between routine nursing tasks, independent safety interventions, and critical physiological threats.
The analgesic request and consent signature are routine tasks. The missing ID band is a safety issue the nurse can fix independently. The INR of 5.2 is a critical laboratory abnormality.
Prioritization requires identifying which situation poses the most immediate risk of harm that exceeds the practical nurse's independent scope of practice.
2
Evaluate the clinical significance of an International Normalized Ratio (INR) of 5.2.
An INR of 5.2 is dangerously high and greatly exceeds the standard therapeutic range of 2.0 to 3.0 for a client with atrial fibrillation.
Elevated coagulation times indicate that the client's blood is clotting too slowly, creating a severe risk for internal or spontaneous bleeding.
3
Determine the appropriate nursing action for the critical finding.
The practical nurse must immediately communicate this critical laboratory value to the registered nurse.
The registered nurse must collaborate with the healthcare provider to potentially hold medications, administer antidotes, or order further diagnostic testing.

Key Concept

Prioritization of critical laboratory values and bleeding risks
Question 749Question →

A 68-year-old client is recovering from abdominal surgery. The practical nurse (PN) is reviewing the medication administration record and current client data. The client's vital signs are: blood pressure 88/54 mm Hg, heart rate 118 beats/min, and respiratory rate 20 breaths/min. The provider has prescribed oral lisinopril, subcutaneous enoxaparin, and a continuous intravenous (IV) analgesic infusion. Which of the following actions by the PN are correct? Select all that apply.

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Answer: Withholding the scheduled oral lisinopril and notifying the registered nurse (RN) of the current vital signs.; Reinforcing education with the client regarding bleeding precautions prior to the enoxaparin injection.; Administering the subcutaneous enoxaparin injection into the anterolateral abdominal wall.

Answer

The correct actions are withholding the lisinopril and notifying the RN, reinforcing bleeding precautions, and administering the enoxaparin into the anterolateral abdominal wall.
The practical nurse demonstrates safe care by withholding the antihypertensive medication in the presence of significant hypotension and escalating the abnormal vital signs to the RN. Furthermore, reinforcing previously taught information about bleeding risks associated with anticoagulants and utilizing the correct anatomical site (abdomen) for subcutaneous enoxaparin are safe, standard practices within the practical nursing scope.

Step-by-Step Solution

1
Analyze the client's vital signs in relation to the prescribed medications.
The client is hypotensive (88/54 mm Hg) and tachycardic (118 beats/min). Lisinopril is contraindicated at this time.
Administering an antihypertensive to a hypotensive client compromises safety and perfusion.
2
Evaluate the remaining tasks against the PN scope of practice.
Reinforcing teaching and administering subcutaneous injections are within the PN scope. Titrating IV infusions is out of scope.
The PN must only perform tasks that are legally and clinically within their designated role.
3
Review standard medication administration procedures.
Two client identifiers must always be checked, and abnormal vital signs must be reported, not ignored.
Adhering to National Patient Safety Goals prevents medication errors and recognizes early signs of clinical deterioration.

Key Concept

Safe Pharmacological Administration and Scope of Practice
Question 750Question →

During a routine wellness clinic visit for a 24-month-old toddler, the practical nurse (PN) observes the child's behavior and gathers developmental data from the parents. Which observation represents a deviation from expected developmental milestones that the PN should report to the provider?

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Answer: The toddler uses only single words and does not combine words to communicate.

Answer

The observation that the toddler uses only single words and does not combine words to communicate.
At 24 months of age, a toddler is expected to have a vocabulary of at least 50 words and be able to combine two words into simple phrases (e.g., 'want milk' or 'go bye-bye'). The inability to combine words at this stage indicates a potential expressive language delay that must be reported to the provider or RN for comprehensive assessment.

Step-by-Step Solution

1
Identify the client's age and the purpose of the data collection.
The client is a 24-month-old toddler undergoing a developmental screening.
Developmental milestones are highly age-specific, making precise age identification critical for accurate data interpretation.
2
Recall the expected motor, language, and psychosocial milestones for a 24-month-old.
Expected milestones include a 50+ word vocabulary, using 2-word phrases, running, kicking a ball, and engaging in parallel play.
Comparing collected observational data against expected physiological baselines is the core of developmental screening.
3
Evaluate each observed finding to determine if it is age-appropriate or abnormal.
Parallel play, temper tantrums, and an inability to balance on one foot are entirely normal for a 24-month-old. However, using only single words is a delay.
Recognizing which findings deviate from the norm determines what must be reported to the provider for further assessment.
4
Select the finding that represents a developmental delay.
The inability to combine words is identified as the priority reportable finding.
Early identification of expressive language delays allows for timely intervention and support.

