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Question 961Question →

A client in a preoperative holding area is preparing for an elective cholecystectomy. As the practical nurse (PN) presents the informed consent document for a signature, the client puts the pen down and states, "I changed my mind. I am too scared and I do not want this surgery anymore." In which order should the PN take the following actions? (Arrange the actions from first to last.)

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Answer

The correct sequence is to first remove the document to protect the client's right to refuse, then explore their fears to gather data, notify the surgeon who is legally responsible for discussing risks/alternatives, and finally document the event.
The nursing process and prioritization principles dictate that the PN must first address immediate safety and client rights (stopping the consent process). Next, the PN collects data (exploring fears) to inform the next intervention. The intervention is to communicate outside the PN's scope (notifying the surgeon to explain risks/alternatives). Finally, the PN documents the entire sequence of events to maintain legal records.

Step-by-Step Solution

1
Halt the consent process by removing the form.
The client is protected from signing under duress or uncertainty.
The PN's primary role in consent is verifying it is voluntary; if the client hesitates, the process must stop immediately.
2
Use therapeutic communication to assess the client's fears.
The PN gathers relevant subjective data about why the client is refusing.
Data collection is within the PN scope and provides necessary context before contacting the provider.
3
Contact the surgeon performing the procedure.
The provider is informed that consent has not been obtained.
Answering medical questions, explaining the risks of refusal, and providing alternatives fall exclusively under the provider's scope of practice.
4
Document the incident in the electronic health record.
A legal record of the client's refusal and the nursing actions is created.
Documentation is the final step in the nursing process after immediate interventions and communications are complete.

Key Concept

The practical nurse's role in informed consent is limited to witnessing the signature and verifying it is voluntary. If a client revokes consent, the PN must stop the process, gather data, and notify the provider.
Question 962Question →

A practical nurse (PN) is providing morning care for a client when the client suddenly loses consciousness and begins exhibiting generalized tonic-clonic muscle movements. Which action should the PN take first to prevent injury to the client?

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Answer: Turn the client onto their side and support their head on a soft surface

Answer

Turn the client onto their side and support their head on a soft surface.
The immediate priority during a seizure is to protect the airway and prevent trauma. Turning the client to a side-lying position allows saliva and emesis to drain, preventing aspiration. Simultaneously, supporting the head on a soft surface prevents blunt head trauma caused by the rhythmic, forceful muscle contractions.

Step-by-Step Solution

1
Recognize the onset of a tonic-clonic seizure.
The nursing priority shifts immediately to client safety and airway protection.
Tonic-clonic movements present a high risk for blunt trauma and aspiration of oral secretions.
2
Position the client laterally (side-lying).
Gravity facilitates the outward drainage of saliva and emesis.
This prevents aspiration, thereby maintaining airway patency (the primary ABC priority).
3
Place a soft pad or folded towel under the client's head.
The client's head is protected from repeatedly striking hard surfaces.
Convulsive movements are forceful and involuntary, which can easily cause severe cranial injury against the bed or floor.

Key Concept

Seizure Safety and Injury Prevention
Question 963Question →

A charge nurse is observing a newly licensed practical nurse (PN) provide care for several clients on a medical-surgical unit. Which action by the PN represents a safety hazard and requires immediate intervention by the charge nurse?

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Answer: Raising all four full-length side rails on the bed of a restless, confused client to prevent a fall.

Answer

The action that represents a safety hazard is raising all four full-length side rails on the bed of a restless, confused client.
Raising all four full-length side rails constitutes a physical restraint and requires a provider's prescription. For a restless and confused client, this action creates a severe safety hazard because the client is likely to attempt to climb over the rails, resulting in a fall from a greater height and significantly increasing the risk of traumatic injury. Least restrictive alternatives, such as a bed alarm or placing the mattress close to the floor, must be used instead.

Step-by-Step Solution

1
Analyze the stem to determine the goal.
The goal is to identify which of the four observed actions is UNSAFE, violates protocols, and requires immediate intervention.
The question asks for the action representing a safety hazard, meaning three options will describe safe, correct nursing practices.
2
Evaluate the use of four side rails for a confused client.
Raising all four side rails is a form of physical restraint. Confused clients often attempt to climb over them, which increases the height of the fall and the severity of the injury.
This is a direct violation of restraint policies and fall prevention standards, making it a critical safety hazard.
3
Evaluate the remaining options for safe practice.
The PPE doffing sequence, the reporting of sudden confusion in an older adult, and the refusal to administer IV push medications are all correct and safe nursing actions.
These actions correctly apply principles of infection control, geriatric assessment, and legal scope of practice.

