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During a routine morning assessment, a practical nurse notes that a client recently admitted to a semi-private room is exhibiting hemoptysis, night sweats, and a persistent productive cough. Suspecting potential active pulmonary tuberculosis, the nurse must initiate immediate precautions. Arrange the following nursing actions in the correct prioritized sequence to minimize the risk of pathogen transmission.

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Answer

The correct sequence prioritizes source control first by masking the client, followed by protecting the immediate bystander (roommate), protecting the nurse (donning the N95), ensuring definitive environmental isolation (AIIR transfer), and finally documenting the event.

Infection control prioritization dictates that when a healthcare worker is already at the bedside and discovers an airborne risk, source control (masking the client) is the fastest and most effective first step. This is followed by removing bystanders, protecting oneself with appropriate PPE, establishing long-term environmental controls (AIIR), and concluding with documentation.

Step-by-Step Solution

Place a standard surgical mask over the client's nose and mouth.

The client's infectious respiratory secretions are contained.

Immediate source control is the highest priority to stop the spread of droplet nuclei into the shared environment.

Instruct the client's roommate to leave the room and wait in a safe area.

The secondary contact is removed from the contaminated environment.

Protecting the most immediately vulnerable bystander from further exposure is the next crucial step in infection control.

Exit the room temporarily to perform hand hygiene and don a fit-tested N95 respirator.

The nurse is properly protected against airborne pathogens.

Proper personal protective equipment must be obtained and donned before any further prolonged direct contact or assessment occurs.

Coordinate with the nursing supervisor to transfer the client to an airborne infection isolation room (AIIR).

Definitive environmental isolation is arranged.

Airborne precautions require negative-pressure ventilation, which cannot be achieved in a standard semi-private room.

Document the client's respiratory findings and the initiation of isolation measures in the health record.

An accurate medical and legal record is created.

Documentation must reflect the findings and interventions but is always performed after physical safety is secured.

Key Concept

Prioritization of Airborne Precautions and Immediate Infection Control

Question 1022Question →

A home health licensed practical nurse (LPN) is visiting a client who is recovering from a recent stroke. The client's spouse of 40 years died unexpectedly two weeks ago. When the nurse arrives, the client yells, "Get out! I do not need your help or anyone else's!" Which response by the nurse is the most appropriate?

You are going through the anger stage of grief right now, which is completely expected.

You have experienced a tremendous loss. I will just sit here quietly with you.

Why are you directing your anger at me when I am only here to provide care?

Getting this upset is dangerous for your blood pressure and could cause another stroke.

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Answer: You have experienced a tremendous loss. I will just sit here quietly with you.

Answer

The most appropriate response is to acknowledge the magnitude of the client's loss and offer a supportive, silent presence.

The correct response utilizes the therapeutic communication techniques of acknowledging the client's feelings and 'offering self.' Anger and displacement are normal manifestations of acute grief. By validating the magnitude of the loss and offering a quiet, non-judgmental presence, the nurse provides a safe environment for the client to process their emotions without feeling pressured, abandoned, or confronted.

Step-by-Step Solution

Analyze the underlying cause of the client's behavior.

The client's hostility is identified as a normal manifestation of acute grief related to the sudden death of their spouse, rather than true refusal of care or a personal attack.

Anger is a common emotion during the grieving process and is frequently displaced onto healthcare providers or surviving family members.

Select the nursing response that utilizes therapeutic communication techniques.

The nurse chooses to acknowledge the client's loss and offer a quiet, non-judgmental presence.

Therapeutic communication prioritizes the client's emotional safety. 'Offering self' provides support and validates the client's current emotional state without escalating the conflict.

Key Concept

Therapeutic Communication in Acute Grief

Question 1023Question →

An older adult client is admitted to the medical-surgical unit after three days of severe vomiting and diarrhea. While collecting data, which of the following findings strongly indicate to the practical nurse that the client is experiencing an acute physiological deterioration requiring immediate escalation of care? Select all that apply.

Select all that apply

Blood pressure decreases from an admission baseline of 138/82 mm Hg to 104/66 mm Hg.

The client becomes suddenly disoriented to time and place during the assessment.

The resting apical heart rate is 114 beats per minute with a thready quality.

The client reports diffuse abdominal cramping rated as a 5 on a 0 to 10 pain scale.

Capillary refill time is brisk and evaluated at less than 2 seconds.

The client experiences a large episode of watery diarrhea during the shift.

Show answer & explanation

Answer: Blood pressure decreases from an admission baseline of 138/82 mm Hg to 104/66 mm Hg.; The client becomes suddenly disoriented to time and place during the assessment.; The resting apical heart rate is 114 beats per minute with a thready quality.

Answer

The correct findings are the decrease in blood pressure, the sudden disorientation, and the tachycardic, thready pulse.

The correct findings represent hallmark early signs of hypovolemic shock due to severe fluid volume deficit. A significant downward trend in blood pressure, compensatory tachycardia with a weak pulse, and sudden altered mental status (indicating decreased cerebral perfusion) are acute, life-threatening changes that require immediate rapid intervention.

Step-by-Step Solution

Analyze the client's admitting diagnosis (severe diarrhea and vomiting) to identify the primary physiological risk.

The client is at extremely high risk for fluid volume deficit progressing to hypovolemic shock.