Key Concept

Pediatric Growth and Developmental Data Collection
Estimated Time:1m 0s
Question 751Question →

A client in a long-term care facility is scheduled for a percutaneous endoscopic gastrostomy (PEG) tube placement. The provider has already discussed the procedure with the client. When the practical nurse (PN) brings the written consent form to the client's room, which action is appropriate for the PN to perform?

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Answer: Confirm that the client is willingly agreeing to the procedure without coercion.

Answer

Confirm that the client is willingly agreeing to the procedure without coercion.
The practical nurse acts as a witness during the informed consent process. This legal responsibility involves authenticating the client's signature, verifying their identity, and ensuring they are signing the document voluntarily without any external pressure.

Step-by-Step Solution

1
Identify the practical nurse's legal role in the informed consent process.
The PN acts solely as a client advocate and witness to the signature.
Understanding scope of practice prevents legal liability and ensures client safety.
2
Differentiate between the provider's duty and the nurse's duty.
The provider explains risks, benefits, and alternatives. The nurse ensures the client understands the explanation and signs voluntarily.
The provider is performing the procedure and holds the legal duty to inform.
3
Select the option that aligns with the PN's capacity as a witness.
Confirming voluntary agreement aligns perfectly with the appropriate nursing role.
This action does not cross into the provider's responsibility of explaining medical details or an RN's responsibility of complex assessment.

Key Concept

The practical nurse's role in informed consent is strictly limited to witnessing the client's signature, confirming their identity, and ensuring the agreement is completely voluntary.
Estimated Time:45s
Question 752Question →

During a busy shift on a medical-surgical floor, the registered nurse (RN) delegates several actions to the practical nurse (PN). Which assigned task falls within the legal scope of practice for the PN and is safe to accept?

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Answer: Reinforcing discharge instructions about wound care for a stable client.

Answer

The task within the practical nurse's scope of practice is reinforcing discharge instructions about wound care for a stable client.
Reinforcing established teaching, such as reviewing wound care instructions with a stable client, is well within the practical nurse's scope of practice. The RN is responsible for providing the initial education, and the PN follows up to reinforce the information and ensure client understanding.

Step-by-Step Solution

1
Identify the tasks that require advanced clinical judgment, initial evaluation, or high-risk pharmacological interventions.
Admission assessments, care plan formulation, and IV push medications are identified as strictly RN-level responsibilities.
These tasks involve complex analysis and immediate systemic risks that exceed the foundational scope of practical nursing.
2
Evaluate the remaining tasks for safety and appropriateness within the practical nurse's role.
Reinforcing teaching that was initially provided by the RN or provider for a stable client is determined to be appropriate.
Practical nurses are legally permitted and trained to reinforce established educational plans and care for medically stable clients.

Key Concept

Practical Nurse Scope of Practice in Task Delegation
Estimated Time:45s
Question 753Question →

Match each clinical task with the interprofessional team member who is most appropriate and legally permitted to perform it.

Click a left item, then click its matching right item

Items

Completing the initial comprehensive physical assessment for a newly admitted client
Reinforcing dietary education for a client newly diagnosed with type 2 diabetes
Documenting the total shift oral intake and urine output for a stable client
Explaining the surgical risks and benefits to a client prior to obtaining informed consent

Matches

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Answer

Initial assessment matches to the RN. Reinforcing education matches to the LPN/VN. Documenting intake and output matches to the AP. Explaining surgical risks matches to the HCP.
Each task must be matched to the legally defined scope of practice. The RN completes initial comprehensive assessments; the LPN/VN reinforces established teaching; the AP performs routine data collection like intake/output; and the HCP explains procedures for informed consent.

Step-by-Step Solution

1
Evaluate the requirement for initial comprehensive assessment.
This task must be assigned to the Registered Nurse.
Initial assessments and the creation of care plans require advanced nursing judgment.
2
Determine the appropriate scope for reinforcing education.
This task aligns with the scope of the Licensed Practical/Vocational Nurse.
LPNs/VNs may reinforce teaching originally provided by the RN for stable clients.
3
Identify the team member for routine documentation of intake and output.
This is safely delegated to Assistive Personnel.
Measuring intake and output is a routine, standard task with predictable outcomes.
4
Determine who is responsible for explaining surgical risks for informed consent.
This is the exclusive responsibility of the Health Care Provider.
Only the practitioner performing the procedure can explain its specific risks, benefits, and alternatives.