Key Concept

The use of all four side rails is considered a physical restraint and increases the risk of severe injury in confused clients who may attempt to climb over them.
Estimated Time:1m 15s
Question 964Question →

A client who experienced a recent cerebrovascular accident has unilateral weakness. The nurse is assisting the client out of bed into a wheelchair for the first time. In which order should the nurse execute the following steps to safely perform a stand-and-pivot transfer? Arrange the actions from first to last.

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Answer

The correct sequence ensures safety by preparing the environment, securing the client, and executing the pivot on the client's strong side.
Following this precise chronological sequence minimizes the risk of falls and injury. The nurse must first establish environmental safety (positioning the chair on the strong side and locking wheels) before physically moving the client. Once the environment is secure, the nurse assists the client to sit, applies a safety device (transfer belt), and provides physical support (bracing the weak knee) before finally initiating the pivot maneuver.

Step-by-Step Solution

1
Position the wheelchair at a 45-degree angle on the client's unaffected side.
The destination equipment is properly positioned.
Setting up the environment first ensures the client can pivot toward their strong side with the shortest possible transfer distance.
2
Engage the wheel locks on both the bed and the wheelchair.
The bed and wheelchair are completely immobilized.
Immobilizing the equipment is a mandatory safety check to prevent the chair or bed from sliding away during the weight transfer.
3
Assist the client to sit on the edge of the bed and secure a transfer belt around their waist.
The client is sitting upright and equipped with a safety device.
Dangling allows the nurse to assess the client for orthostatic hypotension and dizziness, while the belt provides a secure hold for lifting.
4
Stand facing the client, grasp the transfer belt, and brace the client's weakened knee with your own knee.
Physical support and leverage are established.
Bracing the affected knee prevents it from buckling under the client's weight during the standing phase of the transfer.
5
Instruct the client to bear weight on the strong leg while pivoting to reach back for the wheelchair armrests.
The client safely transitions from a standing position into the wheelchair.
Reaching back provides a physical target and helps the client control their descent into the chair without falling.

Key Concept

Safe stand-and-pivot transfers for clients with unilateral weakness
Question 965Question →

A client with a history of epilepsy suddenly begins to experience a generalized tonic-clonic seizure while sitting in a bedside chair. To prevent injury, in what order should the practical nurse perform the following actions? (Arrange the actions from first to last.)

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Answer

The correct sequence of actions for a client having a seizure in a chair is to first safely guide them to the floor, protect their head, turn them on their side to protect the airway, loosen restrictive clothing, and finally note the time and duration.
During a generalized tonic-clonic seizure, the nurse's primary goal is to prevent physical injury and maintain a patent airway. The nurse must first safely lower the client to the floor to prevent a traumatic fall from the chair. Next, the head must be protected from striking the floor. The client is then rolled onto their side to allow saliva or emesis to drain, preventing aspiration. Loosening tight clothing further supports respiratory function. Once the client is physically secure and breathing safely, the nurse notes the exact time to monitor the seizure's duration and document the clinical event.

Step-by-Step Solution

1
Guide the client safely to the floor.
The client is placed on a flat, secure surface.
The client is unsafe in a chair and at immediate risk of an uncontrolled, traumatic fall.
2
Protect the client's head with a soft pad.
The head is cushioned against the floor.
Active convulsions against a hard floor can cause severe head injury and contusions.
3
Turn the client onto a lateral (side-lying) position.
The airway is cleared of potential obstruction.
Lateral positioning allows saliva and emesis to drain freely, preventing aspiration pneumonia and maintaining respiratory function.
4
Loosen restrictive clothing around the neck and chest.
Breathing effort is facilitated.
Tight clothing can restrict airflow and compromise oxygenation during a neurologic emergency.
5
Note the onset time and observe the duration.
Accurate clinical data is gathered.
Documentation and timing are essential for medical follow-up but are secondary to immediate physical safety.

Key Concept

Seizure Safety and Injury Prevention
Estimated Time:1m 0s
Question 966Question →

A competent adult client informs the practical nurse (PN) that they wish to designate their oldest child as their healthcare proxy and create a living will. Arrange the actions the PN should take in the correct chronological order.

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Answer

The correct sequence is: First, determine the client's current understanding. Second, provide the facility's standardized written information. Third, notify the registered nurse and request a social services consultation. Finally, document the actions in the medical record.
Clinical prioritization requires following the nursing process. Data collection (determining understanding) comes first. Next, the PN implements care within their scope by providing standardized information. The PN then advocates for the client by communicating the need for advanced assistance to the RN and social worker. Finally, all actions must be accurately documented in the client's medical record.