Prolonged gastrointestinal fluid loss significantly decreases circulating blood volume.

Evaluate each assessment finding to differentiate between expected baseline symptoms and acute, life-threatening complications.

Abdominal cramping and diarrhea are expected. Normal capillary refill is reassuring. The dropping blood pressure, tachycardia, and confusion are unexpected acute changes.

Safe prioritization requires identifying new, unstable, or systemic changes over localized, expected symptoms.

Identify the specific findings that indicate compromised Airway, Breathing, or Circulation (ABCs).

The dropping blood pressure, compensatory tachycardia (114 beats/min), and sudden disorientation indicate poor systemic and cerebral perfusion.

These are early hallmark signs of impending hypovolemic shock requiring immediate escalation to the registered nurse.

Key Concept

Recognizing early signs of hypovolemic shock and acute physiological deterioration.

Question 1024Question →

An unresponsive client requires morning oral hygiene. How should the nurse sequence the following interventions? (Arrange the steps from first to last.)

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Answer

The correct sequence is to first turn the client onto their side, then arrange the towel and basin, proceed to swab the oral cavity, and finally apply moisturizer to the lips.

The absolute priority when providing oral care to an unresponsive client is airway management. Positioning the client on their side must always occur first to allow fluids to drain out of the mouth, thereby preventing aspiration. After the airway is secure, preparation of the physical environment with a towel and basin ensures cleanliness. The actual mechanical cleaning of the oral cavity follows. Finally, applying a water-soluble moisturizer provides comfort and preserves skin integrity.

Step-by-Step Solution

Protect the airway

The client is placed in a side-lying position.

An unresponsive client lacks an intact gag reflex. Turning them on their side ensures fluids drain out of the mouth rather than pooling in the back of the throat, which prevents aspiration.

Prepare the immediate area

A towel and emesis basin are placed near the client's face.

This setup catches oral secretions and cleaning solutions, keeping the client's skin and bed linens dry and clean.

Perform oral hygiene

The teeth, gums, and tongue are gently cleansed.

Using a moistened sponge removes plaque, bacteria, and crusts to maintain oral health.

Provide skin protection

Water-soluble moisturizer is applied to the lips.

Moisturizer prevents the lips from drying, cracking, and bleeding, completing the comfort care procedure.

Key Concept

Oral Hygiene for the Unresponsive Client

Question 1025Question →

A client with a history of a mood disorder is receiving care on a medical-surgical unit. The client begins pacing the hallway rapidly, speaking in a loud, demanding tone, and clenching their fists. Which actions should the practical nurse (PN) take? (Select all that apply.)

Select all that apply

Direct other clients and visitors to leave the immediate area.

Maintain a personal distance of at least two arm lengths from the client.

Ask the client, "Why are you becoming so angry and aggressive today?"

Communicate using a calm, low-pitched voice and concise sentences.

Apply bilateral soft wrist restraints immediately to prevent physical injury.

Prepare and administer an intravenous (IV) push sedative.

Show answer & explanation

Answer: Direct other clients and visitors to leave the immediate area.; Maintain a personal distance of at least two arm lengths from the client.; Communicate using a calm, low-pitched voice and concise sentences.

Answer

The correct actions are to direct other clients and visitors to leave the immediate area, maintain a personal distance of at least two arm lengths, and communicate using a calm, low-pitched voice and concise sentences.

When a client exhibits signs of escalating behavior, the immediate priority is milieu safety and de-escalation. Directing other clients and visitors away removes them from potential harm and decreases the audience, which can help calm the escalated client. Maintaining at least two arm lengths of distance protects the nurse from sudden physical strikes. Finally, communicating with a calm, low-pitched voice and using concise sentences provides clear, non-threatening direction without increasing the client's sensory overload.

Step-by-Step Solution

Identify the clinical situation from the data collected.

The client is demonstrating signs of acute behavioral escalation and potential aggression, evidenced by rapid pacing, loud speech, and clenched fists.

Recognizing early signs of a behavioral crisis dictates the priority of nursing interventions.

Determine the priority nursing goals.

The primary goals are to ensure the safety of the milieu (client, staff, and bystanders) and to attempt non-pharmacological verbal de-escalation.

Safety is always the immediate priority in any psychiatric or behavioral emergency.

Evaluate each intervention against safety standards and the PN scope of practice.

Removing bystanders, maintaining distance, and using calm communication promote safety and de-escalation. Asking 'why', using immediate restraints, and administering IV push medications violate therapeutic communication, least restrictive alternative mandates, and the PN scope of practice, respectively.

Nursing interventions must be safe, therapeutic, legally sound, and follow a stepwise approach from least to most restrictive.

Key Concept

Crisis De-escalation and Milieu Safety

Question 1026Question →

A practical nurse is providing instructions to a female client who needs to collect a midstream clean-catch urine specimen for laboratory analysis. In what order should the nurse instruct the client to perform these actions? Arrange the steps in the correct chronological sequence.

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Answer

The correct sequence for a midstream clean-catch urine collection is: cleanse the perineal area, begin voiding into the toilet, place the container in the active stream, remove the container before stopping urination, and securely apply the lid.

