All practice questions

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Staffing changes on an acute care unit require the nursing team to rapidly redistribute client assignments. The team consists of a registered nurse (RN), a licensed practical nurse (LPN), and an assistive personnel (AP). Which action taken by the LPN demonstrates safe practice regarding delegation, scope of practice, and client rights?

Accepting an assignment to independently manage a client who was just transferred from the intensive care unit with unresolved sepsis

Describing the alternative treatment options and procedural risks to a client prior to witnessing their signature on the consent form

Assigning the AP to ambulate a client who is two days post-appendectomy, while the LPN conducts focused data collection on a client's resolving pneumonia

Discussing a client's pending discharge needs and new medication regimen with the RN while riding together in a crowded public elevator

Show answer & explanation

Answer: Assigning the AP to ambulate a client who is two days post-appendectomy, while the LPN conducts focused data collection on a client's resolving pneumonia

Answer

Assigning the AP to ambulate a stable postoperative client while the LPN conducts focused data collection on a client with a resolving condition.

The correct answer demonstrates appropriate task delegation and adherence to the LPN/VN scope of practice. Ambulating a stable postoperative client is a routine, standardized task that falls squarely within the AP's scope. Furthermore, conducting focused data collection on a client with a resolving, stable condition (like resolving pneumonia) is an appropriate expectation for the LPN/VN, as it relies on established baselines and does not require the initial, comprehensive assessment skills reserved for the RN.

Step-by-Step Solution

Evaluate each nursing action against the LPN/VN legal scope of practice and the NCSBN five rights of delegation.

Identified that managing unstable clients with systemic infections and explaining procedural risks exceed the LPN/VN scope.

LPN/VNs are restricted from performing comprehensive initial assessments, managing unstable acuities, and obtaining initial informed consent from clients.

Assess the actions for potential violations of client rights and environmental safety.

Identified that discussing client information in a public elevator breaches confidentiality (HIPAA).

Nurses must actively protect client privacy and only discuss protected health information in secure, private areas away from unauthorized individuals.

Analyze the remaining delegation and care assignment action for appropriateness.

Determined that ambulating a stable postoperative client is safely delegable to an AP, and focused data collection on a stable client is appropriate for the LPN/VN.

This action correctly matches client stability and task complexity with the competency and legal scope of both the AP and the LPN/VN, demonstrating a clear contrast between LPN focused data collection and RN comprehensive assessment.

Key Concept

Delegation and LPN/VN Scope of Practice

Question 922Question →

A practical nurse (PN) is evaluating the safety of a room transfer for a client who has right-sided hemiplegia and moderate dementia. The client is currently agitated, attempting to get out of bed unassisted, and unable to follow verbal instructions or bear weight on the affected leg. An unlicensed assistive personnel (UAP) brings a powered stand-assist lift into the room to move the client to a bedside chair. Which action is the priority for the PN?

Intervene and request a full-body mechanical sling lift, as the client's current cognitive and physical status contraindicates a stand-assist lift.

Direct the UAP to assess the client's bilateral hand grip strength to determine if the client can safely hold onto the stand-assist handles.

Apply bilateral soft wrist restraints prior to the transfer to prevent the agitated client from pulling on the mechanical lift components.

Instruct the UAP to manually lift the client under the axillae while pivoting toward the unaffected side to expedite the transfer and reduce agitation.

Show answer & explanation

Answer: Intervene and request a full-body mechanical sling lift, as the client's current cognitive and physical status contraindicates a stand-assist lift.

Answer

Intervene and request a full-body mechanical sling lift, as the client's current cognitive and physical status contraindicates a stand-assist lift.

The correct action is to intervene and switch to a full-body mechanical sling lift. Ergonomic safety standards dictate that powered stand-assist lifts are only safe for clients who can bear weight on at least one leg, possess adequate upper body strength, and can follow multi-step commands. Because this client is agitated, unable to follow commands, and has hemiplegia, utilizing the stand-assist lift poses a critical risk for falls and mechanical injury.

Step-by-Step Solution

Evaluate the client's physical and cognitive status against the requirements of the intended equipment.

The client has hemiplegia (cannot bear weight safely), dementia, agitation, and cannot follow instructions.

Safe equipment use requires matching the device specifications to the client's capabilities.

Recall the safety prerequisites for a powered stand-assist lift.

Stand-assist lifts require the client to bear weight on at least one leg, have sufficient upper body tone, and consistently follow simple commands.

Using a stand-assist lift on a client who cannot follow directions or bear weight risks a severe fall or injury during the transfer.

Determine the appropriate intervention.

The PN must stop the UAP from using the contraindicated equipment and select a full-body mechanical sling lift instead.

A full-body sling lift safely supports clients who are non-weight-bearing and unable to follow commands.

Key Concept

To safely use a powered stand-assist lift, a client must be able to bear weight on at least one leg, possess sufficient upper body strength to grasp the device, and follow instructions. Clients lacking these abilities require a full-body mechanical sling lift for safe transfer.

Question 923Question →

While rounding on a medical-surgical unit, a practical nurse observes that a 72-year-old individual who recently had intestinal surgery is suddenly highly disoriented and aggressively trying to climb over the bed rails. An assistive staff member recommends immediately securing the client's wrists to prevent a dangerous fall. Which nursing intervention is the initial priority?

