All practice questions

2933 questions

All types2,933 Multiple choice1,506 Multiple select653 Numeric68 Matching70 Ordering636

A practical nurse (PN) is assigned to care for a diverse group of clients on a medical-surgical unit. Which of the following data collection and reporting actions by the PN demonstrate appropriate scope of practice and clinical understanding? Select all that apply.

Select all that apply

Palpating the uterine fundus to evaluate firmness and location on a client who is 24 hours postpartum.

Documenting sudden-onset confusion in an older adult client as an expected age-related change without notifying the registered nurse (RN).

Evaluating pupillary light response as part of a focused neurological check for a client with a recent mild concussion.

Formulating a revised nursing care plan after auscultating newly developed bilateral lung crackles in a client with heart failure.

Auscultating the apical pulse for one full minute before administering a scheduled oral dose of digoxin.

Withholding notification to the RN regarding a steadily increasing heart rate and decreasing blood pressure in a postoperative client because the values are borderline.

Show answer & explanation

Answer: Palpating the uterine fundus to evaluate firmness and location on a client who is 24 hours postpartum.; Evaluating pupillary light response as part of a focused neurological check for a client with a recent mild concussion.; Auscultating the apical pulse for one full minute before administering a scheduled oral dose of digoxin.

Answer

The correct actions include palpating the postpartum uterine fundus, evaluating pupillary light response for a concussion client, and auscultating the apical pulse for a full minute before administering digoxin.

Within the practical nurse (PN) scope of practice, appropriate data collection involves focused, standardized techniques. Palpating the uterine fundus for firmness in a postpartum client, evaluating pupillary response in a client with a concussion, and auscultating the apical pulse for one full minute before giving digoxin are all examples of focused, task-oriented data collection techniques that fall safely within the PN's scope and ensure safe client care.

Step-by-Step Solution

Analyze the role of the practical nurse (PN) in data collection across various clinical populations.

The PN is responsible for gathering focused physical data, performing specific vital sign techniques accurately, and recognizing abnormal findings to report to the registered nurse (RN).

Understanding the PN scope of practice helps separate appropriate data collection tasks from those requiring RN-level comprehensive assessment or clinical judgment.

Evaluate the correct actions based on the scope of focused data collection.

Palpating a postpartum fundus, checking a pupillary response, and auscultating an apical pulse for 60 seconds prior to digoxin administration are all focused, task-oriented techniques within the PN's scope.

These actions involve collecting specific data points for stable or predictable client conditions without requiring independent care plan formulation.

Identify the incorrect actions based on clinical traps and scope limitations.

Assuming sudden confusion is normal aging, revising a care plan independently, and ignoring borderline shock signs are incorrect actions.

Sudden confusion indicates delirium (often from infection), care plan revision is an RN duty, and borderline dropping vital signs in a postoperative client suggest early shock and require immediate reporting.

Key Concept

The practical nurse (PN) scope includes performing focused, task-oriented data collection and promptly reporting abnormal or changing conditions to the RN.

Question 822Question →

During a shift in a neurological rehabilitation unit, a client with a traumatic brain injury becomes intensely agitated after a sudden schedule change. The client begins pacing the hallway rapidly, clenching their fists, and shouting at staff. Arrange the following nursing interventions in the correct sequence, prioritizing from least restrictive to most restrictive.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence from least to most restrictive is: verbal de-escalation, voluntary environmental modification, oral PRN medication, IM chemical restraint, and finally mechanical restraints.

Behavioral management follows a strict hierarchy designed to protect client rights, dignity, and safety. The nurse must always begin with the least restrictive intervention (verbal de-escalation), progress to environmental changes (quiet room), step up to voluntary chemical interventions (oral medication), move to rapid-acting chemical restraints (IM medication), and only use physical interventions (mechanical restraints) as a final, emergency option to prevent imminent harm.

Step-by-Step Solution

Identify the least restrictive and least invasive intervention.

Select verbal de-escalation techniques.

Standard behavioral guidelines require starting with non-physical, non-chemical communication to help the client regain control independently.

Determine the next level of intervention involving the milieu.

Select offering a voluntary transition to a quiet room.

Environmental modification is slightly more restrictive than simple conversation but still relies on voluntary client cooperation.

Identify the least invasive pharmacological intervention.

Select administering a prescribed PRN oral sedative.

Voluntarily taking an oral medication is less invasive and less restrictive than receiving an involuntary or rapid-acting injection.

Determine the next pharmacological step if severe agitation persists.

Select administering a prescribed IM medication.

IM injections are considered a chemical restraint when used to rapidly manage severe agitation, making them highly restrictive.

Identify the most restrictive safety intervention.

Select applying mechanical restraints.

Physical or mechanical restraints completely eliminate the client's mobility and are only legally and ethically permissible as a final alternative to prevent imminent injury.

Key Concept

Hierarchy of Restrictive Interventions

Question 823Question →

An assigned client has left-sided hemiplegia resulting from a recent cerebrovascular accident. The healthcare provider prescribes out-of-bed activity to a chair for all meals. Arrange the following nursing actions for a safe bed-to-wheelchair transfer in the correct chronological order. (Place the initial action at the top and the final action at the bottom.)

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct chronological sequence prioritizes environmental safety first, followed by physiological adaptation (dangling), equipment application (gait belt), biomechanical stabilization (bracing the weak leg), standing utilizing the strong side, and finally pivoting to safely complete the transfer.