The correct chronological sequence ensures the urine sample is as sterile as possible. Cleansing the area removes surface bacteria. Voiding a small amount flushes the urethra. Collecting the midstream sample captures urine directly from the bladder. Removing the cup before stopping prevents terminal contamination, and securing the lid safely finalizes the aseptic technique.

Step-by-Step Solution

Identify the first necessary action to prevent specimen contamination.

Cleanse the perineal area from front to back with the provided antiseptic wipes.

Removing external bacteria from the meatus is the essential first step before any urination begins.

Determine the next action to further clear potential contaminants.

Begin voiding a small amount of urine directly into the toilet.

The initial stream flushes resident bacteria out of the distal urethra.

Identify when to actually collect the urine sample.

Place the sterile specimen container into the active stream to collect the sample.

The midstream portion of the urine represents the most uncontaminated sample from the bladder.

Determine the action needed to conclude the collection safely.

Remove the specimen container from the urine stream before stopping urination.

Pulling the cup away while the stream is still strong prevents contamination from the skin as the flow dwindles.

Identify the final step to secure the specimen.

Securely apply the lid to the container without touching its inner surface.

Properly sealing the container maintains its internal sterility until it reaches the laboratory.

Key Concept

Specimen Collection protocols to reduce the risk of false-positive laboratory results.

Question 1027Question →

A practical nurse is preparing to administer a scheduled dose of oral metoprolol to a client who is alert and watching television. The client's heart rate is $72\text{ beats/min}$ and blood pressure is $118/76\text{ mmHg}$ . Which action must the nurse perform to correctly verify the client's identity before giving the medication?

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

Ask the client, "Are you Mr. Smith?" and wait for the client to verbally agree.

Compare the client's room and bed number to the information on the medication administration record.

Verify the client's identity by checking the name listed on the dry-erase board in the client's room.

Show answer & explanation

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

Answer

The nurse must verify the client's identity by asking them to state their first and last name and date of birth while checking their identification band.

The standard of care for medication administration requires nurses to use at least two distinct, acceptable client identifiers before giving any medication. Asking the client to actively state their full name and date of birth, while comparing this information to their physical identification band and the medication administration record, fulfills this critical safety requirement and prevents errors.

Step-by-Step Solution

Review the principles of safe medication administration, specifically the 'Right Client' check.

Identify that at least two distinct, acceptable patient identifiers are required by safety standards.

This ensures the medication is given to the correct individual.

Evaluate the options to determine which represents acceptable identifiers.

Recognize that asking the client to actively state their full name and date of birth, while comparing it to an identification band, meets this requirement.

Active identification prevents errors associated with yes/no questions or unreliable location-based identifiers.

Key Concept

Rights of Medication Administration: Right Client Verification

Question 1028Question →

During morning rounds, a client receiving daily oral levothyroxine $150\text{ mcg}$ for primary hypothyroidism reports feeling restless and unusually warm. The practical nurse notes a heart rate of $112\text{ bpm}$ and a blood pressure of $142/88\text{ mmHg}$ . A review of the morning laboratory results reveals a thyroid-stimulating hormone (TSH) level of $0.1\text{ mU/L}$ (normal: $0.4\text{ to }4.0\text{ mU/L}$ ). Which action should the practical nurse take first?

Administer the levothyroxine as prescribed because the low TSH level indicates worsening hypothyroidism.

Verify the client's identity using two identifiers and administer the medication with a prescribed PRN antipyretic.

Withhold the scheduled dose of levothyroxine and report the assessment findings to the registered nurse.

Independently reduce the levothyroxine dose by half to safely manage the client's elevated heart rate.

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Answer: Withhold the scheduled dose of levothyroxine and report the assessment findings to the registered nurse.

Answer

The practical nurse should withhold the scheduled dose of levothyroxine and notify the registered nurse.

The client is exhibiting clinical signs of hyperthyroidism (tachycardia, heat intolerance, restlessness, elevated blood pressure) alongside a suppressed TSH level. These findings indicate levothyroxine toxicity. The safest and most appropriate action within the practical nurse's scope of practice is to withhold the scheduled dose to prevent further physiological harm and immediately escalate the critical findings to the registered nurse or healthcare provider for medical re-evaluation.

Step-by-Step Solution

Analyze the client's physical symptoms and vital signs.

Restlessness, feeling warm, and tachycardia (

112\text{ bpm}

) are identified as classic signs of a hypermetabolic state.

Identifying abnormal assessment findings is the critical first step in evaluating medication safety prior to administration.

Interpret the laboratory results in the context of the medication.

A TSH level of

0.1\text{ mU/L}

is significantly below the normal range, indicating excessive circulating thyroid hormone.

TSH has an inverse relationship with thyroid hormone levels; a suppressed TSH confirms hyperthyroidism or levothyroxine toxicity.

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

The medication must be withheld and the clinical findings immediately escalated to the registered nurse or provider.

Administering the medication would exacerbate the toxicity, and altering the prescribed dose independently is strictly outside the practical nurse's scope.

Key Concept

Recognizing medication toxicity, understanding lab value relationships, and adhering to the practical nurse scope of practice.

Question 1029Question →

A practical nurse is preparing to apply a newly prescribed transdermal clonidine patch to a client with hypertension. The client currently has an old patch in place on their right upper chest. In what order should the nurse perform the following actions?