Move the client to a room with high visibility for continuous monitoring.

Telephone the attending provider to obtain an emergency prescription for soft wrist restraints.

Direct the assistive staff member to apply the protective devices while the nurse gathers documentation forms.

Document the sudden disorientation as a routine age-related change and darken the room to promote sleep.

Show answer & explanation

Answer: Move the client to a room with high visibility for continuous monitoring.

Answer

Move the client to a room with high visibility for continuous monitoring.

The correct answer correctly identifies that the nurse must prioritize the least restrictive environment. Moving the client to a highly visible area provides necessary supervision to prevent falls without unnecessarily restricting the client's freedom of movement.

Step-by-Step Solution

Assess the client's immediate safety and the nature of the behavioral change.

The client is experiencing sudden acute confusion and poses a fall risk.

Sudden confusion requires both immediate safety measures and a subsequent investigation for underlying causes like infection or hypoxia.

Evaluate the recommendation to apply physical restraints.

Physical restraints are identified as a last resort.

Standards of care and legal guidelines require that all less restrictive alternatives be exhausted before chemical or physical restraints are utilized.

Select the least restrictive intervention that ensures patient safety.

Continuous monitoring and relocation closer to the nursing station are chosen.

Direct observation protects the client from falling while avoiding the physical and psychological risks associated with restraints.

Key Concept

Restraint Alternatives and Least Restrictive Environment

Estimated Time:1m 0s

Question 924Question →

A toddler weighing $33\text{ lbs}$ is diagnosed with acute otitis media. The healthcare provider prescribes cefdinir $14\text{ mg/kg/day}$ orally in two divided doses. The pharmacy dispenses cefdinir oral suspension with a concentration of $125\text{ mg}/5\text{ mL}$ . How many milliliters ( $\text{mL}$ ) should be administered per dose?

Record your answer to the nearest tenth. Do not include units in your answer.

Show answer & explanation

Answer: 4.2

Answer

4.2

To safely administer this weight-based medication, the practical nurse must first convert the child's weight to kilograms (

33\text{ lbs} \div 2.2\text{ lbs/kg} = 15\text{ kg}

). Next, the total daily dose is calculated by multiplying the weight in kilograms by the prescribed rate (

15\text{ kg} \times 14\text{ mg/kg/day} = 210\text{ mg/day}

). Because the prescription specifies two divided doses, the daily dose is halved to find the single administration amount (

210\text{ mg} \div 2 = 105\text{ mg/dose}

). Finally, the required volume is determined using the dispensed concentration of

125\text{ mg}/5\text{ mL}

. Using the formula

\frac{\text{Desired}}{\text{Have}} \times \text{Quantity}

\frac{105\text{ mg}}{125\text{ mg}} \times 5\text{ mL} = 0.84 \times 5\text{ mL} = 4.2\text{ mL}

Step-by-Step Solution

Convert the client's weight from pounds to kilograms.

15\text{ kg}

Weight-based medication prescribing requires the client's weight to be accurately calculated in kilograms (

33\text{ lbs} \div 2.2 = 15\text{ kg}

Calculate the total daily dose of the medication.

210\text{ mg/day}

The prescription is ordered based on the total amount needed for a full 24-hour period (

15\text{ kg} \times 14\text{ mg/kg/day}

Determine the amount of medication required for a single dose.

105\text{ mg/dose}

The total daily dose must be divided into two equal doses as prescribed (

210\text{ mg} \div 2

Calculate the liquid volume to administer per dose using the available concentration.

4.2\text{ mL}

Using the formula (Desired / Have)

\times

Quantity: (

\frac{105\text{ mg}}{125\text{ mg}}) \times 5\text{ mL} = 4.2\text{ mL}

Key Concept

Weight-Based Pediatric Dosage Calculation

Question 925Question →

A practical nurse (PN) enters the room of a client with post-traumatic stress disorder (PTSD) who was admitted for pneumonia. The client is crouching in the corner, trembling, and shouting, "Get down! They are coming over the wall!" Which action should the PN take first?

Maintain a safe distance near the doorway and calmly state the nurse's name and purpose.

Inquire why the client believes someone is coming over the wall.

Apply physical restraints immediately to ensure the client does not run out of the room and fall.

Prepare and administer an intravenous push sedative medication to rapidly decrease the client's agitation.

Show answer & explanation

Answer: Maintain a safe distance near the doorway and calmly state the nurse's name and purpose.

Answer

Maintain a safe distance near the doorway and calmly state the nurse's name and purpose.

When a client is experiencing an active flashback or severe agitation, the primary focus is on safety. By maintaining a safe distance and staying near the door, the nurse ensures a clear exit route. Calmly identifying oneself and one's purpose helps ground the client in the present reality without directly confronting or arguing with their distorted perception.

Step-by-Step Solution

Analyze the clinical scenario to identify the client's current state.

The client is experiencing an active flashback or severe panic related to PTSD, posing a potential safety risk to themselves and staff.

Understanding the nature of the crisis dictates the appropriate therapeutic intervention.

Evaluate the proposed nursing actions against the principles of safety, therapeutic communication, and PN scope of practice.