Step-by-Step Solution

1
Determine the client's current understanding of advance directives.
The PN establishes a baseline for the client's knowledge and needs.
Data collection must always precede nursing interventions to ensure that care is individualized and appropriate.
2
Provide the client with the facility's standardized written information about advance directives.
The client receives factual, approved information to help them make an informed decision.
The Patient Self-Determination Act requires healthcare facilities to provide written information regarding advance directives, which is within the PN's scope to distribute and reinforce.
3
Notify the registered nurse (RN) and request a social services consultation.
The appropriate interdisciplinary team members are mobilized to assist the client.
While the PN can provide standard information, completing and witnessing complex legal forms such as a healthcare proxy typically requires collaboration with a social worker or the RN.
4
Document the client's request, the materials provided, and the referrals made in the medical record.
A permanent legal record of the advocacy actions is created.
Documentation should accurately reflect all nursing actions and client interactions immediately after they occur.

Key Concept

The practical nurse's role in client advocacy regarding advance directives involves initial data collection, providing standardized information, collaborating with the interdisciplinary team for legal execution, and comprehensive documentation.
Question 967Question →

A practical nurse (PN) is caring for an 82-year-old client admitted with bacterial pneumonia and a history of moderate Alzheimer's disease. The client is receiving continuous intravenous (IV) antibiotics and oxygen therapy. During the evening shift, the client becomes acutely disoriented, highly agitated, and repeatedly attempts to climb over the bed rails. Which of the following actions should the PN implement to ensure client safety and prevent injury? Select all that apply.

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Answer: Camouflage the IV tubing and insertion site by gently covering the client's arm with a stockinette or long-sleeved gown.; Perform a focused data collection to identify potential physiological triggers for the agitation, such as hypoxia, pain, or urinary retention.; Lower the bed to the lowest possible setting, activate the bed exit alarm, and place high-impact fall mats next to the bed.

Answer

The correct actions are to camouflage the IV site, perform a focused data collection for physiological triggers, and utilize environmental safety measures like lowering the bed and activating alarms.
The priority for an agitated, confused client is maintaining safety using the least restrictive methods. Camouflaging tubes, utilizing bed alarms, lowering the bed, and investigating underlying physiological causes (such as hypoxia from pneumonia) effectively prevent injury without unlawfully restraining the client or delegating outside of the nursing scope of practice.

Step-by-Step Solution

1
Analyze the client's clinical presentation and recent cognitive changes.
The client has a history of chronic dementia but is experiencing a sudden, acute onset of severe agitation and disorientation.
Recognizing that acute confusion is indicative of delirium rather than chronic dementia is crucial for identifying life-threatening physiological causes.
2
Apply the principle of least restrictive interventions for client safety.
Identify environmental modifications and diversionary tactics that can be implemented before resorting to physical restraints.
Physical restraints are a last resort due to the high risk of compounding injury, skin breakdown, and psychological distress.
3
Evaluate the proposed safety interventions against the Practical Nurse (PN) scope of practice.
Determine that assessing physiological triggers is within the PN scope, but delegating the evaluation of orientation to a UAP is unlawful.
The PN remains accountable for the assessment and evaluation of the client; unlicensed personnel can observe for safety but cannot clinically evaluate.

Key Concept

Prioritizing least restrictive safety interventions and differentiating acute delirium from chronic dementia while maintaining strict delegation standards.
Question 968Question →

A client with advanced dementia is at high risk for severe falls and has a new prescription for a belt restraint while sitting in a wheelchair. The practical nurse (PN) is preparing to initiate the use of the restraint. Arrange the following actions the PN should take in the correct chronological order from first to last.

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Answer

The correct sequence is to first verify the prescription, explain the procedure to the client, place the restraint over clothing, check the fit with two fingers, and finally secure the ties to the structural wheelchair frame.
The proper sequence for restraint application begins with verifying the provider's prescription to ensure authorization. The nurse then communicates with the client to explain the procedure and reduce anxiety. Next, the restraint is positioned over clothing to protect the skin from breakdown. The nurse subsequently evaluates the fit by sliding two fingers underneath the restraint to prevent constriction of breathing or circulation. Lastly, the restraint is anchored to a stable, structural component of the wheelchair with a quick-release knot, ensuring it can be removed immediately if a safety emergency occurs.

