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Question 81Question →

A client recovering from a radical neck dissection has a newly established tracheostomy. The client exhibits restlessness, and coarse rhonchi are heard upon auscultation. The practical nurse prepares to suction the artificial airway. Arrange the following steps of the procedure in the correct chronological order from first to last.

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Answer

The correct sequence is to first hyperoxygenate the client, then advance the catheter without suction, apply intermittent suction only during withdrawal, flush the catheter with saline, and finally reassess the client's lung sounds.
Airway clearance via tracheostomy suctioning must follow strict chronological steps to ensure safety and prevent hypoxia. The client must first be pre-oxygenated to build a respiratory reserve. The catheter is then advanced without suction to protect the mucosal lining from trauma. Once resistance is met or the desired depth is reached, intermittent suction is applied only during withdrawal for a maximum of 10 to 15 seconds to remove secretions while limiting oxygen deprivation. Afterward, the catheter is flushed to maintain patency, and the client's respiratory status is reassessed to evaluate the procedure's success.

Step-by-Step Solution

1
Hyperoxygenate the client with 100% oxygen.
The client's oxygen reserves are maximized.
To prevent severe hypoxemia when oxygen is removed from the airway along with secretions.
2
Advance the sterile suction catheter into the airway without applying suction.
The catheter reaches the proper depth safely.
Applying negative pressure during insertion strips and traumatizes the tracheal mucosa, increasing the risk of bleeding.
3
Apply intermittent suction for no longer than 10 to 15 seconds during catheter withdrawal.
Secretions are cleared from the airway.
Intermittent suction clears the mucus, while the strict time limit minimizes oxygen deprivation and mucosal damage.
4
Flush the suction catheter and connecting tubing with sterile saline.
The catheter and tubing are cleared of thick secretions.
To maintain patency for subsequent passes or future use.
5
Auscultate bilateral lung sounds to evaluate the effectiveness of the intervention.
The client's respiratory status is documented.
To confirm whether the airway is clear or if the suctioning process needs to be repeated.

Key Concept

Airway Management: Tracheostomy Suctioning Sequence
Question 82Question →

A practical nurse in a long-term care facility is preparing to administer an intermittent enteral tube feeding via a nasogastric tube to a client who is recovering from a cerebrovascular accident (stroke). In what order should the nurse perform the following actions? Arrange the steps from first to last.

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Answer

The correct sequence for administering an intermittent enteral feeding is to first elevate the head of the bed to prevent aspiration, then aspirate to verify placement and check residuals, return the residuals to the stomach, flush the tube to ensure patency, and finally administer the feeding formula.
The correct sequence prioritizes client safety by first ensuring proper positioning to prevent aspiration. Following positioning, verifying tube placement and assessing gastric residual volume are essential before introducing any fluids. Returning the residual prevents electrolyte loss, and flushing ensures the tube is patent before the formula is administered.

Step-by-Step Solution

1
Elevate the head of the client's bed to at least 30 degrees.
The client is placed in a safe position for enteral intake.
Elevating the head of the bed utilizes gravity to help prevent gastric reflux and aspiration into the airway.
2
Aspirate gastric contents to verify tube placement and measure residual volume.
Tube location in the stomach is confirmed and delayed emptying is assessed.
Ensures the formula will enter the gastrointestinal tract safely and that the client is digesting previous feedings appropriately.
3
Return the aspirated gastric residual volume into the stomach.
Stomach contents are restored.
Prevents the loss of essential gastric electrolytes and fluids, which could lead to metabolic imbalances.
4
Flush the nasogastric tube with 30 mL of water.
The tube is cleared and patency is confirmed.
Flushing prevents tube occlusion and ensures there is no resistance before administering the thicker feeding formula.
5
Administer the prescribed intermittent enteral feeding formula.
The client receives the prescribed nutrition.
This is the final step once safety, placement, and patency have all been systematically verified.

Key Concept

Basic Care and Comfort: Enteral Nutrition Administration Sequence
Question 83Question →

While receiving a continuous enteral tube feeding, a client with a history of stroke suddenly begins to cough forcefully, gasp for air, and develop circumoral cyanosis. The practical nurse (PN) is present at the bedside. Arrange the following actions in the priority order the PN should perform them, from first to last.

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Answer

The correct sequence is to first turn off the feeding pump, position the client laterally, suction the airway, apply oxygen, and finally alert the RN.
The correct sequence follows the ABC prioritization framework and the principle of mitigating immediate harm. Stopping the feeding immediately halts further aspiration. Positioning the client laterally uses gravity to protect the airway from further fluid entry. Suctioning clears the existing obstruction to establish patency. Oxygenation treats the resulting hypoxia once the airway is clear. Finally, notifying the RN ensures the client receives advanced assessment and ongoing medical management after the immediate crisis is stabilized.