Restraints are premature, 'why' questions are non-therapeutic, and IV push medications are out of scope. Providing space and calm orientation prioritizes safety and de-escalation.

Safety (for both the client and the nurse) is the absolute first priority in any psychiatric emergency.

Key Concept

Prioritizing safety and utilizing de-escalation techniques during an active PTSD flashback or crisis.

Question 926Question →

At an outpatient health center, a practical nurse assists with a 12-month-old infant's wellness examination. Which finding should the nurse recognize as a deviation from expected developmental transitions that requires reporting to the registered nurse?

The infant uses a raking motion with the entire hand to pick up small oat cereals.

The infant's anterior fontanel remains open, flat, and soft to the touch.

The infant's head circumference measurement is equal to their chest circumference.

The infant repeatedly drops a toy from the examination table and looks down to watch it fall.

Show answer & explanation

Answer: The infant uses a raking motion with the entire hand to pick up small oat cereals.

Answer

The infant using a raking motion with the entire hand to pick up small oat cereals.

By 12 months of age, an infant should have developed a neat, precise pincer grasp (using the thumb and index finger) to pick up small objects. Using a whole-hand raking motion is a fine motor milestone typically expected around 6 to 7 months of age. The persistence of a raking grasp at one year indicates a developmental delay in fine motor skills that must be reported for further evaluation.

Step-by-Step Solution

Analyze the fine motor behavior described in the options.

The infant is using a raking grasp instead of a pincer grasp.

Fine motor skills progress from gross hand movements to precise finger movements. A 12-month-old should use a neat pincer grasp. A raking grasp indicates a delay.

Evaluate the anatomical finding regarding the fontanel.

The anterior fontanel is open, flat, and soft.

This is a normal finding because the anterior fontanel does not typically close until 12 to 18 months of age.

Evaluate the physical growth measurements.

The head circumference equals the chest circumference.

This equalization occurs naturally around 1 to 2 years of age and represents normal physical development.

Analyze the cognitive and play behavior.

The infant drops a toy and watches it fall.

This behavior confirms the development of object permanence and cause-and-effect understanding, which are expected cognitive milestones at 1 year.

Key Concept

Infant Developmental Milestones (12 Months)

Question 927Question →

A practical nurse (PN) receives the shift report and begins medication administration for a group of assigned clients. Which of the following actions demonstrate adherence to safe pharmacological principles and the practical nurse scope of practice? (Select all that apply.)

Select all that apply

Asking the client to state their full name and date of birth while verifying their identification band before giving an oral antihypertensive.

Proceeding to administer subcutaneous enoxaparin to a client who has a morning platelet count of

38,000/\text{mm}^3

without alerting the registered nurse.

Accepting a delegated task from the registered nurse to administer an intravenous (IV) push dose of furosemide to a client with fluid volume overload.

Withholding a scheduled dose of oral potassium chloride for a client whose laboratory report shows a serum potassium level of

6.2\text{ mEq/L}

and notifying the charge nurse.

Documenting the administration of an oral analgesic in the electronic health record immediately after observing the client swallow the medication.

Bypassing a broken barcode scanner and identifying a sleeping client by confirming the room number matches the medication record before giving oral levothyroxine.

Show answer & explanation

Answer: Asking the client to state their full name and date of birth while verifying their identification band before giving an oral antihypertensive.; Withholding a scheduled dose of oral potassium chloride for a client whose laboratory report shows a serum potassium level of $6.2\text{ mEq/L}$ and notifying the charge nurse.; Documenting the administration of an oral analgesic in the electronic health record immediately after observing the client swallow the medication.

Answer

The correct actions include verifying two unique client identifiers (name and date of birth), withholding potassium for a hyperkalemic client (

6.2\text{ mEq/L}

) while notifying the charge nurse, and documenting medication administration immediately after it is swallowed.

The correct actions align with the fundamental rights of medication safety and the boundaries of the practical nurse's scope of practice. Using two valid identifiers (name, date of birth) guarantees the right client receives the medication. Withholding potassium in the presence of an elevated serum level (

6.2\text{ mEq/L}

) and immediately notifying the charge nurse demonstrates appropriate clinical vigilance and escalation. Finally, documenting medications immediately after administration prevents accidental double-dosing by other staff.

Step-by-Step Solution

Evaluate the principles of medication safety and client identification.

Safe practice requires the use of two unique identifiers (e.g., name and date of birth) and immediate documentation after administration.

These steps are foundational to the 'rights' of medication administration to prevent wrong-client errors and duplicate dosing.

Analyze the clinical data and laboratory values presented in the scenarios.

A potassium level of

6.2\text{ mEq/L}

(hyperkalemia) and a platelet count of

38,000/\text{mm}^3

(severe thrombocytopenia) are critical laboratory abnormalities.

Administering potassium to a hyperkalemic client or an anticoagulant to a severely thrombocytopenic client can precipitate life-threatening complications.

Apply the practical nurse (PN) scope of practice to the scenarios.

The PN correctly withholds contraindicated medications and reports critical findings, but must refuse to administer medications via the intravenous (IV) push route.

IV push administration requires complex assessment and rapid clinical judgment that belongs within the registered nurse's scope of practice.