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Answer

The correct sequence is to first don clean gloves and remove the old patch, fold it in half for disposal, cleanse and dry a new application site, apply the new patch with firm pressure, and finally label the patch with the date, time, and initials.

Applying a transdermal patch requires a systematic approach to ensure safety for both the client and the nurse. The nurse must first protect themselves with gloves and remove the old patch to prevent a medication overdose. The old patch is immediately folded and discarded safely. A new site is then cleansed and dried to prevent irritation and ensure adhesion. The new patch is applied with pressure, and finally, it is labeled so the next nurse knows when it was administered.

Step-by-Step Solution

Don clean gloves and remove the old patch.

The client is no longer receiving medication from the previous patch.

Gloves protect the nurse from absorbing the medication. Removing the old patch first prevents delivering a double dose.

Fold the old patch in half with the adhesive sides together and discard it.

The old patch is safely secured.

This prevents anyone else from accidentally coming into contact with residual medication on the patch.

Cleanse a new, hairless application site and allow it to dry completely.

A fresh, clean site is prepared.

Site rotation prevents tissue breakdown. Clean, dry skin is necessary for the adhesive to work properly.

Apply the new patch and hold it firmly in place for 10 to 15 seconds.

The new patch is securely attached.

Applying pressure ensures the edges do not peel up and the medication will be absorbed properly.

Write the date, time, and initials on the outside of the new patch.

The administration is clearly documented.

Proper labeling communicates with the rest of the nursing staff so they know exactly when the patch was placed.

Key Concept

Transdermal Medication Administration

Estimated Time:1m 0s

Question 1030Question →

A practical nurse is preparing to perform a routine capillary blood glucose test for a client with diabetes mellitus. In what order should the nurse perform the following actions to obtain an accurate sample and minimize complications? Arrange the steps from first to last.

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Answer

The correct sequence is to first clean the site with alcohol, allow it to dry completely, puncture the side of the finger, wipe away the initial drop of blood, and then apply the second drop to the test strip.

To obtain an accurate capillary blood glucose reading and reduce the risk of potential complications, the practical nurse must follow a strict procedural sequence. First, the site is cleaned to prevent infection. Second, the alcohol must dry completely to prevent it from altering the glucose reading. Third, the puncture is made on the less sensitive side of the finger. Fourth, the first drop of blood is wiped away because it contains tissue fluid that dilutes the sample. Finally, the second drop of pure capillary blood is applied to the test strip for an accurate measurement.

Step-by-Step Solution

Clean the selected puncture site with an alcohol swab.

The skin surface is sanitized.

Reduces the risk of infection by removing surface pathogens before breaking the skin.

Allow the alcohol on the skin to dry completely.

The alcohol evaporates from the puncture site.

Prevents alcohol from mixing with the blood sample, which can cause an inaccurate glucose reading and increase stinging for the client.

Puncture the lateral aspect of the fingertip using a sterile lancet.

A small capillary puncture is created.

The side of the finger has a rich blood supply but fewer nerve endings, minimizing client discomfort.

Wipe away the first drop of blood using a dry, sterile gauze pad.

The initial blood drop is removed.

The first drop contains tissue fluids that can dilute the blood sample and skew the test result.

Apply the second drop of blood directly to the reagent test strip.

The sample is collected on the strip.

The second drop consists of pure capillary blood, providing the most accurate glucose measurement.

Key Concept

Proper technique for capillary blood glucose sampling ensures accurate diagnostic results and minimizes the risk of client harm or discomfort.

Question 1031Question →

A practical nurse and an unlicensed assistive personnel (UAP) are preparing to move a postoperative client up in bed using a draw sheet. Arrange the following actions in the correct chronological sequence to ensure client and staff safety.

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Answer

The correct sequence is to first flatten and raise the bed, then protect the client's head with a pillow, have the client cross their arms and bend their knees, grasp the draw sheet closely on both sides, and finally execute the move on a synchronized count.

Moving a client up in bed safely requires strict adherence to body mechanics and safety protocols. Flattening the bed removes gravity as an obstacle. Placing a pillow at the headboard protects the client from head trauma. Having the client fold their arms and bend their knees minimizes friction and allows them to assist with the move. Grasping the draw sheet closely provides the necessary leverage, and moving synchronously on a count ensures smooth, safe repositioning.

Step-by-Step Solution

Position the bed flat and adjust the height.

Gravity resistance is minimized and working posture is optimized.

This establishes a safe starting environment that prevents musculoskeletal injuries.

Place a pillow against the headboard.

The headboard is padded.

This prevents trauma to the client's head if they slide up too quickly.

Instruct the client to cross arms and bend knees.

Friction is reduced and the client is ready to assist.

Keeping limbs compact prevents injury and bending knees provides client leverage.

Grasp the rolled draw sheet tightly.

A secure hold is established on the lifting device.

Holding near the client's body maximizes mechanical advantage.

Shift weight and move on the count of three.

The client is safely repositioned higher in the bed.

Synchronized teamwork ensures a smooth transfer without jerking motions.