Executing a safe transfer for a client with hemiplegia requires a highly systematic approach based on biomechanical principles. The sequence must begin with securing the environment by placing the chair on the client's strong (right) side. Next, physiological safety is ensured by having the client dangle to prevent orthostatic hypotension. Once seated safely, the gait belt is applied to provide the nurse with a safe handling point. Before standing, the nurse must physically brace the weak (left) leg to prevent it from buckling under the client's weight. The client then actively participates by pushing up with their strong (right) arm. Finally, a controlled pivot leads the client to the chair, where they reach for the armrest to guide a safe descent.

Step-by-Step Solution

Prepare the wheelchair on the client's right side and lock brakes.

The environment is secure and oriented for a strong-side transfer.

Clients with hemiplegia must always transfer toward their unaffected side to utilize their intact muscle strength and coordination.

Assist the client to dangle and assess for dizziness.

The client adapts to the upright posture safely.

Moving a client from supine to standing too quickly risks orthostatic hypotension, which could cause a sudden fall during the transfer.

Apply a gait belt securely around the waist.

A safe handling interface is established.

A gait belt provides a center-of-gravity hold, preventing the nurse from lifting the client by their flaccid or weak arms.

Brace the client's left knee.

The hemiplegic leg is externally stabilized.

The affected leg lacks the motor control to support body weight independently and will collapse unless physically blocked by the nurse's knee.

Have the client push off the bed with their right hand to stand.

The client reaches a standing position.

Pushing off a solid surface (the mattress) with the unaffected arm maximizes the client's functional ability and reduces the physical load on the nurse.

Pivot toward the chair and have the client reach for the armrest.

The transfer is completed safely.

Pivoting as a single unit maintains alignment, and grasping the armrest provides necessary support to control the sitting motion.

Key Concept

Safe mobility and transfer techniques for clients with hemiplegia require utilizing the unaffected side for weight-bearing and spatial orientation, while physically supporting the affected side.

Question 824Question →

A client with major depressive disorder is admitted to the inpatient psychiatric unit with active suicidal ideation. The registered nurse has initiated suicide precautions. In which order should the practical nurse (PN) implement the following actions? (Arrange from first action to last.)

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence prioritizes immediate life-safety (continuous observation), followed by the removal of environmental hazards (searching belongings), assessment for hidden hazards/injuries (changing into a gown), therapeutic communication (explaining the rationale), and finally, administrative duties (documentation).

In psychiatric emergencies involving active suicidal ideation, nursing prioritization follows the hierarchy of immediate physical safety. Continuous one-to-one observation ensures the client is never left alone, making it the most critical initial intervention. Next, removing environmental hazards and changing the client into a gown prevents access to contraband that could be used for self-harm. Once the physical environment and the client's person are secured, the nurse addresses psychosocial needs by explaining the rationale for the precautions. Finally, after all direct care is completed, the nurse documents the events and findings in the medical record.

Step-by-Step Solution

Establish continuous visual observation.

The client is immediately protected from attempting self-harm.

Immediate life-safety is the highest priority. A suicidal client must never be left unobserved while other tasks are completed.

Search belongings and remove hazards.

Means of self-harm are removed from the client's immediate environment.

Once the client is actively observed, environmental risks must be systematically mitigated.

Assist into a gown and observe the skin.

Hidden contraband is discovered, and existing injuries are noted.

This further secures physical safety on the client's person and contributes to the admission data collection.

Explain the rationale for the precautions.

The client understands the purpose of the restrictive measures.

Psychosocial interventions follow physical safety. Explaining the rules helps de-escalate fear and builds rapport.

Document the interventions and findings.

The medical record accurately reflects the care provided.

Charting must be completed only after all direct client care and life-safety measures are securely in place.

Key Concept

Prioritization of physical safety and least-restrictive environment in clients with active suicidal ideation.

Question 825Question →

A practical nurse (PN) is providing care for a client who is 12 hours post-operative following a left-sided pneumonectomy for lung cancer. Which basic care and comfort interventions should the PN implement? Select all that apply.

Select all that apply

Elevate the head of the bed to a semi-Fowler's position.

Turn the client onto the right, unoperated side every two hours.

Provide a firm pillow for the client to splint the chest incision when coughing.

Encourage early, gentle range-of-motion exercises for the left arm and shoulder.

Lower the head of the bed completely flat when repositioning the client.

Instruct the client to suppress coughing to prevent tension on the chest incision.

Show answer & explanation

Answer: Elevate the head of the bed to a semi-Fowler's position.; Provide a firm pillow for the client to splint the chest incision when coughing.; Encourage early, gentle range-of-motion exercises for the left arm and shoulder.

Answer

The correct interventions are elevating the head of the bed to a semi-Fowler's position, providing a firm pillow for splinting the incision, and encouraging early range-of-motion exercises for the operative arm and shoulder.

The correct interventions focus on maximizing respiratory function and managing localized pain. Elevating the head of the bed allows gravity to pull the diaphragm downward, maximizing lung expansion. Providing a pillow for splinting minimizes incision pain during necessary coughing, making the client more willing to clear secretions. Finally, encouraging gentle range-of-motion exercises for the arm and shoulder on the operative side prevents joint stiffness and contractures, which are common sources of delayed post-operative pain after chest surgery.

Step-by-Step Solution

Identify the surgical procedure and its physiological impact.

The client had a left pneumonectomy, meaning the entire left lung was removed. The client relies entirely on the remaining right lung for oxygenation and gas exchange.

Understanding the anatomical changes is required to determine safe positioning and care.

Determine appropriate positioning to optimize ventilation.

A semi-Fowler's position is indicated. Positioning on the unoperated side must be avoided.