Step-by-Step Solution

1
Verify the healthcare provider's current prescription for the restraint.
Ensures legal and clinical appropriateness.
Restraints cannot be applied without a valid medical order, except in extreme emergencies where an order must be obtained immediately after application.
2
Explain the purpose of the restraint to the client in a calm and reassuring manner.
Promotes cooperation and respects client rights.
Communication is essential to decrease fear and agitation, even when caring for clients with advanced dementia.
3
Place the belt restraint around the client's waist, over their clothing or gown.
Protects the client's skin from direct contact.
Applying restraints directly to bare skin increases the risk of friction and skin breakdown over time.
4
Slide two fingers between the restraint and the client's body to ensure adequate fit.
Prevents injury and respiratory restriction.
A properly fitted belt restraint allows two fingers to fit between the device and the client, ensuring it is secure but not overly constrictive.
5
Attach the restraint ties to the structural frame of the wheelchair using a quick-release knot.
Secures the device safely while allowing emergency access.
Ties must be attached to a non-removable part of the chair (not armrests or footrests) using a knot that allows for rapid release.

Key Concept

The correct procedural steps for applying a restraint prioritize legal verification, client communication, safe physical application, fit assessment, and secure attachment for emergency accessibility.
Question 969Question →

A practical nurse (PN) is preparing to administer scheduled oral digoxin to an adult client diagnosed with heart failure. Which of the following actions should the PN take to ensure safe medication administration? (Select all that apply.)

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Answer: Auscultate the client's apical pulse for a full 6060 seconds before giving the medication.; Verify the client's identity by checking two distinct identifiers against the medication administration record.; Withhold the dose and notify the registered nurse if the client's morning serum potassium level is 2.92.9 mEq/L.

Answer

The appropriate actions are: auscultating the apical pulse for a full 60 seconds, verifying the client's identity using two distinct identifiers, and withholding the dose while reporting a critically low potassium level.
Safe administration of digoxin requires comprehensive monitoring and strict adherence to established protocols. Auscultating the apical pulse for one full minute is necessary because digoxin slows the heart rate. Verifying two distinct patient identifiers ensures the right client receives the medication, maintaining a fundamental medication right. Additionally, hypokalemia (such as a potassium level of 2.9 mEq/L) significantly increases the risk of digoxin toxicity, meaning the practical nurse must withhold the medication and immediately escalate this critical laboratory value to the registered nurse.

Step-by-Step Solution

1
Identify the medication class and primary nursing considerations for digoxin.
Digoxin is a cardiac glycoside that requires strict heart rate monitoring and is highly sensitive to electrolyte imbalances.
Understanding the drug profile dictates the necessary pre-administration clinical assessments.
2
Evaluate the client's vital sign monitoring requirements.
An apical pulse must be auscultated for 60 seconds; the medication should typically be withheld if the heart rate is less than 60 beats per minute.
Digoxin slows the heart rate and can cause severe bradycardia, making accurate pulse measurement critical.
3
Assess laboratory values relevant to digoxin therapy.
A potassium level of 2.9 mEq/L indicates hypokalemia, which must be immediately reported because it significantly increases the risk of digoxin toxicity.
Electrolyte imbalances directly impact the safety of administering this specific medication.
4
Apply the practical nurse scope of practice and general medication safety rules to the remaining choices.
IV push administration is outside the practical nurse scope, and barcode scanning with dual identifiers is mandatory for all patients in all circumstances.
Ensuring legal and institutional safety compliance prevents life-threatening administration errors.

Key Concept

Safe digoxin administration, hypokalemia implications, and practical nurse scope of practice
Question 970Question →

A client admitted with a severe novel respiratory virus is placed on airborne, contact, and eye precautions requiring full personal protective equipment (PPE). A practical nurse is at the dedicated donning station outside the client's room. Place the following steps for donning PPE in the correct chronological sequence.

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Answer

The correct sequence for donning full PPE is: hand hygiene, gown, N95 respirator, face shield/goggles, and finally gloves.
According to the Centers for Disease Control and Prevention (CDC) guidelines, the safest chronological sequence for donning full PPE begins with hand hygiene to prevent contamination. Next, the gown is applied to cover the torso and arms. The mask or respirator is then placed and sealed to protect the airway, followed by eye protection to prevent mucous membrane exposure. Finally, gloves are donned last so they can be securely pulled over the gown's cuffs, creating a continuous barrier.

Step-by-Step Solution

1
Perform hand hygiene.
Hands are clean and ready to handle uncontaminated PPE.
Prevents the transfer of pathogens from the nurse's hands onto the clean protective equipment.
2
Don the isolation gown.
The torso and arms are protected.
The gown requires tying at the neck and waist, which is easiest to do without gloves or face gear in the way.
3
Apply the N95 respirator.
The respiratory tract is protected.
The respirator must sit directly against the skin to form a tight seal; applying it before eye protection ensures the straps are correctly positioned.
4
Apply the face shield or goggles.
The eyes and mucous membranes are protected from splashes.
Eye protection sits over the bridge of the nose and the respirator straps, completing facial protection.
5
Don gloves.
Hands are protected and the wrist gap is sealed.
Gloves are placed last so they can be pulled up and over the cuffs of the isolation gown, leaving no skin exposed.