Key Concept

Safe client handling, body mechanics, and mobility transfers

Question 1032Question →

A client is 6 hours post-operative following a total knee arthroplasty. During a routine assessment, the practical nurse notes that the client has produced only 15 mL of urine via the indwelling catheter over the past hour. The client's current vital signs are blood pressure 100/62 mm Hg, heart rate 108 bpm, and respirations 20 breaths/min. The client reports surgical site pain as 5 on a 0 to 10 scale. Which action should the practical nurse take first?

Notify the registered nurse about the urine output and vital signs.

Administer the prescribed as-needed analgesic for the surgical site pain.

Document the findings and reassess the urinary output in one hour.

Increase the continuous intravenous fluid infusion rate.

Show answer & explanation

Answer: Notify the registered nurse about the urine output and vital signs.

Answer

The priority action is to notify the registered nurse about the urine output and vital signs.

A urine output of less than 30 mL/hr combined with an increasing heart rate and low-normal blood pressure in a post-operative client strongly suggests fluid volume deficit or bleeding. The priority action is to immediately escalate these critical findings to the registered nurse or healthcare provider to reduce the risk of hypovolemic shock.

Step-by-Step Solution

Analyze the clinical data provided in the scenario.

The client has a urine output of 15 mL/hr (normal is greater than 30 mL/hr), an elevated heart rate of 108 bpm, and a low-normal blood pressure of 100/62 mm Hg.

Identifying abnormal clinical findings is the first step in risk reduction and early complication management.

Determine the potential complication based on the findings.

The combination of oliguria, tachycardia, and a dropping or borderline blood pressure in a post-operative client indicates a high risk for hypovolemia, hemorrhage, or impending shock.

Recognizing patterns of clinical deterioration guides proper prioritization.

Select the priority nursing action based on the practical nurse's scope of practice.

The most appropriate immediate action is to alert the registered nurse or healthcare provider.

The practical nurse must rapidly escalate signs of clinical instability to ensure the client receives prompt medical intervention.

Key Concept

Reduction of Risk Potential: Early Recognition of Post-Operative Complications

Question 1033Question →

A practical nurse is caring for a 78-year-old client who is 12 hours post-operative following abdominal surgery. The client suddenly becomes restless, confused, and has a resting heart rate of 114 beats per minute. Which action should the practical nurse take first?

Measure the client's oxygen saturation and report the findings to the registered nurse.

Ask the client about their current pain level and prepare to administer prescribed analgesics.

Reorient the client to the room and document the new confusion as a standard age-related change.

Continue to monitor the client routinely, as mild tachycardia is an expected finding after surgery.

Show answer & explanation

Answer: Measure the client's oxygen saturation and report the findings to the registered nurse.

Answer

Measure the client's oxygen saturation and report the findings to the registered nurse.

Sudden restlessness, confusion, and tachycardia are classic early indicators of hypoxia, hemorrhage, or shock in a post-operative client. The priority action is to assess the client's respiratory status (ABCs) and immediately notify the registered nurse so that prompt medical intervention can be initiated.

Step-by-Step Solution

Analyze the client's new symptoms: sudden restlessness, confusion, and tachycardia in a post-operative older adult.

These findings point to an acute physiological change.

Identifying changes from the baseline is the first step in clinical reasoning.

Correlate the symptoms with potential post-operative complications.

Restlessness, confusion, and an elevated heart rate are classic early signs of hypoxia or impending shock.

The brain is highly sensitive to decreased oxygen and perfusion, often manifesting as altered mental status before blood pressure significantly drops.

Apply the Airway, Breathing, and Circulation (ABC) prioritization framework.

Assessing oxygenation status directly addresses the highest-priority threat to the client's life.

ABC issues always take precedence over comfort measures or routine monitoring.

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

The nurse must gather focused data (oxygen saturation) and immediately escalate the acute change to the registered nurse.

Acute physiological decompensation requires rapid intervention and RN/provider collaboration.

Key Concept

Early recognition of hypoxia and shock (ABCs)

Estimated Time:1m 0s

Question 1034Question →

An individual is receiving ongoing rehabilitative care one week after a unilateral below-the-knee amputation for severe peripheral arterial disease. The care plan focuses on promoting optimal healing, preparing the residual limb for future prosthetic fitting, and maintaining overall well-being. Which of the following actions are appropriate for the practical nurse to include in the client's daily care? Select all that apply.

Select all that apply

Assist the client into a prone position with the hips completely flat for 20 to 30 minutes several times daily.

Wrap the residual limb with an elastic compression bandage using a figure-eight technique, proceeding from distal to proximal.

Encourage the client to actively push the residual limb downward against the bed mattress while resting in a supine position.

Maintain continuous elevation of the residual limb on two firm pillows to prevent swelling and promote comfort.

Accept delegation from the registered nurse to administer an intravenous push analgesic prior to performing painful dressing changes.

Provide the standard high-protein meal tray to support tissue healing without confirming the client's cultural or religious dietary needs.

Show answer & explanation

Answer: Assist the client into a prone position with the hips completely flat for 20 to 30 minutes several times daily.; Wrap the residual limb with an elastic compression bandage using a figure-eight technique, proceeding from distal to proximal.; Encourage the client to actively push the residual limb downward against the bed mattress while resting in a supine position.

Answer

The correct interventions are assisting the client into a prone position, wrapping the residual limb with a figure-eight technique, and encouraging the client to actively push the limb against the mattress.