Step-by-Step Solution

1
Identify the immediate life threat.
Recognize that the client is exhibiting signs of active aspiration and airway compromise.
Forceful coughing, gasping, and cyanosis during a tube feeding indicate that formula is entering the respiratory tract.
2
Apply the principle of removing harm.
Determine that stopping the feeding pump is the first action.
Halting the source of the aspiration is the most direct and immediate way to prevent further respiratory compromise.
3
Apply the ABC (Airway, Breathing, Circulation) priority framework to remaining actions.
Order the remaining actions: protect airway (position), clear airway (suction), support breathing (oxygen), and escalate (notify RN).
Airway management physically precedes breathing support. Oxygen is ineffective if the airway is blocked with fluid. Escalation occurs only after immediate bedside stabilization.

Key Concept

Prioritization of Airway Emergencies and Aspiration Precautions
Question 84Question →

A practical nurse is providing oral care to a client who is unconscious and unable to swallow. Arrange the following nursing actions in the correct chronological sequence to ensure client safety and hygiene. (Place the first action at the top and the last action at the bottom.)

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Answer

The correct sequence begins with protecting the airway by positioning the client in a side-lying position. Next, the nurse places a towel and emesis basin to catch fluids. The mouth is then safely opened using a padded tongue blade, followed by cleaning the oral cavity with a moistened sponge swab. Finally, the nurse applies a water-soluble lubricant to the client's lips.
Safety is the highest clinical priority when providing care to an unconscious client who has lost their protective swallow and gag reflexes. The nurse must first secure the airway by placing the client in a side-lying position to prevent aspiration. Once the airway is protected, the nurse prepares the immediate environment for cleanliness. The mouth is safely accessed using appropriate equipment (a padded tongue blade) to prevent injury, the hygiene is performed, and finally, comfort measures (lubricant) are applied to the lips.

Step-by-Step Solution

1
Position the client in a side-lying or lateral position.
The client's airway is protected from aspiration.
Gravity allows saliva and cleaning fluids to pool in the cheek and drain out of the mouth rather than sliding back into the pharynx.
2
Place a towel under the chin and position the emesis basin.
The area is prepared to manage fluid drainage.
This maintains cleanliness and dignity by preventing the client's gown and bed linens from becoming soiled during the procedure.
3
Open the mouth using a padded tongue blade.
The oral cavity is safely accessed.
Unconscious clients may have an unpredictable bite reflex. A padded blade protects both the client's oral mucosa and the nurse's fingers.
4
Swab the teeth, gums, and tongue.
The oral cavity is cleansed of debris and bacteria.
Regular cleaning prevents halitosis, oral infections, and the buildup of thick secretions.
5
Apply water-soluble lubricant to the lips.
The lips are moisturized and protected.
Unconscious clients often breathe through their mouths, leading to severely dry and cracked lips if not properly lubricated.

Key Concept

Oral Care for the Unconscious Client
Question 85Question →

A practical nurse is preparing to administer prescribed otic drops to an adult client diagnosed with otitis externa. Arrange the following actions for administering this medication in the correct chronological sequence.

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Answer

The correct sequence is: Position the client laterally, straighten the auditory canal by pulling the pinna upward and backward, instill the drops, apply gentle pressure to the tragus, and instruct the client to remain in the lateral position.
The correct chronological sequence ensures patient safety, anatomical alignment, and maximum medication efficacy. First, positioning the client uses gravity to direct the drops. Second, pulling the adult pinna upward and backward properly straightens the naturally curved ear canal. Third, instilling the drops while avoiding physical contact maintains sterility. Fourth, pressing the tragus actively moves the fluid inward toward the tympanic membrane. Finally, having the client remain in position prevents the medication from prematurely leaking out of the ear.

Step-by-Step Solution

1
Establish the correct patient position.
The client is lying on their side with the affected ear facing the ceiling.
Gravity is required to keep the instilled liquid inside the ear canal.
2
Prepare the anatomical pathway.
The ear canal is straightened by pulling the pinna upward and backward.
Adult ear canals have a natural curve; straightening them ensures the medication reaches deep into the canal rather than resting on the outer walls.
3
Administer the medication.
The prescribed drops are instilled into the ear.
Instillation immediately follows anatomical preparation. Avoiding contact between the dropper and the ear prevents contamination.
4
Facilitate medication transit.
Gentle pressure is applied to the tragus.
This creates an inward pumping mechanism that moves the drops past any air pockets toward the eardrum.
5
Maintain medication placement.
The client remains on their side for several minutes.
This dwell time prevents the medication from leaking out when the client sits up.

Key Concept

Administration of Otic Medications in Adults
Question 86Question →

A client with a spinal cord injury at the T4 level reports a sudden, severe pounding headache and blurred vision. The practical nurse (PN) notes the client is profusely sweating and has a flushed face. The client's blood pressure is 208/112 mm Hg. In what order should the PN perform the following actions? Arrange the actions from first to last.