Gravity helps pull the diaphragm downward in semi-Fowler's, maximizing the expansion of the remaining lung. Laying on the good lung would compress it and limit ventilation.

Select basic comfort measures that prevent post-operative complications specific to thoracic surgery.

Splinting the incision and performing range-of-motion exercises are selected.

Splinting controls pain to allow for vital airway clearance. Arm movement prevents 'frozen shoulder' contractures on the operative side.

Evaluate the remaining options for potential risks.

Lowering the head of the bed flat and suppressing coughs are identified as unsafe actions.

Both actions prioritize secondary concerns (shearing forces, incision tension) over primary airway and breathing needs (ABC prioritization).

Key Concept

Post-Operative Thoracic Care and Positioning

Question 826Question →

A client with a history of seizure disorder is receiving continuous enteral nutrition via a gastrostomy tube. The healthcare provider prescribes liquid phenytoin to be administered via the gastrostomy tube every $12\text{ hours}$ . Which action by the practical nurse (PN) demonstrates safe and effective pharmacological management?

Pause the continuous enteral feeding for

1

2\text{ hours}

prior to and following the administration of the medication.

Add the prescribed volume of the liquid medication directly into the hanging enteral nutrition formula bag.

Delegate the administration of this scheduled liquid medication to an unlicensed assistive personnel (UAP).

Proceed with administering the scheduled dose after noting a morning serum phenytoin level of

28\text{ mcg/mL}

Show answer & explanation

Answer: Pause the continuous enteral feeding for $1$ to $2\text{ hours}$ prior to and following the administration of the medication.

Answer

The correct action is to pause the continuous enteral feeding for

1

2\text{ hours}

before and after administering the liquid phenytoin.

Enteral feeding formulas contain high amounts of proteins that strongly bind to phenytoin, significantly decreasing its absorption in the gastrointestinal tract. To prevent subtherapeutic serum drug levels and subsequent breakthrough seizures, the practical nurse must pause the continuous feeding for

1

2\text{ hours}

before and after administering the scheduled medication dose. The tube must also be flushed adequately with water before and after the dose.

Step-by-Step Solution

Identify the prescribed medication and the client's current method of nutritional support.

The client is receiving liquid phenytoin and continuous enteral nutrition formula via a gastrostomy tube.

Understanding the concurrent therapies is the essential first step in identifying potential drug-nutrient interactions.

Evaluate potential interactions between oral phenytoin and enteral feeding formulas.

Enteral nutrition formulas significantly decrease the gastrointestinal absorption of phenytoin.

Phenytoin binds strongly to the proteins present in the enteral formula, which can lead to subtherapeutic serum drug levels and poor seizure control.

Determine the appropriate nursing intervention to prevent the drug-nutrient interaction.

The continuous enteral feeding must be stopped for a specific window of time (

1

2\text{ hours}

) before and after the medication is given.

This time window allows the stomach to empty, preventing the formula from binding to the medication and ensuring adequate drug absorption.

Key Concept

Drug-Nutrient Interactions and Safe Enteral Medication Administration

Question 827Question →

Following the vaginal delivery of a macrosomic infant 2 hours ago, a 25-year-old client reports feeling extremely thirsty and dizzy. The practical nurse (PN) observes that the uterine fundus is boggy and displaced to the right of the umbilicus. Additionally, the client's perineal pad has been completely saturated with lochia rubra within the last 30 minutes. Current vital signs reveal a heart rate of 112 beats/min and a blood pressure of 100/60 mm Hg. Which actions should the PN take? Select all that apply.

Select all that apply

Massage the uterine fundus firmly until it contracts.

Notify the registered nurse (RN) immediately about the clinical findings.

Weigh the saturated perineal pads to accurately quantify the client's blood loss.

Reassure the client that saturating one pad in 30 minutes is expected at this stage.

Administer a prescribed intravenous (IV) push dose of oxytocin to control the bleeding.

Delegate the continuous monitoring of the client's vital signs to an unlicensed assistive personnel (UAP).

Show answer & explanation

Answer: Massage the uterine fundus firmly until it contracts.; Notify the registered nurse (RN) immediately about the clinical findings.; Weigh the saturated perineal pads to accurately quantify the client's blood loss.

Answer

The appropriate actions are to massage the uterine fundus firmly, immediately notify the registered nurse, and weigh the saturated pads to quantify blood loss.

The client's presentation of a boggy, displaced fundus with rapid pad saturation, tachycardia, and dizziness are classic signs of postpartum hemorrhage and early hypovolemic shock (compounded by a full bladder). The immediate priority is to physically stimulate the uterus to contract by massaging the fundus. Because the client is hemodynamically unstable, the PN is required to immediately notify the RN to facilitate advanced interventions. Weighing the saturated pads is an appropriate independent data collection action within the PN's scope to precisely quantify blood loss for the healthcare provider.

Step-by-Step Solution

Analyze the client's clinical findings and symptom presentation.

The combination of a boggy fundus, saturated pad in 30 minutes, dizziness, thirst, and tachycardia indicates active postpartum hemorrhage and early hypovolemic shock.

Recognizing life-threatening complications is the first step in prioritizing clinical interventions.

Determine the immediate priority physical intervention.

The nurse must immediately massage the boggy fundus.

Fundal massage mechanically stimulates the uterine muscle fibers to contract, which is the most direct way to tamponade bleeding vessels at the placental site.

Evaluate the planned actions against the PN scope of practice.

The PN must report the unstable findings to the RN and collect data by weighing pads, while avoiding out-of-scope actions like IV push medications or improper delegation.

Maintaining client safety requires strict adherence to legal and professional boundaries regarding task delegation and medication administration.