Key Concept

Safe Medication Administration and Scope of Practice

Question 928Question →

The charge nurse on an inpatient oncology unit presents the shift assignment to a practical nurse (PN). Which assigned client task should the PN immediately question and return to the registered nurse (RN) for management?

Conducting the initial comprehensive admission assessment for a client arriving from the emergency department.

Witnessing the client's signature on an informed consent form for an upcoming bone marrow aspiration.

Administering scheduled oral opioid analgesics to a client experiencing chronic pain from bone metastasis.

Reinforcing previously established infection prevention teaching for a client with chemotherapy-induced neutropenia.

Show answer & explanation

Answer: Conducting the initial comprehensive admission assessment for a client arriving from the emergency department.

Answer

Conducting the initial comprehensive admission assessment for a client arriving from the emergency department.

The initial comprehensive admission assessment requires advanced clinical judgment, synthesis of data, and the formulation of an initial nursing care plan. According to national standards and nurse practice acts, these responsibilities strictly fall within the registered nurse (RN) scope of practice and cannot be delegated to or accepted by a practical nurse (PN).

Step-by-Step Solution

Analyze the role and scope of practice of the practical nurse (PN) compared to the registered nurse (RN).

The PN can collect data, perform routine procedures, and care for stable clients. The RN is responsible for initial assessments, nursing diagnoses, care planning, and initial education.

Understanding the legal boundaries of the PN scope of practice is essential for safe delegation and assignment acceptance.

Evaluate each assigned task to determine if it falls within the PN's legal scope of practice.

Witnessing consent, giving oral narcotics, and reinforcing teaching are all within the PN scope. Conducting an initial comprehensive assessment is exclusively an RN responsibility.

The PN must recognize which tasks require the advanced clinical judgment of an RN to ensure client safety.

Identify the task that the PN must refuse or question.

The initial comprehensive admission assessment must be questioned and reassigned to the RN.

Accepting an assignment outside of the PN scope of practice violates the nurse practice act and jeopardizes client safety.

Key Concept

The practical nurse (PN) cannot perform initial comprehensive assessments or develop initial care plans; these tasks must be completed by a registered nurse (RN).

Question 929Question →

An adult client is scheduled for an elective bronchoscopy. The provider has not yet visited the room to discuss the procedure. The client's spouse, who is not the designated healthcare proxy, approaches the practical nurse (PN) in a public corridor and asks, "Can you explain exactly what they will do during this test and what the risks are?" Which action should the PN take?

Inform the spouse that the client must give permission to share medical details, and notify the provider to speak with them.

Describe the procedural steps and associated risks to the spouse to alleviate their anxiety before the provider arrives.

Open the electronic health record on a mobile workstation in the hallway to show the spouse the procedural order.

Delegate the task of reviewing the standard preoperative educational brochure with the spouse to an unlicensed assistive personnel.

Show answer & explanation

Answer: Inform the spouse that the client must give permission to share medical details, and notify the provider to speak with them.

Answer

The correct action is to inform the spouse that the client must give permission to share medical details, and to notify the provider to speak with them.

This action upholds client confidentiality by requiring explicit permission before releasing medical information. It also correctly identifies that discussing the specifics of a medical procedure and its inherent risks falls strictly under the provider's legal responsibility for informed consent.

Step-by-Step Solution

Identify the primary legal and ethical issues presented in the scenario.

The scenario involves client confidentiality, scope of practice regarding informed consent, and appropriate task delegation.

Understanding the multiple domains of nursing practice being tested is essential to selecting the safest action.

Evaluate the request for information against confidentiality regulations.

Sharing specific medical information with a spouse without the client's explicit consent violates confidentiality laws.

Unless the spouse is the designated healthcare proxy and the client is incapacitated, the client holds the right to privacy.

Assess the PN's scope of practice regarding the spouse's request for risk explanation.

Explaining procedural risks falls under the provider's responsibility for obtaining informed consent, not the PN's role.

The PN may witness a consent signature but cannot legally initiate the disclosure of risks and alternatives.

Determine the most appropriate professional response.

The PN must protect the client's privacy and contact the provider to fulfill the informed consent requirements.

This comprehensively addresses both the ethical duty of confidentiality and the legal duty of adhering to scope of practice.

Key Concept

Legal and Ethical Practice Boundaries (Confidentiality and Consent)

Question 930Question →

The practical nurse (PN) is collecting vital signs on a client who is 4 hours postoperative following abdominal surgery. Which finding requires the PN to notify the registered nurse (RN) immediately?

Blood pressure of 88/56 mm Hg and a heart rate of 118 beats per minute

The client reporting incisional pain of 6 on a 0 to 10 numerical scale

A tympanic temperature of 37.4°C (99.3°F)

A postoperative hemoglobin level of 13.5 g/dL (135 g/L)

Show answer & explanation

Answer: Blood pressure of 88/56 mm Hg and a heart rate of 118 beats per minute

Answer

The correct answer is the finding of a blood pressure of 88/56 mm Hg and a heart rate of 118 beats per minute.

A low blood pressure (hypotension) combined with a fast heart rate (tachycardia) in a postoperative client are classic early signs of hypovolemic shock or internal hemorrhage. This indicates compromised circulation, which is a life-threatening emergency that must be immediately reported to the RN.