Appropriate basic care for a client with a recent lower extremity amputation involves interventions that prepare the limb for a prosthesis and prevent complications. Assisting the client to a prone position for 20 to 30 minutes multiple times a day stretches the flexor muscles and prevents hip flexion contractures. Wrapping the residual limb with a figure-eight technique from distal to proximal reduces edema and properly shapes the limb for a future prosthesis, while avoiding the restricted blood flow associated with circular wrapping. Encouraging the client to push the limb down against the mattress strengthens the necessary muscles and further prevents contracture formation.

Step-by-Step Solution

Evaluate the positioning, mobility, and healing needs for a client recovering from a lower extremity amputation.

Identified that preventing hip flexion contractures and correctly shaping the residual limb are primary priorities for basic care and comfort during the rehabilitative phase.

Contractures can permanently prevent the successful fitting and use of a prosthetic limb, undermining the entire rehabilitation process.

Analyze each proposed intervention against evidence-based basic care standards and the practical nursing scope of practice.

Selected prone positioning, figure-eight wrapping, and active muscle pushing as correct actions. Rejected continuous pillow elevation, intravenous push administration, and bypassing cultural dietary assessments as unsafe or inappropriate.

Safe nursing practice requires strict adherence to physiological principles (avoiding contractures), legal boundaries (refusing out-of-scope tasks), and psychosocial integrity (respecting cultural diets).

Key Concept

Basic care and comfort following an amputation focuses on contracture prevention, proper limb shaping, and holistic, safe care within the practical nurse's legal scope.

Question 1035Question →

A practical nurse (PN) is collecting data on a client who is 2 hours postoperative following an abdominal surgery. The client's vital signs are: heart rate 112 beats/minute, blood pressure 98/62 mm Hg, respiratory rate 18 breaths/minute, and oxygen saturation 97% on room air. The client reports incisional pain of 6 on a 0 to 10 scale and states, 'I feel a little dizzy when I try to sit up.' Which of the following is the priority action for the PN?

Notify the registered nurse (RN) immediately regarding the client's vital signs and dizziness.

Administer the prescribed as-needed (PRN) analgesic to manage the client's postoperative pain.

Document the findings as expected early postoperative changes and continue routine monitoring.

Elevate the head of the bed to a high-Fowler's position to assist with the client's dizziness.

Show answer & explanation

Answer: Notify the registered nurse (RN) immediately regarding the client's vital signs and dizziness.

Answer

Notify the registered nurse (RN) immediately regarding the client's vital signs and dizziness.

The client is exhibiting tachycardia, borderline hypotension, and dizziness, which are classic early signs of hypovolemia or hemorrhage following surgery. Within the practical nurse scope of practice, recognizing acute decompensation requires immediate escalation. The priority is to notify the RN so that a comprehensive assessment can be performed and emergency interventions can be initiated promptly.

Step-by-Step Solution

Analyze the collected data for abnormalities.

The client has tachycardia (112 beats/min), borderline hypotension (98/62 mm Hg), and orthostatic symptoms (dizziness when sitting up).

Identifying abnormal vital signs is the first step in recognizing clinical deterioration.

Correlate the abnormal findings with the clinical context.

In a 2-hour postoperative client, these findings are early indicators of hypovolemia, hemorrhage, or impending shock.

Understanding the significance of the data allows for proper prioritization of care.

Determine the most appropriate action within the PN scope of practice.

The PN must immediately escalate these critical findings to the RN.

The RN needs to perform a comprehensive assessment and coordinate potentially life-saving interventions (such as fluid resuscitation) with the healthcare provider.

Key Concept

Recognition of Early Shock and Scope of Practice

Question 1036Question →

A client who is comatose due to a traumatic brain injury requires routine oral hygiene. Arrange the steps the practical nurse should take to safely provide mouth care in the correct sequence.

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Answer

The correct sequence prioritizes airway safety by first positioning the client laterally, followed by preparing the equipment, safely accessing the oral cavity, performing the cleaning, and finally removing the fluids with suction.

The sequencing of oral care for an unconscious client is strictly dictated by airway safety. Positioning the client laterally is always the first priority to prevent aspiration. Only after the airway is protected from gravity-induced pooling should the nurse prepare the linens, open the mouth safely with an instrument, perform the hygiene, and finally suction out the debris.

Step-by-Step Solution

Establish a safe position for the unconscious client.

The client is placed in a lateral (side-lying) position with the head turned to the side.

Because the client cannot swallow or expectorate, this position allows fluids to drain out of the mouth, preventing pulmonary aspiration.

Prepare the immediate area.

A towel and emesis basin are placed under the client's chin and cheek.

This protects the bed linens and provides a direct path for fluids to drain into the basin.

Open the oral cavity safely.

A padded tongue blade is inserted between the upper and lower back teeth.

This ensures safe access to the oral cavity without risking injury to the nurse's fingers if the client experiences an involuntary bite reflex.

Perform oral hygiene.

The oral cavity is thoroughly cleaned with a moistened sponge swab or soft-bristled toothbrush.

Cleaning removes plaque, bacteria, and crusts, preventing infection and maintaining the integrity of the mucous membranes.

Remove excess fluids.

The mouth is suctioned using a Yankauer or standard suction catheter.

Suctioning eliminates pooling fluids and loosened secretions, completing the cleaning process while continuing to protect the airway.