Key Concept

Delegation and Scope of Practice within the Interprofessional Team
Question 754Question →

While performing afternoon rounds at a skilled nursing facility, the practical nurse observes that a client currently being treated for a urinary tract infection is unusually lethargic and takes several seconds to answer simple questions. The client's baseline mental status is fully alert and oriented. Current vital signs reveal a temperature of 97.2°F (36.2°C), a heart rate of 108 beats/minute, a respiratory rate of 26 breaths/minute, and a blood pressure of 94/56 mm Hg. What is the priority nursing action?

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Answer: Immediately communicate the vital signs and altered mental status to the registered nurse.

Answer

Immediately communicate the vital signs and altered mental status to the registered nurse.
The client is demonstrating classic signs of clinical deterioration and impending septic shock, which include altered mental status, hypothermia (common in older adults with sepsis), tachycardia, tachypnea, and hypotension. The practical nurse's immediate priority is to recognize this life-threatening shift in physiological adaptation and escalate the findings to the registered nurse to facilitate prompt emergency treatment.

Step-by-Step Solution

1
Analyze the client's current vital signs and mental status against their baseline.
The client has a new onset of lethargy, hypothermia, tachycardia, tachypnea, and hypotension.
Identifying acute deviations from baseline is essential to recognize clinical deterioration.
2
Synthesize the data in the context of the current diagnosis (urinary tract infection).
The combination of infection and these specific vital sign changes indicates a systemic inflammatory response, pointing toward septic shock.
Sepsis can present atypically in older adults, often with hypothermia rather than fever, alongside cardiovascular compromise.
3
Determine the priority action within the practical nurse's scope of practice.
The priority is to escalate the critical findings to the registered nurse for immediate collaborative intervention.
Septic shock is a life-threatening emergency that requires rapid fluid resuscitation and intravenous antibiotics, necessitating immediate RN and provider involvement.

Key Concept

Recognition of Sepsis and Septic Shock
Question 755Question →

A practical nurse (PN) is assigned to a 68-year-old client who is 4 hours postoperative following a total thyroidectomy. The client's current vital signs are: blood pressure 94/58 mm Hg (baseline 132/82 mm Hg), heart rate 116 beats/minute, and respiratory rate 24 breaths/minute. The client is also experiencing new-onset restlessness and confusion. Which of the following actions should the PN take? (Select all that apply.)

Select all that apply

Show answer & explanation

Answer: Notify the registered nurse (RN) and healthcare provider immediately about the client's status.; Inspect the surgical dressing and the area behind the client's neck for pooling blood.; Verify that suction equipment and an emergency tracheostomy tray are readily accessible.

Answer

The correct actions are to notify the registered nurse (RN) immediately, inspect the dressing and the back of the neck for bleeding, and verify that emergency airway equipment is accessible.
The client is demonstrating signs of acute physiological decompensation, specifically early hypovolemic shock (tachycardia, hypotension) and hypoxia (restlessness, confusion), likely due to postoperative hemorrhage or airway compromise. Appropriate actions include immediately notifying the RN, assessing the surgical site and the dependent area behind the neck for pooling blood, and ensuring emergency airway equipment is available due to the high risk of airway obstruction following a thyroidectomy.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has tachycardia, hypotension, tachypnea, and new-onset confusion compared to their baseline.
These are hallmark signs of impaired tissue perfusion, hypoxia, and potential hypovolemic shock, requiring immediate attention.
2
Identify the specific surgical risks.
A total thyroidectomy carries high risks for hemorrhage and airway obstruction due to edema or bleeding in the neck.
Understanding procedure-specific complications guides targeted data collection and emergency preparation.
3
Determine the priority nursing actions within the PN scope of practice.
The PN must immediately escalate the findings to the RN, physically inspect for hemorrhage (including dependent areas), and ensure airway rescue equipment is present.
Recognizing acute instability requires rapid collaboration and safeguarding of the client's airway and circulation before the condition worsens.