Key Concept

Standard Sequence for Donning Personal Protective Equipment (PPE)
Question 971Question →

A practical nurse is providing care for a client who is 48 hours postoperative following a right above-the-knee amputation. To help prevent a hip flexion contracture, which of the following positioning interventions should the nurse implement?

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Answer: Assist the client to a prone position for 20 to 30 minutes every 3 to 4 hours.

Answer

Assist the client to a prone position for 20 to 30 minutes every 3 to 4 hours.
Placing a client with an above-the-knee amputation in a prone position for 20 to 30 minutes multiple times a day actively stretches the flexor muscles and extends the hip joint. This targeted positioning is essential to prevent hip flexion contractures, which can severely limit future mobility and make prosthetic fitting impossible.

Step-by-Step Solution

1
Identify the primary complication risk specific to the postoperative time frame and surgical site.
The client is at high risk for a hip flexion contracture following an above-the-knee amputation.
Without proper positioning, the hip joint naturally rests in a flexed position, which can permanently impair mobility and prevent future use of a prosthetic limb.
2
Evaluate the anatomical effect of each positioning option.
Pillows, high Fowler's, and drawing knees to the chest all promote hip flexion. The prone position promotes hip extension.
Extending the hip counteracts the natural tendency for the joint to flex and stiffen.
3
Select the intervention that actively extends the hip joint.
The prone position for short intervals is identified as the correct nursing action.
This directly aligns with evidence-based basic care principles for amputation recovery after the initial 24 hours.

Key Concept

Postoperative Positioning for Amputation
Question 972Question →

A practical nurse is observing an unlicensed assistive personnel (UAP) remove personal protective equipment (PPE) after caring for a client placed on contact and droplet precautions. The UAP is currently wearing a disposable fluid-resistant gown, a surgical mask, a protective face shield, and clean gloves. Which action by the UAP indicates a breach in infection control protocol and requires immediate intervention by the nurse?

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Answer: Using heavily soiled gloves to reach behind the neck and untie the upper strings of the gown.

Answer

The action that requires immediate intervention is using soiled gloves to reach behind the neck to untie the upper strings of the gown.
The exterior surfaces of the gloves are highly contaminated after providing client care. Reaching behind the neck with soiled gloves will transfer infectious agents directly to the worker's skin, hair, and scrub top. According to standard infection control protocols, gloves must be removed first (or peeled off simultaneously with the gown) so that bare, clean hands can safely untie the clean strings at the back of the neck.

Step-by-Step Solution

1
Identify the goal of the question
Determine which PPE removal action performed by the UAP is incorrect and poses a contamination risk.
The nurse must intervene to stop unsafe practices that could spread infection.
2
Evaluate the 'clean' versus 'contaminated' areas of the PPE
The outside front of the gloves, gown, mask, and face shield are contaminated. The back of the gown, ties, ear loops, and headbands are considered clean.
Understanding which areas have been exposed to pathogens dictates safe handling.
3
Analyze the action of reaching behind the neck with soiled gloves
This action brings highly contaminated gloves into direct contact with the clean neck area, hair, and uniform.
Gloves should be removed first (or simultaneously pulled off with the gown) to ensure clean hands are used to untie the neck strings.
4
Review the remaining actions for correctness
Pinching the outside of the glove, handling the face shield by the back strap, and removing the mask by the ear loops are all standard, safe doffing techniques.
Actions that follow proper CDC guidelines do not require intervention.

Key Concept

Personal Protective Equipment (PPE) Doffing Sequence and Cross-Contamination Prevention
Estimated Time:1m 0s
Question 973Question →

A practical nurse (PN) is preparing to transfer a client from the bed to a bedside chair for the first time following abdominal surgery. To ensure client safety and comfort, in what order should the PN perform the following actions? (Arrange the steps in the correct chronological sequence.)

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Answer

The nurse must first raise the head of the bed, assist the client to sit on the edge, allow them to dangle while assessing for dizziness, apply a transfer belt, and finally assist them to stand and pivot into the chair.
Safe mobility for a post-operative client requires a deliberate, step-by-step approach to prevent orthostatic hypotension and protect the surgical site. The head of the bed is elevated first to initiate cardiovascular adjustment and ease movement. After pivoting to the edge of the bed, the client must dangle to ensure they are not experiencing dizziness. Only after stability is confirmed is a transfer belt applied to provide physical support. Finally, the nurse assists the client to stand and pivot into the chair.