Key Concept

Recognition of postpartum hemorrhage and adherence to PN scope of practice during obstetric emergencies.

Question 828Question →

A client of Hindu faith is receiving palliative care and is rapidly declining. Extended family members have gathered in the room to support the client during their final days. Which actions should the licensed practical nurse (LPN) take to provide culturally and spiritually competent care? Select all that apply.

Select all that apply

Ensure the client's sacred thread remains undisturbed on their body.

Offer a clear liquid dietary tray including warm beef broth to maintain hydration.

Comfort the grieving family by assuring them that the client is going to a better place.

Provide privacy for the family to administer drops of sacred water into the client's mouth.

Explain the specific surgical procedures involved when the family asks about tissue donation.

Support the family's request to ritually wash and prepare the client's body after death.

Show answer & explanation

Answer: Ensure the client's sacred thread remains undisturbed on their body.; Provide privacy for the family to administer drops of sacred water into the client's mouth.; Support the family's request to ritually wash and prepare the client's body after death.

Answer

The appropriate nursing actions are to leave the sacred thread undisturbed, allow the family to administer sacred water, and support the family in washing the body after death.

In Hinduism, end-of-life and post-mortem rituals are deeply sacred. The sacred thread (janoi) worn by some Hindus should not be removed unless absolutely medically necessary. Administering drops of sacred water (such as from the Ganges River) or placing a tulsi (basil) leaf in the mouth is a common ritual for the dying to assist the soul's transition. Additionally, it is traditional for the family of the same gender to ritually wash and prepare the body after death. The nurse should facilitate all of these practices to provide culturally competent care.

Step-by-Step Solution

Identify the client's cultural and spiritual background.

The client practices Hinduism, which involves specific dietary, spiritual, and end-of-life rituals.

Culturally competent care requires knowledge of specific religious practices to honor the client's dignity.

Evaluate the proposed interventions regarding end-of-life traditions.

Sacred threads (janoi), drops of sacred water, and family-led post-mortem washing are highly important Hindu rituals.

Nurses must facilitate and protect these sacred rituals to provide holistic psychosocial care.

Identify inappropriate actions based on LPN scope of practice, dietary restrictions, and therapeutic communication standards.

Beef broth violates dietary laws, explaining surgical procedures exceeds LPN scope, and offering clichés is non-therapeutic.

Ensuring safety and psychosocial integrity means avoiding cultural dietary violations, staying within scope for consent/teaching, and using active listening rather than false reassurance.

Key Concept

Culturally Competent End-of-Life Care in Hinduism

Question 829Question →

While reviewing morning laboratory data for a client prescribed furosemide, a practical nurse observes a serum potassium level of 2.8 mEq/L (2.8 mmol/L). What is the most appropriate initial action by the nurse?

Report the laboratory finding to the registered nurse immediately.

Record the value in the electronic health record and proceed with routine care.

Administer the scheduled morning dose of furosemide as prescribed.

Initiate an intravenous potassium replacement protocol independently.

Show answer & explanation

Answer: Report the laboratory finding to the registered nurse immediately.

Answer

The practical nurse must report the laboratory finding to the registered nurse immediately.

A serum potassium level of 2.8 mEq/L is considered hypokalemia (normal range: 3.5 to 5.0 mEq/L). Furosemide is a potassium-wasting diuretic that can further lower these levels. Within the legal scope of practice, the practical nurse must immediately report this critical laboratory value to the registered nurse or healthcare provider so the diuretic can be held and appropriate potassium replacement prescribed.

Step-by-Step Solution

Identify the normal range for serum potassium.

The expected normal range for serum potassium is 3.5 to 5.0 mEq/L.

Establishing the baseline is necessary to determine if the client's current value is abnormal.

Analyze the client's laboratory value.

The client's level of 2.8 mEq/L indicates severe hypokalemia.

Hypokalemia poses a high risk for life-threatening cardiac dysrhythmias and requires prompt intervention.

Determine the appropriate nursing action within the practical nurse scope of practice.

The finding must be immediately escalated to the registered nurse or healthcare provider.

A critical lab value requires medical evaluation and possible medication adjustments that fall under RN or provider responsibility.

Key Concept

Identifying critical laboratory values and escalating them appropriately

Question 830Question →

An older adult client who recently had a percutaneous endoscopic gastrostomy (PEG) tube placed is receiving continuous enteral nutrition. The client has been incontinent of bowel, and the unlicensed assistive personnel (UAP) requests assistance from the practical nurse to clean the client. The UAP states, "I need to lay the bed completely flat so we can roll him safely without injuring our backs." Which instruction should the practical nurse provide to the UAP?

Keep the feeding pump running, but ensure we roll the client onto the left side to naturally reduce the risk of reflux.

I will lower the bed while you disconnect the feeding tubing from the gastrostomy port to give us more room to maneuver.

We must pause the feeding pump before lowering the head of the bed, and wait to restart it until we raise the bed back up.

Secure the client's hands with soft restraints first, as rolling older adults flat often causes them to reflexively pull their tubes.

Show answer & explanation

Answer: We must pause the feeding pump before lowering the head of the bed, and wait to restart it until we raise the bed back up.

Answer

The practical nurse must instruct the UAP to pause the continuous enteral feeding pump before lowering the head of the bed, and to resume the feeding only after the client is repositioned with the head of the bed elevated.

Lowering the head of the bed below 30 degrees while enteral nutrition is infusing significantly increases the risk of regurgitation and pulmonary aspiration. Even with a percutaneous endoscopic gastrostomy (PEG) tube, gravity is necessary to keep stomach contents from refluxing into the esophagus. The standard of nursing care dictates that the feeding must be paused any time the client needs to be laid flat for turning, bed-making, or hygiene, and resumed immediately upon returning the client to a semi-Fowler's position.