Key Concept

Recognizing and managing acute postoperative complications (hemorrhage, airway obstruction) and prioritizing airway, breathing, and circulation (ABCs).
Question 756Question →

A practical nurse (PN) is reviewing the medication administration record and morning laboratory results for a client with end-stage renal disease. The client is scheduled to receive oral sevelamer, subcutaneous epoetin alfa, and oral lisinopril. The laboratory results indicate a serum potassium of 5.8 mEq/L, hemoglobin of 11.5 g/dL, and serum phosphorus of 6.5 mg/dL. The client's blood pressure is 148/88 mm Hg. Which of the following actions should the PN take? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Withhold the scheduled dose of oral lisinopril.; Notify the registered nurse (RN) regarding the client's laboratory results.; Administer the oral sevelamer while the client is eating their morning meal.

Answer

The correct actions are to withhold the oral lisinopril, notify the registered nurse (RN) of the laboratory results, and administer the oral sevelamer with the client's meal.
In a client with end-stage renal disease, managing medications around critical laboratory values is essential. Lisinopril (an ACE inhibitor) must be withheld because it can exacerbate the client's hyperkalemia (potassium 5.8 mEq/L). The phosphate binder sevelamer must be administered directly with meals to effectively bind to dietary phosphorus and lower the elevated serum phosphorus (6.5 mg/dL). Finally, the PN must strictly operate within their scope of practice by notifying the RN of these critical laboratory values and the withheld medications to ensure collaborative management.

Step-by-Step Solution

1
Analyze the client's morning laboratory results against normal reference ranges.
The potassium (5.8 mEq/L) is high, hemoglobin (11.5 g/dL) is above the target range for epoetin therapy, and phosphorus (6.5 mg/dL) is high.
Recognizing critical laboratory values is the first step in ensuring safe medication administration.
2
Evaluate the scheduled medications in relation to the abnormal laboratory findings.
Lisinopril worsens hyperkalemia, epoetin alfa is contraindicated with hemoglobin > 11.0 g/dL, and sevelamer treats hyperphosphatemia when given with food.
Medications must be correlated with current data to determine if they should be administered or withheld.
3
Determine the appropriate interventions within the practical nurse scope of practice.
The PN must withhold the unsafe medications (lisinopril, epoetin alfa), administer the safe medication correctly (sevelamer with meals), and escalate the findings to the RN.
The PN is responsible for safe medication administration and timely reporting of significant changes.

Key Concept

Pre-administration Assessment of Laboratory Values and PN Scope of Practice
Question 757Question →

A practical nurse (PN) is preparing to leave the facility at the end of their shift. The PN has a handwritten report sheet containing client names, vital signs, and room numbers that was used to organize care during the day. Which of the following is the appropriate action for the PN to take regarding this document?

Show answer & explanation

Answer: Place the document in a secure, designated shredding bin before leaving the facility.

Answer

The appropriate action is to place the document in a secure, designated shredding bin before leaving the facility.
Placing physical documents containing protected health information in a secure, designated shredding receptacle guarantees that the confidential client data is irretrievably destroyed. This complies with legal and ethical standards for maintaining client confidentiality.

Step-by-Step Solution

1
Identify the type of information contained on the handwritten report sheet.
The sheet contains client names, vital signs, and room numbers.
Determining the nature of the information is necessary to apply the correct handling procedures.
2
Classify the information according to privacy regulations.
The data constitutes protected health information (PHI).
Identifying the data as PHI dictates that it must be protected under HIPAA guidelines and facility policies.
3
Determine the appropriate method of disposal for physical PHI.
Physical documents containing PHI must be completely and securely destroyed before leaving the clinical area.
Secure destruction prevents unauthorized access to confidential client information after it is no longer needed.

Key Concept

Secure Disposal of Physical Protected Health Information
Estimated Time:45s
Question 758Question →

A facility evaluator is observing a staff member don personal protective equipment prior to entering a room that requires contact and droplet precautions. The staff member has just performed hand hygiene and secured a clean isolation gown. What is the correct next step in the donning sequence?

Show answer & explanation

Answer: Apply a standard surgical mask.

Answer

Apply a standard surgical mask.
The correct sequence for donning personal protective equipment is to perform hand hygiene, don the gown, secure the mask or respirator, apply goggles or a face shield, and finally pull on the gloves. Because the staff member has just secured the gown, applying the surgical mask is the immediate next step to properly protect the respiratory tract before addressing eye protection or hand coverage.