Step-by-Step Solution

Identify the client's clinical context.

The client is 4 hours postoperative.

Surgical clients are at high risk for complications such as hemorrhage in the immediate postoperative period.

Analyze each assessment finding for severity and priority.

The low blood pressure and tachycardia indicate circulatory compromise.

According to the ABCs (Airway, Breathing, Circulation) framework, circulatory issues are life-threatening and take highest priority.

Determine the appropriate PN nursing action.

The PN must report the vital signs indicating shock to the RN.

Signs of physiological instability must be immediately escalated to the RN for further assessment and intervention.

Key Concept

Early recognition of hypovolemic shock and prioritization of circulatory compromise.

Question 931Question →

While rounding on a surgical unit, a practical nurse observes a client holding an unsigned surgical consent form. The client states, 'The surgeon was just here, but I still do not understand how they will perform the operation.' Which action should the nurse take next?

Notify the surgeon to return to the unit and clarify the procedure for the client.

Explain the steps of the operation using a facility-approved educational pamphlet.

Agree to provide the detailed surgical explanation when asked by the registered nurse.

Ask the client's family members in the public waiting area to help clarify the surgery.

Show answer & explanation

Answer: Notify the surgeon to return to the unit and clarify the procedure for the client.

Answer

Notify the surgeon to return to the unit and clarify the procedure for the client.

The correct action is to notify the surgeon to return and answer the client's questions. For a consent to be truly informed, the client must fully understand the procedure. It is the legal responsibility of the primary healthcare provider performing the procedure to explain it. The practical nurse advocates for the client by halting the signing process and ensuring the provider addresses the knowledge deficit.

Step-by-Step Solution

Assess the client's level of understanding regarding the planned surgical procedure.

The client verbalizes a lack of understanding about how the operation will be performed.

Determines if the criteria for informed consent have been met prior to obtaining the signature.

Identify the appropriate scope of practice for the practical nurse regarding informed consent.

The practical nurse recognizes that their role is to witness the signature and advocate for the client, not to explain the procedure.

Prevents the nurse from practicing outside their legal scope.

Intervene by contacting the individual responsible for explaining the procedure.

The surgeon is notified to return and provide the necessary clarification.

Ensures the client's right to fully informed consent is protected.

Key Concept

The practical nurse's role in informed consent is to act as a witness to the signature and advocate for the client, while the primary healthcare provider is solely responsible for explaining the procedure, risks, and benefits.

Question 932Question →

Following a severe myocardial infarction, an adult client is prescribed a strict cardiac diet. When the practical nurse enters the room with afternoon medications, the client is eating a large pepperoni pizza brought by a visitor. The client remarks, 'My heart issue was just a minor cramp. Besides, cheese has calcium, which strengthens muscles, so this food is actually helping me heal.' Which response by the practical nurse is the most therapeutic?

It can be overwhelming to make sudden lifestyle changes. What is your understanding of the reason for your hospital admission?

You did not have a muscle cramp; you had a heart attack. Eating this pizza goes directly against your prescribed treatment plan.

Why would you choose to eat outside food when the dietitian has already planned meals specifically for your cardiac recovery?

I will let you finish this slice since it has calcium, but I need to alter your care plan so the dietitian provides more appealing food tomorrow.

Show answer & explanation

Answer: It can be overwhelming to make sudden lifestyle changes. What is your understanding of the reason for your hospital admission?

Answer

The response validating the client's potential feelings of being overwhelmed and asking about their understanding of the admission.

The correct response effectively uses therapeutic communication by validating the underlying stress of the situation ('overwhelming to make sudden lifestyle changes') without agreeing with the client's distorted rationale. By asking an open-ended question about the client's understanding of their admission, the practical nurse encourages dialogue and assesses the client's current reality orientation and readiness to learn, which is the safest initial step when addressing severe denial and rationalization.

Step-by-Step Solution

Identify the defense mechanisms being used by the client.

The client is using denial ('just a minor cramp') and rationalization ('cheese has calcium... helping me heal') to cope with the anxiety of a life-threatening cardiac event.

Recognizing the underlying psychological coping mechanisms is essential before selecting a therapeutic response.

Evaluate the provided options against principles of therapeutic communication and the practical nursing scope of practice.

Direct confrontation increases anxiety, 'why' questions cause defensiveness, and altering care plans is outside the PN scope.

Eliminating non-therapeutic and out-of-scope actions isolates the safest and most effective nursing intervention.

Select the response that maintains safety while preserving the therapeutic relationship.

The option that acknowledges the difficulty of lifestyle changes and uses an open-ended question to assess understanding is selected.

This approach gathers data about the client's readiness to learn without aggressively stripping away their protective defense mechanisms.

Key Concept

Therapeutic Communication and Defense Mechanisms

Estimated Time:1m 30s

Question 933Question →

A practical nurse (PN) discovers a small fire in a trash can in a client's room. According to standard fire response protocols, in what order should the PN perform the following actions? Arrange the actions from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: Move the client to a safe area, activate the fire alarm, close the door to the room, and attempt to put out the fire.