Step-by-Step Solution

1
Raise the head of the bed to a high-Fowler's position.
The client is transitioned from a supine to an upright seated position in bed.
This gradually introduces orthostatic changes and minimizes physical strain on the abdominal surgical site when moving.
2
Assist the client to pivot and sit on the edge of the bed.
The client is positioned at the edge of the mattress with their feet toward the floor.
This is a prerequisite physical maneuver before weight-bearing and standing.
3
Allow the client to dangle their legs while assessing for dizziness.
The client rests in a seated position while the nurse evaluates their physiological tolerance.
Post-operative clients are at high risk for orthostatic hypotension. Dangling prevents syncope and potential falls.
4
Apply a transfer belt securely around the client's waist.
The nurse establishes a safe, mechanical gripping point on the client.
Applying the belt while the client is sitting ensures it is snug and ready for the standing transfer without compromising the client's balance.
5
Assist the client to stand, pivot, and sit in the bedside chair.
The client is safely relocated from the bed to the chair.
This finalizes the transfer using safe body mechanics and physical support.

Key Concept

Safe Post-Operative Client Transfer and Positioning
Question 974Question →

A practical nurse is conversing with the spouse of a client who has advanced amyotrophic lateral sclerosis (ALS) and recently entered hospice care. The spouse states, "I keep telling my wife that everything is going to be fine and she just needs to stay positive, but she just cries." Which of the following is the most appropriate response by the nurse?

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Answer: It is hard to see her upset, but allowing her to cry and express her feelings without pressure is important right now.

Answer

The most appropriate response acknowledges the spouse's difficulty while advocating for the client's need to express sadness openly.
The correct answer utilizes therapeutic communication by first validating the spouse's feelings (acknowledging it is hard to see a loved one upset) and then providing gentle education. It advocates for the client's psychosocial needs, emphasizing that expressing negative emotions like sadness is a healthy and necessary part of the end-of-life process.

Step-by-Step Solution

1
Analyze the spouse's statement to identify the underlying dynamic.
The spouse is providing false reassurance and toxic positivity, which is suppressing the client's ability to express genuine grief.
Understanding the communication barrier helps determine the best therapeutic intervention.
2
Evaluate the nursing options based on principles of therapeutic communication in end-of-life care.
Responses offering advice, asking 'why', or predicting strict grief stages are non-therapeutic.
The nurse must support both the client and family while advocating for the client's emotional needs.
3
Select the response that validates the spouse's feelings while guiding them toward a more supportive approach.
The response validating how hard it is to see a loved one cry, while explaining the importance of expressing sadness, is chosen.
This approach is empathetic, avoids communication blocks, and promotes a healthy grieving environment.

Key Concept

Therapeutic Communication in End of Life Care
Question 975Question →

A school-aged client weighing 44 lb is prescribed acetaminophen 15 mg/kg orally every 4 hours for a temperature of 101.8°F (38.8°C). The pharmacy provides acetaminophen oral suspension with a concentration of 160 mg/5 mL. How many mL will the practical nurse administer per dose? Record the answer to the nearest tenth. Do not include units in answer.

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Answer: 9.4

Answer

9.4
To determine the correct dose, the practical nurse must first convert the child's weight to kilograms (44 lb ÷ 2.2 = 20 kg). Next, calculate the desired dose in milligrams (20 kg × 15 mg/kg = 300 mg). Finally, calculate the volume to administer using the supplied concentration (300 mg desired ÷ 160 mg available × 5 mL = 9.375 mL). Following standard rounding rules, 9.375 rounds to 9.4.

Step-by-Step Solution

1
Convert the client's weight from pounds (lb) to kilograms (kg).
44 lb ÷ 2.2 = 20 kg
The medication dosage is prescribed based on kilograms, so a weight conversion is required first.
2
Calculate the total required dose in milligrams (mg).
20 kg × 15 mg/kg = 300 mg
This establishes the total amount of medication needed for a single dose based on the client's body weight.
3
Calculate the required volume in milliliters (mL) using the formula (Desired / Have) × Volume.
(300 mg ÷ 160 mg) × 5 mL = 9.375 mL
This converts the required dose in mg to the physical volume needed based on the pharmacy's supplied concentration.
4
Round the final calculated volume to the nearest tenth.
9.375 mL rounds to 9.4 mL
The question explicitly requires the answer to be recorded to the nearest tenth.