Step-by-Step Solution

1
Recall the standardized Centers for Disease Control and Prevention (CDC) sequence for donning personal protective equipment.
The correct sequence is: hand hygiene, gown, mask or respirator, goggles or face shield, and finally gloves.
Adhering to the specific order ensures optimal protection and minimizes the risk of cross-contamination.
2
Determine the staff member's current progression in the donning sequence based on the scenario.
The staff member has successfully completed hand hygiene and secured the isolation gown.
Identifying the current step allows the nurse to accurately determine the immediate next required action.
3
Select the appropriate item that follows the gown in the sequence.
The standard surgical mask must be applied next to protect the mucous membranes.
The mask must be secured to the face before placing the face shield over it, and gloves are always applied last over the gown cuffs.

Key Concept

Standard PPE Donning Sequence
Question 759Question →

During a community health visit, a practical nurse (PN) is evaluating an infant who has just reached 6 months of age. The parents are anxious to know if their baby's physical and social progress is on track. Which finding should the PN recognize as a significant deviation from expected developmental milestones that warrants a referral?

Show answer & explanation

Answer: The infant's head falls backward when pulled by the arms into a sitting posture.

Answer

The infant's head falling backward (head lag) when pulled to a sitting position.
By 4 months of age, an infant should have sufficient neck strength and head control so that there is no head lag when pulled to a sitting position. The presence of significant head lag at 6 months is an abnormal finding that indicates poor muscle tone or a potential neurological deficit (such as cerebral palsy) and requires prompt reporting for further medical evaluation.

Step-by-Step Solution

1
Analyze the client's age and the developmental domains being assessed.
The client is a 6-month-old infant. The observations cover gross motor, fine motor, and psychosocial development.
Accurate assessment requires matching the infant's chronological age with expected milestone timelines.
2
Evaluate the fine motor, gross motor, and psychosocial findings against 6-month developmental expectations.
Tripod sitting (leaning on hands), the raking grasp (sweeping motion), and stranger anxiety (crying when approached) are all normal and expected findings for a 6-month-old.
Identifying expected behaviors eliminates normal variations from the list of concerns.
3
Identify the finding that falls outside the normal timeline for milestone achievement.
Head lag when pulled to a sitting position is observed. This reflex should completely disappear by 4 months of age.
Persistent head lag at 6 months suggests abnormal hypotonia or a neurological deficit, requiring immediate provider notification.

Key Concept

Infant Developmental Milestones and Red Flags
Question 760Question →

An adult client whose primary language is not English is scheduled for a below-the-knee amputation. The surgeon previously obtained the signed informed consent utilizing a certified medical interpreter. As a practical nurse (PN) prepares to administer an ordered preoperative sedative, the client becomes tearful, points to the leg, and states in broken English, 'No cut leg, only toes.' The unit charge nurse tells the PN, 'The consent is already legally signed. Just review the paperwork with the client and administer the medication.' Which action by the PN demonstrates appropriate client advocacy?

Show answer & explanation

Answer: Delay the administration of the sedative and insist that the surgeon evaluate the client's current understanding of the procedure.

Answer

The priority advocacy action is to delay the administration of the sedative and insist that the surgeon evaluate the client's current understanding of the procedure.
The correct action demonstrates client advocacy by protecting the client's right to informed consent. When a client expresses a fundamental misunderstanding of a scheduled surgery, their previous consent is invalidated. The practical nurse (PN) must act as a client advocate by withholding any preoperative sedatives—which would alter the client's cognition—and immediately notifying the provider. Furthermore, the PN must recognize that the charge nurse's directive is an inappropriate delegation; assessing comprehension of complex medical procedures and clarifying surgical risks are outside the PN's legal scope of practice. Only the performing provider can clarify the procedure.

Step-by-Step Solution

1
Analyze the client's statement
The client's statement ('No cut leg, only toes') indicates a complete misunderstanding of the scheduled below-the-knee amputation.
Identifying knowledge deficits is the first step in recognizing that informed consent has been compromised.
2
Determine the legal and ethical implications
A signed piece of paper does not override the client's current lack of comprehension. The client cannot give legally binding informed consent without understanding the true anatomical extent of the surgery.
Informed consent is an ongoing process of understanding, not just a signature on a form.
3
Evaluate the charge nurse's directive
The charge nurse's order to 'review the paperwork' and administer the sedative requires the PN to assess comprehension and perform primary teaching, which is outside the PN scope of practice.
The PN must refuse inappropriate delegation that endangers the client or violates legal scopes of practice.
4
Select the appropriate advocacy intervention
The PN must withhold the preoperative sedative (which would impair the client's ability to consent) and escalate the issue directly to the provider.
Only the healthcare provider who is performing the procedure can legally provide primary education and clarify the surgical details.

Key Concept

Client Advocacy and Scope of Practice in Informed Consent
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