The correct sequence for responding to a fire is dictated by the RACE acronym: Rescue (move the client), Alarm (activate the alarm), Confine (close the door), and Extinguish (use the fire extinguisher). This sequence prioritizes life safety above all else.

Step-by-Step Solution

Identify the standard protocol for fire response in a healthcare facility.

The acronym RACE is the standard emergency response protocol.

RACE provides a step-by-step prioritization to ensure safety and minimize damage.

Determine the first action (Rescue).

Moving the client out of the room to a safe area.

Life safety is always the highest priority.

Determine the second action (Alarm).

Activating the facility fire alarm system.

Others must be alerted to the emergency immediately after securing the client.

Determine the third action (Confine).

Closing the door to the client's room.

Closing doors limits oxygen supply to the fire and prevents smoke from spreading.

Determine the fourth action (Extinguish).

Attempting to put out the fire with an extinguisher.

This is the final step, and should only be attempted if the fire is contained and it is safe to do so.

Key Concept

Fire Response Protocol (RACE)

Question 934Question →

An 84-year-old client recovering from sepsis is receiving continuous intravenous (IV) fluids. The client suddenly begins thrashing in bed and forcefully grabbing at the IV insertion site. After less restrictive measures fail, the registered nurse (RN) applies bilateral soft wrist restraints as prescribed. Which actions are appropriate for the practical nurse (PN) when caring for this client? Select all that apply.

Select all that apply

Fasten the restraint ties to a movable section of the bed frame using a quick-release knot.

Assume the sudden thrashing and agitation are expected signs of age-related cognitive decline.

Release one restraint at a time every 2 hours to provide skin care and perform range-of-motion exercises.

Assign the unlicensed assistive personnel (UAP) the task of evaluating whether the client still needs the restraints.

Assess the capillary refill, skin temperature, and radial pulses of both upper extremities every 2 hours.

In the future, reapply the physical restraints immediately at the first sign of agitation before trialing less restrictive alternatives.

Show answer & explanation

Answer: Fasten the restraint ties to a movable section of the bed frame using a quick-release knot.; Release one restraint at a time every 2 hours to provide skin care and perform range-of-motion exercises.; Assess the capillary refill, skin temperature, and radial pulses of both upper extremities every 2 hours.

Answer

The appropriate actions are fastening the ties to a movable section of the bed frame using a quick-release knot, releasing one restraint at a time every 2 hours for skin care and range of motion, and assessing neurovascular status every 2 hours.

When a client is in restraints, the nurse must ensure physical safety and physiological integrity. This includes securing the restraints to a movable part of the bed frame with a quick-release knot to prevent injury when the bed moves and to allow rapid removal in an emergency. The nurse must also release the restraints one at a time every 2 hours to provide skin care and perform range-of-motion exercises, and conduct neurovascular checks every 2 hours to verify adequate perfusion and prevent nerve damage.

Step-by-Step Solution

Analyze the clinical scenario and the nursing intervention.

The client has bilateral soft wrist restraints applied to protect the IV line. The PN must identify safe monitoring, application, and delegation protocols.

Understanding the purpose of the restraint determines the specific safety and monitoring requirements mandated by care standards.

Identify correct safety and assessment procedures.

Correct actions include securing ties to the movable bed frame with a quick-release knot, releasing restraints sequentially every 2 hours for care, and performing frequent neurovascular assessments.

These actions prevent nerve damage, ischemia, skin breakdown, and asphyxiation or injury if the bed position is altered.

Rule out actions that violate scope of practice or safety standards.

Dismissing sudden confusion as normal aging, delegating clinical evaluation to a UAP, and bypassing less restrictive alternatives in the future are all incorrect and dangerous practices.

Sudden confusion indicates acute illness (delirium), evaluation requires nursing judgment, and restraints must always be a last resort.

Key Concept

Safe Application and Monitoring of Physical Restraints

Question 935Question →

During morning rounds, a practical nurse (PN) receives the updated coagulation profile for a client with atrial fibrillation. The client has an order for warfarin 5 mg orally each day at 0900. The laboratory report shows an International Normalized Ratio (INR) of 4.6. Which of the following is the priority action for the PN to take?

Withhold the scheduled dose of warfarin and immediately notify the registered nurse.

Administer the scheduled dose of warfarin and monitor the client for signs of bleeding.

Decrease the warfarin dose to 2.5 mg to reduce the risk of spontaneous hemorrhage.

Proceed with medication administration after verifying the client's identity using two identifiers.

Show answer & explanation

Answer: Withhold the scheduled dose of warfarin and immediately notify the registered nurse.

Answer

Withhold the scheduled dose of warfarin and immediately notify the registered nurse.

For a client with atrial fibrillation, the therapeutic INR range is typically 2.0 to 3.0. An INR of 4.6 is significantly elevated, indicating that the client's blood is clotting too slowly and they are at a high risk for spontaneous bleeding. The correct and safe action for the practical nurse is to withhold the scheduled dose of warfarin to prevent further elevation of the INR and to immediately notify the registered nurse or healthcare provider so that the medication regimen can be evaluated and potentially adjusted.

Step-by-Step Solution

Review the client's laboratory results in relation to the prescribed medication.

The INR is 4.6, which is significantly above the standard therapeutic target of 2.0 to 3.0 for atrial fibrillation.