Key Concept

Weight-based medication dosage calculation and fluid volume conversion
Question 976Question →

A practical nurse is applying therapeutic communication principles during various client interactions. Connect each observed client behavior or statement to the most effective nursing response.

Click a left item, then click its matching right item

Items

A client walks rapidly back and forth in the room and tightly grips the bed rail.
A client facing a difficult decision asks, 'Do you think I should consent to this risky surgical procedure?'
A client stares blankly at the wall and weeps silently after the provider leaves the room.
A client states, 'I just don't know how I am going to manage my care when I go home.'

Matches

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Answer

The correct pairings match each client's specific verbal or nonverbal cues with the therapeutic technique that best addresses their immediate psychological needs: making observations for nonverbal agitation, reflecting questions back to the client, offering silent support for acute distress, and restating verbalized concerns.
Each correct pairing matches the client's presentation with an evidence-based therapeutic communication strategy: making observations for nonverbal agitation, reflecting for advice-seeking, offering self for silent grief, and restating for expressed anxiety.

Step-by-Step Solution

1
Analyze the client pacing and gripping the bed rail.
Identify this as nonverbal agitation.
Recognizing nonverbal cues requires a response that observes the behavior (making observations) to gently invite the client to share their feelings.
2
Analyze the client asking for advice about surgery.
Identify this as a situation where giving advice should be avoided.
The nurse must reflect the question back to the client to promote client autonomy and self-exploration.
3
Analyze the client weeping silently after a provider visit.
Identify this as acute grief or shock.
In moments of acute distress where the client is nonverbal, simply offering presence (offering self) is the most supportive therapeutic intervention.
4
Analyze the client expressing worry about home care.
Identify this as verbalized anxiety regarding discharge.
Restating the client's words validates their feelings and encourages further discussion about their specific fears.

Key Concept

Therapeutic Communication Techniques
Question 977Question →

Following a recent self-harm attempt, a client is transferred to the inpatient psychiatric unit with provider orders for continuous one-to-one observation. Which interventions must the practical nurse (PN) incorporate into the daily care for this client? (Select all that apply.)

Select all that apply

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Answer: Maintain a physical distance of no more than one arm's length from the client at all times.; Ensure the client's hands remain visible above the bed linens while they are sleeping.; Serve all scheduled meals and snacks using exclusively paper or plastic food service items.

Answer

The correct interventions are maintaining an arm's length distance, keeping the client's hands visible during sleep, and using only paper or plastic food service items.
Continuous one-to-one observation requires the nurse to maintain close physical proximity (usually an arm's length) to intervene instantly if needed. Keeping the client's hands visible above the covers at all times prevents concealed acts of self-harm. Providing meals on paper or plastic prevents the client from hoarding sharp metal utensils or breaking glass to use as a weapon. These actions directly uphold the highest priority of client safety.

Step-by-Step Solution

1
Identify the primary goal for a client on continuous one-to-one observation following a self-harm attempt.
The absolute priority is maintaining client safety by removing environmental hazards and ensuring an immediate ability to intervene.
Clients with active suicidal ideation require strict, uninterrupted safety protocols to prevent self-injury.
2
Evaluate the options against safety standards and the practical nurse (PN) scope of practice.
Proximity (arm's length), visibility (hands above linens), and hazard removal (plastic utensils) are fundamental safety actions within the PN scope.
These actions directly mitigate the risk of impulsive or concealed self-harm acts.
3
Eliminate interventions that violate therapeutic communication, legal constraints, or the PN scope of practice.
Comprehensive evaluations, false reassurance, and prophylactic restraints are excluded.
Evaluations are RN/provider scope, false reassurance blocks therapeutic communication, and restraints are not indicated for prophylactic suicide precautions.

Key Concept

Suicide Precautions and Safety Management in Psychiatric Nursing
Question 978Question →

A young adult client is being monitored on the orthopedic unit several hours after the application of a rigid long-leg cast for a displaced tibial fracture. The client suddenly reports an intense, unrelenting ache in the calf that has worsened significantly despite the recent administration of prescribed intravenous analgesics. Recognizing a potential limb-threatening complication, which specific positioning intervention should the practical nurse implement while notifying the registered nurse?

Show answer & explanation

Answer: Ensure the affected extremity is supported and maintained resting completely flat at the level of the client's heart.

Answer

The nurse should ensure the affected extremity is supported and maintained completely flat at the level of the client's heart.
When a client exhibits signs of acute compartment syndrome (such as severe, unrelenting pain unresponsive to narcotics), the affected extremity must be positioned completely flat at the level of the heart. This neutral position optimizes arterial perfusion to the compromised tissues without increasing venous congestion. Elevating the limb would decrease arterial inflow, worsening ischemia, while a dependent position would increase swelling and interstitial pressure.