Step-by-Step Solution

Identify the primary clinical risk factors presented in the scenario.

The client is receiving continuous enteral feeding via a PEG tube and requires a flat bed position for safe turning and hygiene care.

Recognizing competing priorities (the need for hygiene vs. the risk of aspiration) is essential for safe basic care.

Analyze the physiological relationship between patient positioning and enteral feedings.

Gravity is required to keep stomach contents from refluxing into the esophagus; laying the client flat eliminates this protection.

Understanding why the head of the bed must remain elevated at least 30 degrees guides the clinical decision-making process.

Determine the safest intervention that accommodates both the hygiene need and the physiological safety requirement.

The feeding must be paused while the bed is flat and immediately resumed once the head of the bed is returned to a safe elevation.

This intervention prevents aspiration while allowing the UAP and nurse to practice safe ergonomics during the linen change.

Key Concept

Aspiration Precautions and Enteral Feeding Positioning

Question 831Question →

A practical nurse (PN) discovers that a large container of concentrated glutaraldehyde solution has accidentally spilled across the floor of the facility's equipment processing room. The chemical fumes are strong, and an unlicensed assistive personnel (UAP) is inside the room, coughing heavily while attempting to mop up the fluid. Which of the following actions should the PN take? Select all that apply.

Select all that apply

Escort the coughing unlicensed assistive personnel out of the processing room immediately.

Close the door to the processing room after evacuating the area to contain the chemical fumes.

Notify the facility's hazardous materials response team or safety officer about the spill.

Perform a comprehensive respiratory assessment on the unlicensed assistive personnel to determine the extent of lung injury.

Check the oxygen saturation of the unlicensed assistive personnel before removing them from the contaminated room.

Instruct the unlicensed assistive personnel to remove their respirator mask before taking off their contaminated gloves.

Show answer & explanation

Answer: Escort the coughing unlicensed assistive personnel out of the processing room immediately.; Close the door to the processing room after evacuating the area to contain the chemical fumes.; Notify the facility's hazardous materials response team or safety officer about the spill.

Answer

The correct actions are to immediately escort the UAP out of the room, close the door to contain the fumes, and notify the designated hazardous materials team.

In any hazardous material emergency, the primary goal is life safety. Evacuating the exposed individual ensures immediate airway protection and removes them from the toxic source. Containing the spill by closing the door prevents the further spread of noxious vapors into vulnerable patient care areas. Finally, utilizing the facility's specific hazmat protocol ensures the spill is safely managed by personnel equipped with the proper training and chemical spill kits.

Step-by-Step Solution

Identify the immediate life-safety threat.

The coughing UAP is actively exposed to toxic chemical fumes in an enclosed space.

Airway and breathing are the highest priorities during a hazardous material exposure.

Rescue the individual in immediate danger.

The UAP is evacuated from the processing room.

Removing the victim from the source of the chemical stops further inhalation exposure.

Confine the hazardous material.

The door to the processing room is closed.

Closing the door prevents toxic vapors from drifting into hallways and patient care areas.

Activate the emergency response protocol.

The hazmat team or safety officer is notified.

Standard nursing staff should not clean large, concentrated chemical spills without specialized training and proper spill kits.

Key Concept

Emergency response to hazardous chemical spills prioritizes immediate personnel evacuation, hazard confinement, and notification of specialized teams, while remaining within the PN scope of practice.

Question 832Question →

The adult child of a resident who is actively dying in a long-term care facility is crying at the bedside. The child states, "I have been here for two days straight. I just want to go home for an hour to shower and change, but I am terrified they will pass away the second I leave." What is the most appropriate response by the licensed practical nurse?

It is completely understandable that you are afraid to leave. I can sit at the bedside with your parent while you take a short break.

Do not worry, based on their current breathing pattern, they will not pass away in the next hour.

You should go home right now, because your exhaustion is likely causing your parent to feel distressed.

This anxiety means you have not reached the acceptance stage of grief yet, which is required before they can pass peacefully.

Show answer & explanation

Answer: It is completely understandable that you are afraid to leave. I can sit at the bedside with your parent while you take a short break.

Answer

The most appropriate response is to validate the family member's fears and offer concrete support by volunteering to sit with the dying client.

The correct response utilizes the therapeutic communication techniques of validation and offering self. It acknowledges the family member's valid fear without minimizing it, and provides a tangible solution (nursing presence) that allows the family member to meet their own basic needs while knowing their loved one is not alone.

Step-by-Step Solution

Analyze the family member's statement to identify their primary emotional and physical needs.

The family member is expressing a fear of their parent dying alone, competing with their own physical need for self-care.

Understanding the underlying emotion (fear/guilt) dictates the appropriate therapeutic intervention.

Evaluate the nurse's response options for therapeutic communication techniques.

Validation, empathy, and offering self are recognized therapeutic techniques that directly address the family member's conflict.

Therapeutic communication should provide support without minimizing feelings, giving unsolicited advice, or offering false promises.

Select the response that acknowledges the family member's feelings and provides a safe solution.

The option offering to sit at the bedside is the only choice that validates the child's feelings while ensuring the client is not left alone.

It addresses both the emotional fear and the practical need for the family member to take a break.