Warfarin dosing is directly dependent on coagulation profiles, specifically the INR, to balance clotting prevention and bleeding risk.

Determine the clinical significance of the abnormal result.

An elevated INR indicates that the client's blood is clotting too slowly, placing them at an imminent risk for bleeding if further anticoagulants are administered.

Identifying the risk of hemorrhage is a critical component of pharmacological safety.

Identify the appropriate nursing action based on the practical nurse scope of practice.

The practical nurse must withhold the medication to prevent harm and immediately escalate the critical finding to the registered nurse or healthcare provider.

The PN is responsible for ensuring safe medication administration and reporting significant changes in client condition without altering prescriptions.

Key Concept

The practical nurse must evaluate relevant laboratory values before administering high-alert medications like warfarin, withholding the dose and reporting critical values to ensure client safety.

Estimated Time:1m 0s

Question 936Question →

A 52-year-old client arrives at the nursing unit immediately following an ultrasound-guided right percutaneous liver biopsy. The registered nurse delegates the task of settling the client in bed to the practical nurse. Which positioning action should the practical nurse implement to promote comfort and prevent complications?

Place the client in a left lateral position with the head of the bed flat to minimize dizziness.

Assist the client into a right side-lying position with a rolled towel beneath the puncture area.

Maintain the client in a semi-Fowler's position to relax the abdominal musculature.

Position the client prone with a small pillow placed centrally under the abdomen.

Show answer & explanation

Answer: Assist the client into a right side-lying position with a rolled towel beneath the puncture area.

Answer

Assist the client into a right side-lying position with a rolled towel beneath the puncture area.

Following a percutaneous liver biopsy, the client must be placed in a right side-lying position (the operative side) for at least 2 to 4 hours. Placing a rolled towel or small blanket under the puncture site utilizes the client's own body weight to apply direct pressure to the liver capsule, which helps achieve hemostasis and prevents severe hemorrhage.

Step-by-Step Solution

Identify the anatomical location of the procedure.

The liver is located on the right side of the abdomen, and the biopsy is a right-sided percutaneous puncture.

Knowing the anatomical site is essential for determining post-procedure care.

Recognize the primary post-procedure complication associated with a liver biopsy.

Hemorrhage is the most significant risk because the liver is a highly vascular organ.

Identifying the complication dictates the preventive nursing intervention.

Determine the physical intervention that prevents hemorrhage.

Applying direct, continuous pressure to the puncture site achieves hemostasis.

Pressure promotes blood clotting and minimizes internal and external bleeding.

Select the positioning strategy that applies the necessary pressure.

A right side-lying position with a rolled towel under the site utilizes the client's own body weight to apply pressure.

This specific position safely and effectively maintains continuous pressure on the liver capsule.

Key Concept

Post-Procedure Positioning for Liver Biopsy

Estimated Time:1m 0s

Question 937Question →

During morning rounds, a practical nurse (PN) enters a client's room with their prescribed oral medications. To ensure safe practice, which action must the PN take to confirm the client's identity before handing them the pills?

Ask the client to state their full name and date of birth while checking their identification band.

State the client's name out loud and wait for them to verbally agree before proceeding.

Compare the name on the medication label directly with the room and bed number.

Rely on visual recognition to confirm identity since the PN cared for the same client on the previous shift.

Show answer & explanation

Answer: Ask the client to state their full name and date of birth while checking their identification band.

Answer

Ask the client to state their full name and date of birth while checking their identification band.

The correct action demonstrates strict adherence to the 'Right Client' principle of medication administration. Safe practice requires verifying at least two distinct, acceptable client identifiers (such as the client's full name, date of birth, or medical record number) before giving any medication.

Step-by-Step Solution

Recall the rights of medication administration, specifically the 'Right Client' principle.

The standard protocol requires using at least two acceptable patient identifiers before administration.

This foundational safety check prevents medication errors caused by mistaken identity.

Evaluate each option against safe identification standards.

Only asking for the client's full name and date of birth meets the two-identifier requirement.

Room numbers, yes/no questions, and visual recognition are explicitly forbidden as primary identifiers.

Key Concept

Rights of Medication Administration: Right Client

Question 938Question →

A licensed practical nurse (LPN) is collaborating with the interprofessional healthcare team on a busy medical-surgical unit. The LPN receives a list of client care assignments and delegated tasks for the shift. Which of the following actions by the LPN represent safe and legally appropriate practice? (Select all that apply)

Select all that apply

Reinforcing education regarding proper incentive spirometer use for a client who is two days postoperative.

Evaluating the therapeutic effectiveness of an intravenous diuretic administered by the registered nurse to a client with acute heart failure.

Explaining potential surgical complications to a client who requests further clarification prior to signing an informed consent document.

Performing a prescribed sterile dressing change on a client's healing, chronic stage 3 sacral pressure injury.

Discussing a client's discharge placement needs with the unit case manager while seated in the hospital's public cafeteria.

Administering a scheduled subcutaneous dose of insulin glargine to a clinically stable client with type 2 diabetes mellitus.

Show answer & explanation

Answer: Reinforcing education regarding proper incentive spirometer use for a client who is two days postoperative.; Performing a prescribed sterile dressing change on a client's healing, chronic stage 3 sacral pressure injury.; Administering a scheduled subcutaneous dose of insulin glargine to a clinically stable client with type 2 diabetes mellitus.