Step-by-Step Solution

1
Identify the clinical cues indicating a severe complication.
The client's unrelenting pain that is unresponsive to intravenous analgesics strongly suggests acute compartment syndrome.
Compartment syndrome causes extreme pressure within the muscle fascia, leading to rapid ischemia and severe pain that is disproportionate to the injury.
2
Determine the physiological impact of positioning on a limb with elevated compartment pressures.
Elevating the limb decreases arterial blood flow, while lowering the limb dependently increases venous congestion.
Both extremes compromise circulation and exacerbate tissue ischemia in this specific emergency.
3
Select the optimal position to maximize perfusion and minimize pressure.
The extremity must be kept at the level of the heart.
This neutral position optimizes arterial inflow to save the tissues without promoting excessive venous pooling.

Key Concept

Positioning Precautions for Suspected Compartment Syndrome
Question 979Question →

A practical nurse (PN) is preparing to administer prescribed ophthalmic drops to a client with glaucoma. In what order should the PN perform the following actions? Arrange the steps from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: Verify identity and medication, position the client's head, expose the conjunctival sac, instill the drops, and apply pressure to the nasolacrimal duct.
Safe and effective administration of eye drops follows a specific anatomical and safety sequence. First, baseline safety checks must be completed. Second, the client is positioned to comfortably receive the medication. Third, the conjunctival sac is exposed to create a safe pouch. Fourth, the medication is instilled into this pouch to avoid direct corneal trauma. Finally, pressure is applied to the nasolacrimal duct (inner canthus) to prevent the medication from draining into the nasal mucosa and causing unintended systemic effects.

Step-by-Step Solution

1
Verify identity and medication.
The correct client is identified for the correct medication.
This is the fundamental first step of all medication administration procedures to prevent medication errors.
2
Instruct the client to tilt their head backward and look upward.
The eye is properly positioned for administration.
This position uses gravity to help keep the medication in the eye and moves the cornea away from the lower lid.
3
Pull down gently on the lower eyelid.
The conjunctival sac is exposed.
Creating a small pouch allows the medication to be held in the eye safely without striking the sensitive cornea.
4
Instill the drops into the lower conjunctival sac.
Medication is delivered to the eye.
Placing it in the sac ensures proper distribution across the eye surface when the client blinks.
5
Apply gentle pressure to the nasolacrimal duct.
The tear duct is temporarily blocked.
This prevents the medication from draining into the nasal mucosa and causing unintended systemic absorption.

Key Concept

Safe administration of ophthalmic medications requires verifying safety checks, correct client positioning, instillation into the conjunctival sac, and prevention of systemic absorption.
Question 980Question →

A practical nurse (PN) is assigned to feed a client who is recovering from a recent stroke that caused left-sided hemiparesis and severe dysphagia. The client also has a tracheostomy tube in place. The speech-language pathologist has cleared the client to begin a pureed diet. Which approach by the PN ensures the highest level of safety during this basic care activity?

Show answer & explanation

Answer: Elevate the head of the bed to 90 degrees, place the food on the right side of the client's mouth, and instruct the client to tuck the chin downward when swallowing.

Answer

The correct action is to elevate the head of the bed to 90 degrees, place the food on the right side of the mouth, and instruct the client to tuck their chin downward when swallowing.
A high-Fowler's position (90 degrees) safely utilizes gravity for swallowing. Placing food on the right (unaffected) side allows the client to effectively control the bolus and prevents dangerous pocketing on the paralyzed side. Finally, instructing the client to tuck their chin to their chest mechanically protects the airway by narrowing the laryngeal opening and directing food properly into the esophagus.

Step-by-Step Solution

1
Analyze the client's physical neurological deficits.
The client has left-sided hemiparesis, meaning the left side of the face and throat is weak. The right side is the strong, unaffected side.
Food must be placed on the strong side to prevent pocketing and allow for coordinated chewing and swallowing.
2
Evaluate the risk of aspiration.
Severe dysphagia and the presence of a tracheostomy tube put the client at an extremely high risk for aspiration.
Airway protection is the absolute clinical priority during oral intake for a stroke client.
3
Determine the optimal anatomical positioning and feeding technique.
A high-Fowler's position (90 degrees) combined with a chin-tuck maneuver is required.
The 90-degree angle uses gravity safely. The chin-tuck maneuver mechanically narrows the laryngeal opening (airway) and widens the esophageal opening, protecting the trachea from food entry.

Key Concept

Dysphagia Management and Airway Protection
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