Key Concept

Therapeutic Communication at End of Life

Estimated Time:1m 0s

Question 833Question →

A practical nurse (PN) is providing care for a client who is admitted with heart failure and a respiratory infection. The client's prescriptions include oral furosemide, a weight-based dose of oral amoxicillin, and PRN intravenous (IV) push morphine for severe pain. Which of the following actions should the PN perform to ensure safe medication administration? Select all that apply.

Select all that apply

Verify the client's identity by comparing the medication administration record (MAR) to the client's wristband while asking them to state their name and date of birth.

Administer the prescribed PRN IV push morphine when the client reports a pain level of 8 out of 10.

Rely solely on the registered nurse's (RN) verbal dosage calculation for the amoxicillin without independently verifying the math.

Reinforce previous teaching with the client regarding the importance of consuming potassium-rich foods while taking furosemide.

Bypass the barcode scanning process and use the client's room number for identification if the barcode scanner malfunctions.

Withhold the furosemide and promptly report a critically low serum potassium laboratory result to the RN or provider.

Show answer & explanation

Answer: Verify the client's identity by comparing the medication administration record (MAR) to the client's wristband while asking them to state their name and date of birth.; Reinforce previous teaching with the client regarding the importance of consuming potassium-rich foods while taking furosemide.; Withhold the furosemide and promptly report a critically low serum potassium laboratory result to the RN or provider.

Answer

The correct actions include verifying the client's identity using the MAR and two acceptable identifiers, reinforcing teaching about potassium-rich foods for the prescribed furosemide, and withholding the diuretic while escalating a critically low potassium level to the RN.

Safe medication administration by a practical nurse involves adhering strictly to the medication rights, practicing within the defined legal scope, and applying clinical knowledge to prevent patient harm. Verifying the client using two acceptable identifiers (name and date of birth) ensures the medication is given to the correct person. Reinforcing teaching about dietary potassium is well within the PN scope and essential for clients taking a potassium-wasting loop diuretic like furosemide. Furthermore, recognizing a critically low potassium level as a direct contraindication for furosemide and escalating this finding to the RN demonstrates safe and required clinical judgment.

Step-by-Step Solution

Evaluate each action against the practical nurse (PN) scope of practice and medication safety principles.

Identify actions that are safe, legal, and appropriate for a PN to perform independently.

The NCLEX-PN requires an understanding of proper delegation, scope of practice boundaries, and adherence to the rights of medication administration.

Analyze the action of verifying identity using two identifiers (name and date of birth).

This is a correct action.

It fulfills the 'right client' medication right, which is a critical, non-negotiable safety standard.

Analyze the action of administering IV push morphine.

This is an incorrect action.

Administering IV push medications generally exceeds the PN scope of practice and must be performed by an RN.

Analyze the action of accepting verbal math calculations without independent verification.

This is an incorrect action.

Nurses must independently calculate and verify all medication dosages prior to administration to intercept potential math errors.

Analyze the action of reinforcing teaching about potassium-rich foods.

This is a correct action.

Reinforcing initial teaching provided by an RN is within the PN scope of practice, and furosemide is a potassium-wasting diuretic.

Analyze the action of using a room number for identification.

This is an incorrect action.

A room number is strictly prohibited as a patient identifier due to the high risk of error if a client is moved.

Analyze the action of withholding furosemide for a critically low potassium level and reporting to the RN.

This is a correct action.

Furosemide depletes potassium; giving it to a client with hypokalemia is highly dangerous. PNs must recognize critical labs, withhold contraindicated medications, and notify the RN immediately.

Key Concept

The practical nurse must adhere to their legal scope of practice—which includes administering scheduled oral medications, reinforcing teaching, and escalating abnormal findings—while strictly following the rights of medication administration.

Question 834Question →

While conducting an afternoon assessment on a client who underwent a partial thyroidectomy six hours ago, a licensed practical nurse observes the client's pulse is 114 beats per minute, respirations are 22 per minute, and blood pressure is 94/62 mm Hg. The client states, 'I feel really jittery right now.' What is the priority action for the nurse to take?

Alert the registered nurse to the current clinical findings immediately

Administer a prescribed as-needed medication for anxiety

Record the assessment data and plan to recheck the client in two hours

Reposition the client to lie flat to help improve blood pressure

Show answer & explanation

Answer: Alert the registered nurse to the current clinical findings immediately

Answer

The correct action is to immediately alert the registered nurse to the current clinical findings.

The client is exhibiting early signs of shock or potential internal hemorrhage, characterized by tachycardia, borderline hypotension, and restlessness (described as feeling 'jittery'). In the postoperative period, the licensed practical nurse must prioritize client safety by immediately reporting these subtle but critical changes to the registered nurse so that further medical assessment and life-saving interventions can be initiated.

Step-by-Step Solution

Analyze the client's vital signs and verbal statements.

The pulse of 114 beats per minute and blood pressure of 94/62 mm Hg are borderline abnormal, and feeling 'jittery' is a classic sign of restlessness.

Identifying subtle deviations from normal baseline values is essential for recognizing early complications.

Correlate findings with postoperative risks for a thyroidectomy.

These findings collectively act as early indicators of potential internal hemorrhage or hypovolemic shock, which are critical complications.

Understanding the clinical implications of assessment data guides the urgency of necessary nursing interventions.

Determine the priority action within the practical nurse scope of practice.

The absolute priority is to escalate these critical findings to the registered nurse for further assessment and collaborative intervention.

Practical nurses must promptly report rapid changes indicating a severe risk to client safety rather than attempting to manage a potential crisis independently.

Key Concept

Early recognition of shock and appropriate escalation of critical findings

Question 835Question →

A practical nurse is preparing to perform oral hygiene for a client who is unconscious. To prevent aspiration, which is the most appropriate position for the nurse to place the client?