Answer

The LPN safely practices by reinforcing education for a postoperative client, performing a sterile dressing change on a chronic pressure injury, and administering scheduled subcutaneous insulin to a stable client.

The correct selections represent safe practice within the LPN's legal scope. Reinforcing previously established education plans, performing routine sterile wound care on chronic injuries, and administering subcutaneous medications to stable clients do not require RN-level comprehensive assessment, initial teaching, or complex evaluation.

Step-by-Step Solution

Analyze each option to determine if it falls within the LPN/VN legal scope of practice and adheres to ethical principles.

Identify tasks that represent data collection, routine procedures, or reinforcement of teaching versus tasks requiring RN-level judgment or violating client rights.

The National Council of State Boards of Nursing (NCSBN) delineates specific boundaries for LPNs, explicitly excluding comprehensive assessment, initial evaluation, and provider-level consent explanation.

Evaluate the clinical tasks for client acuity and complexity.

Routine insulin administration, chronic wound care, and education reinforcement are acceptable. Evaluating acute IV diuretic therapy exceeds LPN scope.

LPNs are assigned to clients with predictable outcomes. Unstable clients or interventions requiring complex evaluation must be managed by the RN.

Assess the ethical and legal scenarios presented in the remaining options.

Explaining surgical complications is the provider's duty, and discussing cases in a cafeteria violates confidentiality.

LPNs must protect client privacy at all times and adhere to strict professional roles during the informed consent process.

Key Concept

Delegation, Scope of Practice, and Client Rights

Question 939Question →

A practical nurse is preparing to withdraw a prescribed medication from a glass ampule. In what order should the nurse perform the following steps? Arrange the steps from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence for withdrawing medication from an ampule begins with moving fluid to the bottom chamber, protecting the hands, breaking the ampule safely, using a filter needle to withdraw, and finally changing to an administration needle.

When preparing medication from an ampule, the priority is to ensure accurate dosage and safety from glass shards. First, tapping the ampule ensures all fluid is available to draw. Next, wrapping the neck protects the nurse's fingers, and breaking it away from the body protects the face. A filter needle is then essential to prevent aspirating glass particles. Finally, the filter needle must be discarded and replaced with a proper injection needle to ensure safe administration to the client.

Step-by-Step Solution

Tap the top of the ampule lightly.

Medication moves to the bottom chamber.

Ensures all medication is available for withdrawal and prevents spillage.

Wrap the neck with a sterile gauze pad or unopened alcohol swab.

The glass neck is safely covered.

Protects the nurse's fingers from sharp glass shards during opening.

Snap the neck of the ampule quickly and firmly away from the body.

The ampule is opened safely.

Prevents shattered glass from flying toward the nurse's face or body.

Withdraw the medication using a filter needle attached to the syringe.

Medication is drawn into the syringe without glass particles.

The filter needle traps any microscopic glass fragments that may have fallen into the liquid.

Replace the filter needle with an appropriate administration needle.

The syringe is safely prepared for client injection.

Filter needles are strictly for withdrawal and can cause severe tissue damage or inject trapped glass if used for administration.

Key Concept

Safe withdrawal of medication from a glass ampule

Estimated Time:1m 0s

Question 940Question →

A practical nurse is preparing to collect a sterile urine specimen for a culture and sensitivity test from a client who has an indwelling urinary catheter. Arrange the following procedural steps in the correct chronological order.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: clamp the tubing, scrub the port, withdraw the urine, transfer to the container, and unclamp the tubing.

Obtaining a sterile urine specimen from an indwelling catheter requires maintaining the closed drainage system to prevent infection and ensuring a fresh sample. First, the tubing is clamped to collect fresh urine. Next, the port is disinfected to prevent introducing microorganisms. Then, the sterile syringe is used to withdraw the sample, which is subsequently transferred to a sterile cup. Finally, the tubing must be unclamped immediately to restore continuous urinary flow and prevent bladder distension.

Step-by-Step Solution

Clamp the catheter drainage tubing just below the specimen collection port.

Fresh urine accumulates in the tubing.

Urine collected from the drainage bag is not sterile and cannot be used for a culture. Clamping ensures a fresh sample is available.

Scrub the needleless specimen collection port briskly with an antimicrobial swab.

The surface of the port is disinfected.

This prevents bacteria on the surface from entering the closed catheter system or contaminating the urine sample.

Attach a sterile syringe to the needleless port and withdraw the required volume of urine.

Urine is safely extracted from the tubing.

Using a needleless sterile syringe maintains the sterility of the closed drainage system while retrieving the sample.

Carefully transfer the aspirated urine into a sterile specimen container.

The sample is secured in a sterile environment.

Transferring the sample without touching the inside of the container keeps the urine uncontaminated for accurate laboratory analysis.

Unclamp the catheter drainage tubing and verify the unobstructed flow of urine.

Normal, continuous urine flow is restored.

Forgetting to unclamp the tubing can lead to urinary stasis, severe bladder distension, and an increased risk of infection.

Key Concept

Sterile Urine Specimen Collection from an Indwelling Catheter

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