Key Concept

Oral Care for the Unconscious Client (Aspiration Prevention)

Question 1037Question →

A primary health care provider prescribes a deep intramuscular injection of iron dextran for an adult client with severe anemia. To prevent superficial tissue irritation and skin staining, the practical nurse must utilize the Z-track technique. Arrange the following procedural steps for preparing and administering this medication in the correct chronological order.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: draw the medication and replace the needle, displace the skin laterally, insert the needle at 90 degrees, inject slowly, wait 10 seconds, and finally withdraw the needle while releasing the skin.

The Z-track method is meticulously designed to seal highly irritating or staining medications (such as iron dextran) deep within the muscle tissue. The process begins with drawing up the medication and strictly changing the needle to ensure no residue is on the needle shaft. Next, the skin is pulled laterally to displace the tissue layers. The needle is then inserted at a 90-degree angle, and the medication is injected slowly. The nurse must wait 10 seconds before withdrawing the needle to allow the fluid to disperse and prevent backflow. Finally, withdrawing the needle and immediately releasing the skin creates a staggered track, effectively trapping the medication in the muscle layer and preventing superficial damage.

Step-by-Step Solution

Draw up the medication and change the needle.

A sterile needle without irritating medication residue on the outside is attached to the syringe.

Prevents tracking of the highly irritating or staining medication through superficial tissues during insertion.

Displace the skin and subcutaneous tissue laterally.

The superficial tissue layers are misaligned with the deeper muscle layers.

Creates the mechanical foundation required for the Z-track seal.

Insert the needle at 90 degrees and inject slowly.

Medication is deposited deep into the ventrogluteal muscle.

Ensures proper depth, prevents subcutaneous pooling, and minimizes tissue trauma.

Wait 10 seconds before needle withdrawal.

The medication begins to disperse into the surrounding muscle.

Prevents immediate backflow of the fluid into the needle track.

Withdraw the needle and simultaneously release the skin.

The tissue layers slide back into their natural alignment.

The staggered needle track is closed, physically sealing the medication deep within the muscle layer.

Key Concept

Safe Administration of Intramuscular Medications utilizing the Z-Track Method

Question 1038Question →

A practical nurse (PN) is assessing a client who is $12$ hours postoperative following an open reduction and internal fixation (ORIF) of the right femur. Which of the following findings indicate a potential life-threatening complication that requires IMMEDIATE escalation to the registered nurse (RN)? (Select all that apply.)

Select all that apply

Hemoglobin level of

7.8 \text{ g/dL}

(

78 \text{ g/L}

) and hematocrit of

24\%

Heart rate of

112 \text{ beats/minute}

with a blood pressure of

96/60 \text{ mm Hg}

New-onset petechiae scattered across the anterior chest and axillae

White blood cell (WBC) count of

9,500/\text{mm}^3

(

9.5 \times 10^9\text{/L}

)

Serosanguineous drainage measuring

25 \text{ mL}

in the closed-suction device over the last

4

hours

Client requests an as-needed (PRN) analgesic for localized incisional pain rated as

6

on a

0

10

scale

Show answer & explanation

Answer: Hemoglobin level of $7.8 \text{ g/dL}$ ( $78 \text{ g/L}$ ) and hematocrit of $24\%$ ; Heart rate of $112 \text{ beats/minute}$ with a blood pressure of $96/60 \text{ mm Hg}$ ; New-onset petechiae scattered across the anterior chest and axillae

Answer

The findings that require immediate escalation are the critically low hemoglobin/hematocrit, the tachycardia with borderline hypotension, and the petechial rash on the chest.

Clients with long bone fractures are at high risk for hemorrhage and fat embolism syndrome. A critical drop in hemoglobin, tachycardia combined with borderline hypotension, and a new-onset petechial rash on the chest are hallmark signs of these life-threatening complications. These physiological changes indicate a deteriorating state that falls outside the practical nurse's independent scope and mandates immediate escalation to the registered nurse.

Step-by-Step Solution

Evaluate the surgical context and inherent risks

The client had an ORIF of the femur

Long bone fractures and orthopedic surgeries carry high physiological risks for severe hemorrhage and fat embolism syndrome (FES).

Analyze laboratory and vital signs for indications of shock

Identified that a hemoglobin of

7.8 \text{ g/dL}

and vitals of

112 \text{ bpm}

with

96/60 \text{ mm Hg}

are abnormal

These specific values represent acute blood loss and early hypovolemic shock, requiring immediate RN intervention.

Assess physical findings for FES

Identified petechiae on the anterior chest and axillae

This is a classic, life-threatening clinical indicator of FES that occurs when fat droplets enter the circulation, requiring emergency escalation.

Differentiate expected postoperative findings from emergencies

Excluded the WBC of

9,500/\text{mm}^3

, the

25 \text{ mL}

of drainage, and the pain level of

6/10

These findings are within normal postoperative limits or fall within the independent scope of the practical nurse to manage, preventing unnecessary escalation.

Key Concept

Recognition and escalation of life-threatening postoperative orthopedic complications (hemorrhage, hypovolemic shock, and fat embolism syndrome).