Side-lying (lateral) position

Supine position with the bed flat

High Fowler's position

Prone position with a pillow under the chest

Show answer & explanation

Answer: Side-lying (lateral) position

Answer

Side-lying (lateral) position

Placing the unconscious client in a side-lying (lateral) position, ideally with the head turned to the side, is the safest method for performing oral care. This position uses gravity to allow saliva, water, and oral care products to drain easily out of the mouth, effectively protecting the airway and preventing aspiration.

Step-by-Step Solution

Identify the primary risk during oral care for an unconscious client.

The main risk is aspiration of fluids into the airway.

Unconscious clients lack a functional gag reflex and cannot actively swallow or spit out fluids.

Determine the position that best mitigates this risk using basic care principles.

The side-lying position uses gravity to facilitate fluid drainage.

By turning the client to the side, fluids will naturally flow out of the dependent side of the mouth rather than toward the trachea.

Key Concept

Basic Care and Comfort: Prevention of Aspiration

Question 836Question →

A client is receiving care on a surgical unit 48 hours after undergoing a right below-the-knee amputation. To prevent postoperative complications and promote optimal long-term mobility, which of the following positioning measures should the practical nurse (PN) implement?

Assist the client to lie in a prone position for 20 to 30 minutes several times a day.

Elevate the right residual limb on a soft pillow while the client is resting in bed.

Maintain the client in a continuous semi-Fowler's position to decrease incisional tension.

Encourage the client to sit upright in a bedside chair for the majority of the day.

Show answer & explanation

Answer: Assist the client to lie in a prone position for 20 to 30 minutes several times a day.

Answer

Assist the client to lie in a prone position for 20 to 30 minutes several times a day.

Following a lower extremity amputation, the prevention of hip flexion contractures is a primary positioning goal. Assisting the client into a prone position (lying on the abdomen) for 20 to 30 minutes, three to four times a day, actively stretches the hip flexor muscles and prevents them from shortening.

Step-by-Step Solution

Identify the surgical procedure and the postoperative timeframe.

The client had a below-the-knee amputation 48 hours ago.

Positioning protocols for amputations change significantly after the first 24 hours to transition from edema control to contracture prevention.

Determine the primary musculoskeletal complication associated with lower extremity amputations.

Hip flexion contractures are a major risk because the flexor muscles tend to shorten if the limb is kept in a bent position.

Understanding the risk of muscle shortening guides the selection of the correct preventive positioning measure.

Evaluate the given positioning options against the goal of preventing contractures.

Prone positioning extends and stretches the hip flexors, whereas elevating the limb on a pillow, sitting in a chair, and semi-Fowler's positioning all promote continuous hip flexion.

Selecting the intervention that directly counteracts muscle shortening ensures evidence-based basic care and protects the client's ability to use a future prosthesis.

Key Concept

Prevention of Hip Flexion Contractures Following Amputation

Question 837Question →

A client with a history of chronic stable angina is scheduled to receive a new transdermal nitroglycerin patch. What is the correct sequence of steps the practical nurse should follow to safely administer this medication? Arrange the actions in the correct chronological order.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence ensures safety and proper absorption: perform hand hygiene and don gloves, remove the old patch, cleanse the old site, label the new patch, and apply the new patch to a rotated site.

The correct sequence minimizes the risk of medication errors and protects the nurse. Gloves must be worn first to prevent self-medication. The old patch must be removed and the site cleaned to prevent a dangerous overdose. The new patch must be labeled before application to prevent skin trauma or a sudden bolus dose, and then applied to a new, rotated site to prevent skin irritation.

Step-by-Step Solution

Perform hand hygiene and don clean gloves.

Nurse and client are protected from exposure.

Gloves prevent the nurse from accidentally absorbing nitroglycerin through the skin, which could cause a severe headache or dangerous hypotension.

Remove the old transdermal patch and fold it in half.

Old medication source is safely contained and removed.

Leaving an old patch on while applying a new one can lead to medication toxicity and adverse cardiovascular events.

Cleanse the skin of the old site.

Skin is completely free of residual medication.

Nitroglycerin residue left on the skin continues to absorb and may cause unintended dosing if not washed away.

Label the new patch.

Patch is identified with date, time, and initials prior to application.

Writing on the patch before applying it prevents pressing down on the client's tissue and inadvertently squeezing out a bolus of medication.

Apply the new patch to a new site.

Medication is administered correctly to a fresh area.

Rotating sites prevents contact dermatitis and ensures consistent, reliable systemic absorption of the drug.

Key Concept

Safe administration of transdermal medications

Question 838Question →

A practical nurse (PN) is caring for a client admitted with a severe exacerbation of chronic obstructive pulmonary disease (COPD). The PN observes the client returning from the bathroom smelling strongly of cigarette smoke. The client states, "I only took two puffs because my roommate's television is incredibly loud and stressing me out. It is the only way I can calm my nerves in this place." Recognizing the client is using the defense mechanism of rationalization, which response by the PN is the MOST therapeutic?

It sounds like the noise in your room is making it very difficult to rest. Let's explore some other ways to help you relax without smoking.

Why would you risk worsening your breathing by smoking when you are already in the hospital for a severe lung problem?

You should not blame your roommate's television for your decision to violate the facility's strict no-smoking policy.

Try not to worry about it this time, but please remember that smoking is not allowed anywhere inside the hospital.

Show answer & explanation

Answer: It sounds like the noise in your room is making it very difficult to rest. Let's explore some other ways to help you relax without smoking.