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Answer

The correct sequence is to first elevate the head of the bed, then check the urinary catheter for kinks, notify the registered nurse, and finally monitor the blood pressure frequently.
In the event of autonomic dysreflexia, the primary life-threatening risk is a severe hypertensive crisis that can lead to a stroke. The very first action must always be to elevate the head of the bed to a sitting (high Fowler's) position, as this uses gravity to immediately lower the blood pressure (orthostatic hypotension). Once the client is safely positioned, the practical nurse must quickly assess for and remove the noxious stimulus, which is most commonly a distended bladder caused by a kinked catheter. After these immediate independent bedside interventions are completed, the nurse must notify the registered nurse to coordinate potential pharmacological treatment. Finally, the nurse continues to monitor the blood pressure every 10 to 15 minutes to evaluate the effectiveness of the interventions.

Step-by-Step Solution

1
Elevate the head of the bed to a high Fowler's (sitting) position.
The client is in a sitting position, which promotes orthostatic hypotension.
This is the most rapid and immediate action to lower the dangerously high blood pressure and prevent a cerebrovascular accident (stroke).
2
Check the client's urinary catheter tubing for kinks or obstruction.
The most common noxious stimulus is assessed and potentially resolved.
Bladder distention is the leading cause of autonomic dysreflexia. Removing the stimulus helps resolve the physiological cascade.
3
Notify the registered nurse (RN) of the client's acute symptoms.
The RN is informed of the medical emergency.
The RN and healthcare provider need to be aware, as pharmacological intervention may be required if nursing actions do not relieve the symptoms.
4
Monitor the client's blood pressure every 10 to 15 minutes.
Continuous assessment of the client's hemodynamic status is established.
Frequent monitoring is necessary to determine if the interventions are effective and to ensure the blood pressure is stabilizing.

Key Concept

Prioritization of care for autonomic dysreflexia involves immediate blood pressure reduction through positioning, followed by elimination of the triggering stimulus.
Question 87Question →

A practical nurse (PN) is assigned to collect a sterile urine specimen for culture and sensitivity from a client with a continuous indwelling urinary catheter. In what order should the PN perform the following actions to ensure specimen integrity and minimize the risk of infection? Arrange the steps in the correct chronological sequence.

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Answer

The correct sequence begins with clamping the tubing to collect fresh urine, followed by cleansing the port, aspirating the sample with a sterile syringe, transferring it to a sterile container, and finally unclamping the tubing to restore urinary flow.
Obtaining a sterile urine specimen from a closed drainage system requires a strict aseptic sequence to prevent catheter-associated urinary tract infections (CAUTIs) and ensure accurate laboratory results. The nurse must first clamp the tubing to allow fresh, uncontaminated urine to collect. Next, the port must be disinfected to prevent the introduction of pathogens. A sterile syringe is then used to safely aspirate the urine from the port. The sample is transferred to a sterile cup, and finally, the nurse must unclamp the tubing to prevent urinary retention and potential complications.

Step-by-Step Solution

1
Clamp the drainage tubing.
Fresh urine collects in the tubing.
Ensures the sample is recently produced rather than stagnant urine from the drainage bag.
2
Cleanse the collection port.
The external surface of the port is disinfected.
Prevents the introduction of bacteria into the closed catheter system.
3
Aspirate urine with a sterile syringe.
A sterile urine sample is obtained.
Maintains the closed drainage system integrity while safely extracting the specimen.
4
Transfer urine to a sterile container.
The sample is secured for transport.
Prevents contamination of the specimen en route to the laboratory.
5
Unclamp the drainage tubing.
Normal, continuous urine flow resumes.
Prevents dangerous bladder distention, discomfort, and potential renal complications.

Key Concept

Sterile Specimen Collection from a Closed Drainage System
Question 88Question →

A client with stable angina is prescribed a daily nitroglycerin transdermal patch. Place the following steps for applying the patch in the correct sequential order. (Move the steps into the correct order, starting with the first action.)

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Answer

The correct sequence is: put on gloves, remove the old patch, clean and dry a new site, label the new patch, and apply the new patch.
The correct sequence strictly adheres to safety protocols for transdermal medication administration. It begins with self-protection (gloves), prioritizes client safety by preventing overdose (removing the old patch), ensures optimal drug delivery (cleaning a new site), establishes accurate communication (labeling), and concludes with the actual administration (applying the patch).

Step-by-Step Solution

1
Put on clean gloves.
The nurse's hands are protected.
Nitroglycerin is readily absorbed through the skin and can cause adverse effects like headaches or hypotension in the nurse if handled with bare hands.
2
Remove the old patch and discard it properly.
The continuous delivery of the previous dose is stopped.
Failing to remove the old patch before applying a new one can lead to nitroglycerin toxicity and severe hypotension.
3
Cleanse and dry a new site.
A fresh, hairless area is prepared for the new medication.
Site rotation prevents skin breakdown, and a clean, dry surface is required for the adhesive to stick securely.
4
Label the new patch with date, time, and initials.
The patch is properly identified.
Labeling provides a clear timeline for medication administration and ensures the next nurse knows when the patch is due for removal.
5
Apply the new patch firmly to the skin.
The medication delivery process begins.
Pressing the patch firmly ensures it adheres fully and delivers the correct therapeutic dose.

Key Concept

Safe administration of transdermal medications requires protecting the nurse from exposure, preventing client toxicity by removing prior doses, and ensuring proper site rotation and documentation.
Question 89Question →

A practical nurse is preparing to transfer a client with right-sided weakness (hemiparesis) from the bed to a wheelchair. Arrange the following nursing actions in the correct sequence to ensure a safe transfer.

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Answer

The correct sequence for a safe transfer is: Position the wheelchair on the unaffected (left) side, lock the brakes on the bed and wheelchair, assist the client to sit on the edge of the bed, apply a transfer belt, and finally, instruct the client to bear weight on the strong leg and pivot.
A safe wheelchair transfer relies on proper preparation, biomechanics, and equipment safety. First, the environment must be prepared by placing the wheelchair on the client's unaffected (strong) side to maximize their participation. Next, all equipment brakes must be locked to prevent accidental movement. The client is then assisted to a sitting position to ensure hemodynamic stability and prevent orthostatic hypotension. Once the client is stable, a gait belt is applied to provide the nurse with a secure hold. Finally, the client uses their strong leg to pivot safely into the wheelchair.

Step-by-Step Solution

1
Position the wheelchair on the unaffected side.
The client will be able to reach for the chair with their strong arm.
Transferring toward the strong side ensures the client can support their own weight safely and maintain balance.
2
Lock the brakes on all equipment.
The bed and wheelchair are completely immobilized.
Unsecured equipment can roll backward during the transfer, causing a severe fall.
3
Assist the client to sit on the edge of the bed.
The client is in a seated position with feet on the floor.
Allows the client to regain equilibrium and prevents dizziness from orthostatic hypotension.
4
Apply the transfer belt.
The nurse has a secure grip on the client's waist.
Protects the client from falls and prevents the nurse from pulling on the client's weakened shoulder.
5
Pivot the client into the chair.
The client safely transitions from the bed to the wheelchair.
Using a pivot technique on the strong leg minimizes lifting for the nurse and promotes client independence.

Key Concept

Safe Client Transfer and Mobility Principles
Question 90Question →

A client who is three days postoperative following an abdominal laparotomy suddenly reports a "popping" sensation after a forceful cough. The practical nurse examines the surgical site and observes that the incision has separated and a loop of bowel is protruding. In which order should the nurse perform the following actions? (Arrange from first action to last)

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Answer

The correct sequence is to first stay with the client and call for help, then position them in low Fowler's with flexed knees, followed by covering the wound with sterile saline-moistened dressings, assessing vital signs, and finally documenting the event.
The correct sequence logically follows the principles of emergency nursing care: secure assistance without abandoning the client (call for help), immediately stabilize the mechanical threat using positioning (low Fowler's with bent knees), protect the compromised biological tissue (sterile moist dressings), monitor for systemic decompensation (vital signs), and conclude with accurate administrative recording (documentation).

Step-by-Step Solution

1
Recognize the medical emergency (wound evisceration).
Immediate identification that the client's internal organs are exposed and vulnerable to injury and infection.
Rapid recognition dictates that the client must not be left alone, necessitating a call for help as the absolute first action.
2
Implement immediate mechanical protection without requiring supplies.
The client is placed in low Fowler's position with knees flexed.
This specific position minimizes tension on the abdominal musculature, halting the further evisceration of the bowel.
3
Apply localized tissue protection once supplies are brought to the bedside.
The eviscerated bowel is covered with sterile, saline-moistened dressings.
Moist sterile dressings preserve tissue viability, prevent cellular necrosis, and form a barrier against environmental pathogens.
4
Assess systemic physiological adaptation and stability.
Vital signs are measured to establish a baseline during the acute event.
Monitoring blood pressure and pulse identifies the onset of hypovolemic shock or severe physiological distress.
5
Complete legal and medical record requirements.
The emergency event, interventions, and client status are documented.
Documentation must reflect chronological facts but is prioritized last to ensure direct client care is not delayed.

Key Concept

Prioritization of Nursing Interventions for Surgical Evisceration
Question 91Question →

A practical nurse (PN) is assigned to care for a client who is 24 hours postoperative following abdominal surgery and has a closed-wound drainage system (Jackson-Pratt drain). The PN is preparing to empty the drainage device. Arrange the following actions in the correct sequence to safely perform this procedure.

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Answer

The correct sequence is to first perform hand hygiene and don gloves, then unplug the port, pour the drainage into a measuring container, compress the empty bulb, and finally replace the plug while maintaining compression.
Maintaining a closed-wound drainage system requires strict adherence to infection control and the physical principles of negative pressure. Hand hygiene and gloving are the initial steps to prevent the introduction of pathogens. Opening the port allows the fluid to be emptied and measured, which is an essential nursing responsibility for monitoring postoperative bleeding or fluid shifts to reduce risk potential. Finally, squeezing the bulb and sealing it creates a vacuum, which restores the gentle, continuous suction needed to remove fluid from the surgical site, thereby reducing the risk of hematoma formation and promoting wound healing.

Step-by-Step Solution

1
Perform hand hygiene and put on clean gloves.
Pathogen transmission risk is minimized.
Standard precautions must always be the first step when preparing to handle bodily fluids or invasive devices.
2
Unplug the drainage port on the collection bulb.
The sealed vacuum is released.
The system must be opened to allow the accumulated fluid to be emptied.
3
Pour drainage into a graduated measuring container.
Fluid is collected for accurate measurement.
Careful monitoring of postoperative drainage volume is required to assess for risk of bleeding or excessive fluid loss.
4
Compress the empty bulb fully.
Air is expelled from the bulb.
The bulb must be flattened to prepare for re-establishing negative pressure.
5
Replace the plug into the drainage port while the bulb is compressed.
Negative pressure suction is re-established.
Sealing the flattened bulb creates the gentle vacuum needed to continuously draw fluid away from the surgical site.

Key Concept

Maintaining and Emptying Closed-Wound Drainage Systems
Question 92Question →

A practical nurse is reinforcing teaching for a client who is non-weight-bearing on the right leg and is learning to ascend stairs using crutches without a handrail. In what order should the practical nurse instruct the client to perform the following actions? Arrange the actions in the correct chronological sequence.

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Answer

The correct sequence is: Assume the tripod position, transfer body weight to the crutches, advance the unaffected leg up onto the step, shift body weight to the unaffected leg, and finally bring the affected leg and both crutches up to the step.
When ascending stairs with crutches, the standard safety protocol is 'up with the good, down with the bad.' The client must first establish balance in the tripod position and transfer weight to the crutches. This allows the unaffected (strong) leg to be lifted onto the step safely. Once the strong leg is on the step, the client shifts their weight onto it, using the strong leg to power the body upward while simultaneously bringing the crutches and the affected (weak) leg up to the same step.

Step-by-Step Solution

1
Assume the tripod position at the bottom of the stairs.
The client achieves a stable base of support.
Provides necessary balance before initiating any upward movement.
2
Transfer body weight entirely onto the crutches.
The legs are freed from bearing weight.
Allows the unaffected leg to be lifted without the client losing balance.
3
Advance the unaffected leg up onto the step.
The strong leg is positioned on the higher level.
The unaffected leg must lead when going up to provide the power to lift the body (often remembered as 'up with the good').
4
Shift body weight from the crutches to the unaffected leg.
The strong leg now supports the entire body weight.
Frees the arms and crutches so they can be lifted to the next step.
5
Bring the affected leg and both crutches up to the step.
The client successfully completes one step ascent.
Completes the motion while safely keeping the affected leg non-weight-bearing.

Key Concept

Ascending stairs with crutches (non-weight-bearing)
Question 93Question →

A practical nurse (PN) is preparing to perform open tracheostomy suctioning for a stable adult client. In what order should the PN perform the following actions to reduce the risk of hypoxia and airway trauma? Arrange the steps in the correct chronological sequence.

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Answer

The correct sequence for tracheostomy suctioning is: Assess baseline respiratory status, hyperoxygenate the client, insert the catheter without suction, apply intermittent suction during withdrawal, and finally reassess the respiratory status.
Safe tracheostomy suctioning follows a strict protocol to mitigate risks such as hypoxia and tissue trauma. The process begins with a baseline assessment to ensure the procedure is necessary and to provide comparative data. Next, hyperoxygenation is mandatory to build the client's oxygen reserve. The catheter is then carefully inserted without suction to protect the delicate tracheal mucosa. Active, intermittent suction is applied only while withdrawing the catheter (typically for 10 seconds or less) to safely clear the secretions. Finally, a post-procedure reassessment is conducted to ensure the intervention was successful and the client has stabilized.

Step-by-Step Solution

1
Assess the client's baseline respiratory rate, breath sounds, and oxygen saturation.
Establishes baseline clinical data.
Provides a baseline to compare against after the procedure and confirms that suctioning is indicated.
2
Hyperoxygenate the client.
Increases oxygen reserves in the lungs and bloodstream.
Compensates for the oxygen that will be removed from the airway along with secretions during active suctioning.
3
Insert the sterile suction catheter without applying suction.
Safely advances the catheter to the appropriate depth.
Applying suction during insertion aggressively pulls on the tracheal lining, causing mucosal damage and bleeding.
4
Apply intermittent suction while rotating and withdrawing the catheter.
Removes mucus and secretions from the airway.
Intermittent suction combined with rotation clears all sides of the airway safely while limiting the duration of oxygen deprivation.
5
Reassess the client's respiratory status.
Determines the clinical outcome of the procedure.
Verifies that the airway is clear and confirms the client has returned to or improved beyond baseline oxygenation.

Key Concept

Airway Management and Hypoxia Prevention
Question 94Question →

While walking past a client's room, a practical nurse observes a client who is receiving continuous enteral tube feeding suddenly coughing vigorously and struggling to breathe. Which sequence of actions should the practical nurse implement? Arrange the actions in the correct order from first to last.

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Answer

The practical nurse should first stop the enteral feeding, followed by elevating the head of the bed, then obtaining vital signs and oxygen saturation, and finally notifying the supervising registered nurse.
According to the airway, breathing, and circulation (ABC) prioritization framework, the practical nurse must first stop the immediate threat to the airway (the continuous enteral feeding). Next, positioning the client upright facilitates breathing and lung expansion. Once the client's airway and breathing are stabilized, the nurse collects objective clinical data (vital signs and oxygen saturation) before notifying the supervising registered nurse to escalate care.

Step-by-Step Solution

1
Stop the continuous enteral feeding infusion.
Halts the infusion of formula.
Protects the airway by eliminating the immediate source of suspected aspiration.
2
Elevate the head of the bed to a high Fowler's position.
Places the client in an upright position.
Facilitates lung expansion, decreases work of breathing, and uses gravity to prevent further reflux or aspiration.
3
Obtain the client's oxygen saturation and vital signs.
Gathers objective clinical data.
Establishes a baseline for the acute event and determines the severity of respiratory distress and hypoxia.
4
Notify the supervising registered nurse.
Escalates the client's care.
Ensures the registered nurse and healthcare provider can initiate further collaborative interventions, such as oxygen therapy or diagnostic imaging.

Key Concept

Prioritization in acute respiratory compromise involves addressing the airway first (stopping the immediate threat and positioning), breathing/circulation next (data collection), and then communicating findings to the team.
Question 95Question →

A licensed practical nurse (LPN) enters a client's room and observes them beginning to experience a generalized tonic-clonic seizure while sitting in a bedside armchair. Arrange the following nursing actions in the correct sequence of priority.

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Answer

The correct sequence prioritizes immediate physical safety, followed by airway management, observation, and post-seizure assessment.
In any acute physiological emergency, the nurse must follow the framework of Safety first, followed immediately by Airway, Breathing, and Circulation (ABCs). When a client seizes in a chair, the most imminent threat is a traumatic fall. Guiding them to the floor secures safety. Next, the airway is at risk due to loss of muscle control and excess secretions, making the side-lying position critical. Loosening clothing further assists breathing. Only after these immediate life-preserving steps are taken should the nurse focus on observing the specific details of the seizure. Finally, physical assessment data like vital signs require the client to be relatively still, which is only possible in the post-ictal state.

Step-by-Step Solution

1
Guide the client to the floor.
The client is moved from a precarious position in the chair to a safe, flat surface.
Prevents severe trauma from falling or hitting the extremities against the chair structure.
2
Place the client in a side-lying position.
The client's airway remains clear of the tongue and accumulating saliva or emesis.
Airway protection (the 'A' in ABCs) is the highest physiological priority once the client is protected from immediate mechanical injury.
3
Loosen restrictive clothing.
Neckties, tight collars, or belts are unfastened.
Facilitates unimpeded breathing and venous return.
4
Note the time and characteristics of the seizure.
Crucial clinical data is gathered regarding the onset, type of movements, and duration.
This data collection is essential for the provider to determine the type of seizure and appropriate pharmacological intervention.
5
Obtain vital signs.
Post-ictal heart rate, respiratory rate, blood pressure, and oxygen saturation are recorded.
Provides baseline data on the client's physiological recovery after the acute hypermetabolic state of the seizure has ended.

Key Concept

Prioritization of Care During a Seizure (Safety and ABCs)
Question 96Question →

A practical nurse (PN) is preparing to collect a sterile urine specimen for culture and sensitivity from a client who has a closed indwelling urinary catheter system. After performing hand hygiene and donning clean gloves, in what order should the PN perform the following actions to reduce the risk of infection and ensure an accurate laboratory sample? (Arrange the steps in the correct sequence from first to last.)

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Answer

The correct sequence is: Clamp the tubing below the port, scrub the sampling port, withdraw urine with a sterile syringe, transfer the urine to a sterile container, and finally unclamp the drainage tubing.
The correct sequence ensures that a fresh, uncontaminated sample is collected directly from the closed urinary system while minimizing the risk of introducing pathogens. Clamping allows fresh urine to gather, proper disinfection prevents CAUTI, aseptic withdrawal and transfer maintain sample integrity, and unclamping is essential to prevent severe physical complications from urinary retention.

Step-by-Step Solution

1
Clamp the drainage tubing just below the sampling port for 15 to 30 minutes.
Freshly produced urine collects in the tubing.
Urine in the main drainage bag is stagnant and not suitable for accurate culture due to potential bacterial overgrowth at room temperature.
2
Scrub the needleless sampling port vigorously with an antimicrobial swab.
The access site is disinfected.
Disinfecting the port prevents the introduction of outside microorganisms into the sterile closed urinary system.
3
Attach a sterile syringe to the sampling port and withdraw the required volume of urine.
A sterile sample is securely obtained.
Using a sterile syringe ensures the sample remains uncontaminated during withdrawal.
4
Transfer the collected urine from the syringe into a sterile specimen container.
The sample is safely prepared for laboratory transport.
The laboratory requires a sterile container to ensure that any bacterial growth in the culture originates from the client's urinary tract, not the environment.
5
Unclamp the catheter drainage tubing to restore continuous gravity flow.
Normal urinary drainage resumes.
Prevents dangerous complications such as bladder distention, retrograde infection, and autonomic dysreflexia.

Key Concept

Reduction of Risk Potential: Infection Control and Complication Prevention
Estimated Time:1m 15s
Question 97Question →

A practical nurse (PN) is caring for an alert and conscious client with type 1 diabetes mellitus who suddenly reports feeling shaky, dizzy, and diaphoretic. The PN performs a capillary blood glucose test, which reads 48 mg/dL (2.7 mmol/L). In which order should the PN perform the following actions? (Arrange the actions from first to last.)

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Answer

The correct order is to administer a simple carbohydrate, wait 15 minutes to recheck the glucose, repeat the simple carbohydrate if still low, provide a complex snack once stable, and finally document the event.
The 'Rule of 15' is the standard evidence-based protocol for managing hypoglycemia in a conscious client. The nurse first provides 15 grams of a fast-acting simple carbohydrate to rapidly raise the blood sugar. Waiting 15 minutes allows the sugar to absorb before rechecking the blood glucose. If it remains below 70 mg/dL, the 15-gram carbohydrate dose is repeated. Once the blood glucose is above 70 mg/dL, a complex carbohydrate and protein snack is given to sustain the blood sugar levels. Finally, the nurse documents the entire event.

Step-by-Step Solution

1
Administer 15 grams of a fast-acting simple carbohydrate.
The client receives an immediate source of glucose to rapidly treat the acute hypoglycemia.
Because the client is conscious and can swallow, a fast-acting oral carbohydrate (like 4 ounces of juice) is the fastest and safest way to increase blood sugar and prevent progression to unconsciousness or seizures.
2
Recheck the capillary blood glucose level after 15 minutes.
The PN evaluates the client's response to the initial intervention.
It takes approximately 15 minutes for the simple carbohydrate to enter the bloodstream and effectively raise the blood glucose level.
3
Repeat the simple carbohydrate dose if the blood glucose is still below 70 mg/dL (3.9 mmol/L).
The client receives additional glucose if the first dose was insufficient.
If the blood glucose remains below the safe threshold of 70 mg/dL, the hypoglycemia has not resolved, and another immediate rapid intervention is necessary.
4
Provide a snack containing a complex carbohydrate and a protein.
The client's blood glucose is stabilized over a longer period.
Simple carbohydrates are metabolized quickly. Providing a complex carbohydrate and protein ensures a steady, prolonged release of glucose to prevent a recurrent drop in blood sugar.
5
Document the hypoglycemic episode, interventions, and the client's response.
The medical record is updated with accurate clinical data.
Accurate documentation is legally and clinically required, but it is the lowest priority and must be done only after the client is safe and stable.

Key Concept

Management of Acute Hypoglycemia (Rule of 15)
Question 98Question →

A client with a history of stable angina is prescribed a daily nitroglycerin transdermal patch. After gathering the necessary supplies, entering the client's room, and verifying the client using two identifiers, the practical nurse proceeds with the medication administration. Arrange the following actions in the correct sequential order from first to last.

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Answer

The correct sequence is: Don clean gloves, remove the old patch, clean the old site, label the new patch, and apply the new patch.
Safe transdermal patch administration requires a strict sequence to ensure client safety and protect the nurse. The nurse must first don gloves to prevent absorbing the medication. Next, the old patch must be removed and safely discarded, and the old site must be thoroughly cleaned to prevent an overdose from residual medication. The new patch is then labeled with the date, time, and initials prior to application to avoid causing discomfort by writing directly on the client's skin. Finally, the patch is firmly applied to a new, hairless site to ensure consistent absorption and prevent tissue irritation.

Step-by-Step Solution

1
Put on a pair of clean gloves.
The nurse's hands are protected from the medication.
Nitroglycerin can be absorbed through the nurse's skin, causing adverse effects such as a severe headache or hypotension.
2
Remove the previously applied patch and fold the adhesive sides together.
The continuous delivery of the previous dose is halted.
Failing to remove the old patch before applying a new one can lead to a dangerous medication overdose.
3
Wash the old application site with soap and water, then dry the skin completely.
The skin is clear of residual medication.
Residual nitroglycerin left on the skin continues to be absorbed; cleaning the site ensures accurate dosing of the new patch.
4
Write the current date, time, and nurse's initials on the outer backing of the new patch.
The new patch is properly identified for future shifts.
Writing on the patch before applying it prevents the nurse from pressing a pen into the client's skin.
5
Press the newly labeled patch firmly onto a different, hairless area of the upper chest or arm.
The new dose is securely administered.
Site rotation prevents skin breakdown and irritation, while applying to a hairless area ensures optimal skin contact and absorption.

Key Concept

Safe Administration of Transdermal Medications
Question 99Question →

A practical nurse (PN) is preparing to obtain an aerobic wound culture from a client's sacral pressure injury. In what order should the PN perform the following actions? (Arrange the steps in the correct sequence from first to last.)

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Answer

The correct sequence for obtaining a wound culture is to first remove the soiled dressing, perform hand hygiene and don new gloves, cleanse the wound with normal saline, swab the granulating tissue, and finally place the swab in the collection tube.
To obtain an accurate wound culture without cross-contamination, the PN must first remove the soiled dressing and change gloves. Next, the wound is cleansed with normal saline to remove surface exudate and skin flora. The PN then swabs viable granulating tissue, where the active infection resides, before securing the swab in the sterile tube.

Step-by-Step Solution

1
Remove the soiled dressing.
The wound bed is exposed.
Necessary to access the site for culture.
2
Perform hand hygiene and put on new gloves.
Hands are clean and protected.
Prevents introducing bacteria from the old dressing into the wound.
3
Cleanse the wound with sterile normal saline.
Surface exudate and flora are removed.
Ensures the culture isolates pathogens causing the infection, not surface contaminants.
4
Swab clean, granulating tissue.
A sample of the infecting organism is obtained.
Pathogens are most concentrated in viable, granulating tissue rather than in slough or purulent drainage.
5
Place the swab in the collection tube.
The specimen is secured for transport.
Preserves the sample and prevents environmental contamination.

Key Concept

Proper technique for obtaining a wound culture involves cleansing the wound first to avoid culturing surface flora and swabbing only viable tissue.
Question 100Question →

A practical nurse (PN) is assisting a healthcare provider with a bedside thoracentesis for a client diagnosed with a large pleural effusion. In what order should the PN perform the following actions to minimize the risk of complications and ensure client safety? Arrange the actions from first to last.

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Answer

The correct sequence of actions requires the practical nurse to first verify informed consent, position the client safely to expand the ribs, monitor respiratory status during aspiration, apply an occlusive dressing immediately upon needle withdrawal, and finally ensure a follow-up chest X-ray is completed.
Risk reduction during invasive bedside procedures follows a chronological progression to protect the client. It begins with pre-procedural safety checks (verifying consent), moves to optimal anatomical preparation (upright leaning position) to prevent injury, involves continuous intra-procedural vigilance (oxygen saturation monitoring) for acute complications, utilizes immediate post-procedural site care (occlusive dressing) to prevent air entry, and concludes with post-procedural diagnostic verification (chest X-ray) to definitively rule out a collapsed lung.

Step-by-Step Solution

1
Verify the informed consent.
The client is legally and ethically cleared for the procedure.
Risk reduction begins with confirming that the client is aware of the procedural risks and has agreed to proceed.
2
Position the client upright and leaning forward over a table.
The ribs are separated and the pleural space is safely accessible.
This anatomical positioning pushes the diaphragm down and opens the intercostal spaces, heavily reducing the risk of a lung puncture by the needle.
3
Monitor vital signs and oxygen saturation during the aspiration.
Early signs of respiratory distress are immediately identified.
Removing fluid from the pleural space can cause fluid shifts or accidental lung injury; continuous monitoring ensures rapid intervention if status deteriorates.
4
Apply a sterile occlusive dressing upon needle removal.
The pleural space is sealed from the outside environment.
An airtight seal prevents air from being sucked into the negative-pressure pleural space, which would cause a collapsed lung.
5
Prepare for a post-procedure chest X-ray.
Internal structures are radiologically visualized.
An X-ray is the gold standard for confirming that no iatrogenic pneumothorax occurred during the procedure.

Key Concept

Nursing responsibilities and complication prevention during a thoracentesis
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