Question 1039Question →

An adult client in an inpatient psychiatric unit receives scheduled clozapine for treatment-resistant schizophrenia. During the morning medication pass, the practical nurse observes that the client has a new-onset temperature of $101.4^\circ\text{F}$ ( $38.6^\circ\text{C}$ ), severe pharyngitis, and marked lethargy. The morning laboratory report indicates a white blood cell (WBC) count of $1,800/\text{mm}^3$ ( $1.8 \times 10^9/\text{L}$ ). Based on these findings, which action should the practical nurse take first?

Withhold the scheduled dose of the medication and immediately report the clinical findings and laboratory results to the registered nurse.

Administer the scheduled medication and document the abnormal laboratory values in the client's electronic health record.

Perform a comprehensive, independent physical assessment to determine if the medication should be permanently discontinued.

Administer an as-needed analgesic to relieve the throat pain and ensure the client rests comfortably in bed.

Show answer & explanation

Answer: Withhold the scheduled dose of the medication and immediately report the clinical findings and laboratory results to the registered nurse.

Answer

The correct action is to withhold the scheduled dose of the medication and immediately escalate the clinical findings to the supervising registered nurse.

Clozapine is an atypical antipsychotic associated with a significant risk of agranulocytosis, a potentially fatal drop in white blood cells. A WBC count of

1,800/\text{mm}^3

(

1.8 \times 10^9/\text{L}

), combined with signs of infection such as fever and pharyngitis, strongly indicates this adverse effect. The safest and most appropriate action within the practical nurse scope of practice is to withhold the offending agent and immediately escalate the critical findings to the registered nurse for urgent medical intervention.

Step-by-Step Solution

Analyze the client's presenting symptoms and laboratory results.

The client has a fever, pharyngitis, and a critically low WBC count of

1,800/\text{mm}^3

(normal is typically

4,500

11,000/\text{mm}^3

Identifying abnormal clinical and laboratory findings is the foundational step in safe medication administration.

Correlate the assessment findings with the prescribed pharmacological therapy.

Clozapine carries a severe risk for agranulocytosis, a dangerous depletion of white blood cells that compromises the immune system.

Connecting the drug to its potential life-threatening adverse effect determines the required clinical intervention.

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

The nurse must withhold the drug to prevent further harm and immediately report the findings to the registered nurse.

Administering the medication would worsen the life-threatening condition, and independent medical or complex assessment decisions fall outside the practical nursing scope.

Key Concept

Pharmacological Therapies

Question 1040Question →

During a busy shift on a medical-surgical unit, a practical nurse is prioritizing client care and safety. Which of the following actions by the practical nurse demonstrate the correct application of risk reduction principles? Select all that apply.

Select all that apply

Withholding a scheduled dose of oral furosemide for a client whose morning serum potassium level is 2.8 mEq/L and alerting the registered nurse.

Declining a delegated task to administer an intravenous push (IVP) dose of morphine to a client experiencing severe postoperative pain.

Documenting a one-hour postoperative client's rising heart rate of 114 beats/min and blood pressure of 90/58 mmHg as expected surgical anxiety without further escalation.

Bypassing the electronic barcode scanning system and relying solely on the client's room number to verify identity before administering routine antibiotics.

Leaving a laboratory report showing a serum calcium level of 6.4 mg/dL (1.60 mmol/L) on the chart for the provider to review during afternoon rounds.

Accepting a delegated assignment to independently monitor and titrate a continuous intravenous heparin infusion for a client with a pulmonary embolism.

Show answer & explanation

Answer: Withholding a scheduled dose of oral furosemide for a client whose morning serum potassium level is 2.8 mEq/L and alerting the registered nurse.; Declining a delegated task to administer an intravenous push (IVP) dose of morphine to a client experiencing severe postoperative pain.

Answer

The correct actions are withholding the furosemide due to critical hypokalemia and declining to administer the intravenous push (IVP) morphine.

The correct actions demonstrate a clear understanding of risk reduction. Hypokalemia increases the risk of severe dysrhythmias, so withholding a loop diuretic and notifying the registered nurse is essential. Furthermore, refusing to perform tasks outside the practical nurse scope of practice, such as administering IV push medications, protects the client from potential harm and medication errors.

Step-by-Step Solution

Evaluate each action for adherence to safety protocols, critical value escalation, and practical nursing scope of practice.

Identified that handling medications appropriately and recognizing scope limitations are key components of risk reduction.

Risk reduction requires proactive identification of potential harm.

Analyze the action regarding furosemide administration.

A potassium level of 2.8 mEq/L is critically low. Withholding a potassium-depleting diuretic prevents further life-threatening hypokalemia.

Nurses must verify that current laboratory values support the safe administration of scheduled medications.

Analyze the action regarding the intravenous push (IVP) medication.

Declining the IVP administration is appropriate because it falls outside the legal and educational scope of the practical nurse.

Practicing within legal boundaries prevents client injury and professional liability.

Identify why the remaining actions fail to reduce risk.

The other actions involve ignoring early signs of shock, skipping vital medication identity checks, delaying the report of critical lab values, and accepting assignments beyond the PN scope.

Each of these distractors represents a direct violation of clinical safety and risk potential reduction.

Key Concept

Risk reduction requires the practical nurse to operate strictly within their defined scope of practice, properly verify client identity, and promptly escalate abnormal physiological findings and critical laboratory values.

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