Answer

The most therapeutic response validates the client's stress regarding the loud television and immediately offers to help find alternative, healthy relaxation methods.

The correct response utilizes the therapeutic techniques of acknowledging the client's feelings (frustration with the noise) and offering self to help problem-solve. By redirecting the conversation toward alternative relaxation methods, the practical nurse addresses the underlying anxiety and encourages adaptive coping without validating the harmful behavior of smoking.

Step-by-Step Solution

Identify the defense mechanism the client is using.

The client is using rationalization by providing a plausible, socially acceptable excuse (the loud television) to justify an unacceptable or harmful behavior (smoking with severe COPD).

Understanding the defense mechanism helps the nurse realize the client is attempting to manage underlying stress and anxiety, rather than just deliberately breaking rules.

Evaluate the nurse's goal in responding to maladaptive coping.

The practical nurse must address the underlying emotion (stress) without validating or accepting the harmful behavior, while reinforcing healthy coping strategies.

Confrontation usually increases defensive behavior, whereas validation of feelings builds trust and opens the door for education.

Analyze the options to eliminate non-therapeutic communication blocks.

Eliminate the options that ask 'why' (defensive), act as an authoritarian/judge (confrontational), or minimize the behavior (false reassurance).

Non-therapeutic blocks shut down communication and prevent the client from learning adaptive coping skills.

Select the response that demonstrates therapeutic communication.

The correct action acknowledges the stressor (loud room) and collaboratively offers to explore healthier relaxation techniques.

This falls perfectly within the PN scope of reinforcing education and promoting safe, adaptive coping mechanisms.

Key Concept

Therapeutic Communication and Adaptive Coping

Estimated Time:1m 30s

Question 839Question →

A practical nurse (PN) is working on a subacute rehabilitation unit when a client unexpectedly dies. The client's adult child arrives on the unit, learns of the death, and begins to hyperventilate and pace erratically in the busy main corridor. In which order should the PN implement the following interventions? (Arrange from first action to last.)

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first guide the individual to a private room, then coach them in deep breathing, followed by remaining with them to provide therapeutic presence, then asking about notifying support persons, and finally preparing the body for viewing.

Nursing prioritization follows a framework of safety, physiological needs, psychosocial needs, and finally procedural tasks. Guiding the individual to privacy ensures environmental safety. Coaching breathing addresses the acute physiological threat of hyperventilation. Remaining present provides immediate psychosocial support during shock. Mobilizing external support follows stabilization. Preparing the body is a procedural task that is safely deferred until the living family member's crisis is managed.

Step-by-Step Solution

Guide the adult child into a private, quiet consultation room.

The individual is removed from the busy corridor.

According to Maslow's hierarchy of needs, ensuring a safe and secure environment is a top priority. This protects the grieving individual's privacy and prevents distress among other clients.

Coach the adult child to take slow, deep breaths.

The hyperventilation is addressed and managed.

Physiological needs take precedence over psychosocial ones. Hyperventilation is an acute physical response that requires immediate intervention to prevent further medical complications.

Remain in the room to provide continuous, silent therapeutic presence.

The individual receives immediate emotional grounding.

Therapeutic presence is the most effective initial psychosocial intervention during acute shock, providing safety and support without demanding verbal interaction.

Ask if there are specific relatives or a chaplain who should be notified.

External support systems are identified.

Once the acute physical and emotional reactions are stabilized, mobilizing broader support systems helps the individual begin to process the loss.

Arrange the deceased client's room and prepare the body for family viewing.

The environment is prepared for the family to say goodbye.

Task-oriented post-mortem care is essential but represents a lower priority than managing an acute physiological or psychological crisis in a living client or family member.

Key Concept

Prioritization in Acute Grief Crisis

Question 840Question →

A community emergency is declared following the release of an unidentified, highly contagious airborne biological agent. A practical nurse (PN) is assigned to assist in the hospital's isolation unit. Which action by the PN demonstrates a safe and appropriate emergency response?

Accepting an assignment to independently perform primary disaster triage on newly arriving clients

Removing the N95 respirator in the hallway only after exiting the client's room and closing the door

Doffing all personal protective equipment, including the N95 respirator, inside the client's room

Prioritizing the collection of a comprehensive exposure history before initiating oxygen for a client with stridor

Show answer & explanation

Answer: Removing the N95 respirator in the hallway only after exiting the client's room and closing the door

Answer

The PN must remove the N95 respirator in the hallway only after exiting the client's room and closing the door.

The correct action is to remove the N95 respirator in the hallway or anteroom only after exiting the isolation room. Because the biological agent is airborne, the room air is contaminated. Removing the respirator inside the room would expose the nurse to the pathogen. The respirator must remain in place until the door is completely closed behind the nurse.

Step-by-Step Solution

Analyze the nature of the emergency and the assigned role.

The emergency involves a highly contagious airborne biological agent, requiring strict adherence to airborne precautions and safe delegation.

Understanding the transmission route (airborne) is critical for determining safe PPE protocols and care priorities.

Evaluate the clinical prioritization and scope of practice constraints.

Disaster triage is an RN-level skill. A client with stridor requires immediate airway intervention over history taking.

The PN must recognize tasks that fall outside their scope of practice (triage) and apply the ABC prioritization framework.

Identify the correct sequence for doffing airborne PPE.

The gown and gloves are removed inside the room, but the N95 mask must remain on until the nurse has exited the room and closed the door.

Removing the mask inside the room would expose the nurse's respiratory tract to the suspended aerosolized pathogen.

Key Concept

Airborne Precautions and PN Scope of Practice in Emergencies

PreviousPage 42 / 147Next

All practice questions

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept