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Question 1161Question →

A client who had abdominal surgery two days ago suddenly becomes disoriented during the evening shift and begins tearing at their wound dressing. Which of the following actions should be taken first to prevent the client from injuring the surgical site?

Show answer & explanation

Answer: Provide the client with a safe, tactile object like a folded washcloth to hold.

Answer

The correct action is to provide the client with a safe, tactile object like a folded washcloth to hold and manipulate.
Providing a diversionary tactile object, such as a folded washcloth, is a highly effective, least-restrictive intervention. It safely redirects the confused client's hands and attention away from the surgical dressing, preventing self-injury without unnecessarily limiting their physical mobility or violating safety protocols.

Step-by-Step Solution

1
Assess the immediate risk to the client's safety, which is the potential disruption of the surgical dressing.
Identified the need to quickly redirect the client's hands away from the wound.
Protecting the surgical site from contamination and dehiscence is a priority.
2
Determine the least restrictive intervention that can effectively manage the behavior.
Selected a diversionary activity.
Nursing standards require exhausting non-pharmacological and non-physical restraint alternatives first.
3
Provide a tactile object such as a washcloth for the client to manipulate.
The client's hands are occupied safely, reducing the risk of self-injury.
Tactile diversion satisfies the restless picking behavior without restricting the client's freedom of movement.

Key Concept

Use of least restrictive alternatives to prevent self-injury
Question 1162Question →

After completing wound care for a client colonized with methicillin-resistant *Staphylococcus aureus* (MRSA) and infected with influenza, a practical nurse prepares to exit the client's room. Arrange the following steps for removing the required personal protective equipment in the correct chronological order from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence for removing personal protective equipment is: remove gloves, take off face shield, unfasten and remove gown, remove mask, and finally perform hand hygiene.
According to standard infection control protocols, the correct sequence for removing personal protective equipment is: gloves, eyewear (goggles or face shield), gown, and finally the mask or respirator. Hand hygiene must be performed immediately after all equipment is removed. Gloves are removed first because they are typically the most contaminated. The mask is removed last to prevent the inhalation of pathogens that might be dispersed into the air while removing the gown.

Step-by-Step Solution

1
Identify the most contaminated item.
Gloves are removed first.
Gloves touch the client and environment directly, carrying the highest risk of transmitting pathogens to other surfaces during the removal process.
2
Determine the next items to be removed to protect mucous membranes.
Face shield is removed second, followed by the gown.
Eyewear protects the eyes but is removed before the gown. The gown is then removed to avoid cross-contamination from the gown's front.
3
Identify the last protective item to be removed.
The mask is removed.
The mask protects the respiratory tract and should be kept on until other items are removed to prevent inhalation of any aerosolized particles.
4
Identify the final required action.
Perform hand hygiene.
Hand hygiene removes any unseen pathogens that might have transferred to the hands during the doffing procedure.

Key Concept

The standard CDC sequence for doffing (removing) personal protective equipment is designed to minimize the risk of cross-contamination and self-inoculation. The general rule is to remove the most contaminated items first.
Question 1163Question →

A practical nurse (PN) is preparing an alert and oriented client for a scheduled elective surgery. The surgeon has already discussed the procedure, risks, and benefits with the client. Which action represents the PN's legal responsibility regarding the informed consent document?

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Answer: Witnessing the client's voluntary signature on the consent form

Answer

The correct action is witnessing the client's voluntary signature on the consent form.
The legal role of the nurse during the informed consent process is to act as a witness. This involves confirming that the client is competent, verifying their identity, and witnessing their voluntary signature on the consent form.

Step-by-Step Solution

1
Identify the primary role of the practical nurse in the informed consent process.
The nurse's role is to act as a witness to the signature.
The healthcare provider who will perform the procedure is legally responsible for explaining the risks, benefits, and alternatives.
2
Evaluate each option against the PN scope of practice and legal regulations.
Only witnessing the signature falls within the appropriate legal and ethical boundaries for the PN.
Explaining risks is the provider's job, initial comprehensive assessments belong to the RN, and unauthorized sharing of information violates confidentiality laws.

Key Concept

The nurse's role in informed consent is to witness the client's voluntary signature, not to explain the procedure or its risks.
Estimated Time:45s
Question 1164Question →

A practical nurse is preparing to put on personal protective equipment (PPE) before entering the room of a client on contact and droplet precautions. According to standard infection control guidelines for donning PPE, which item should the nurse put on last?

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Answer: Gloves

Answer

Gloves
According to standard infection control guidelines, the correct sequence for donning personal protective equipment is to first put on the gown, followed by the mask or respirator, then goggles or a face shield, and finally the gloves. The gloves are always put on last so that they can be pulled up and over the cuffs of the isolation gown, sealing the wrists and creating a continuous protective barrier.

Step-by-Step Solution

1
Recall the Centers for Disease Control and Prevention (CDC) standard sequence for donning (putting on) PPE.
The correct sequence is: 1) Gown, 2) Mask or respirator, 3) Goggles or face shield, and 4) Gloves.
Following the standardized sequence ensures that the PPE fits securely and provides the maximum intended protection against exposure to infectious agents.
2
Identify the final step in the established sequence.
Gloves are the final item to be put on.
Putting gloves on last allows the nurse to extend the gloves over the wrists of the isolation gown, eliminating exposed skin and securing the sleeves.

Key Concept

Standard Sequence for Donning Personal Protective Equipment (PPE)
Estimated Time:45s
Question 1165Question →

A charge nurse is assigning clients for the upcoming shift on a medical-surgical unit. Which of the following clients is most appropriate to assign to the practical nurse (PN)?

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Answer: A client who is 3 days post-operative and requires a routine sterile dressing change

Answer

The client who is 3 days post-operative and requires a routine sterile dressing change
The correct answer describes a client who is clinically stable (3 days post-operative) and requires a routine skill (sterile dressing change). Practical nurses are thoroughly trained to care for stable clients with predictable outcomes and to perform standard sterile procedures, making this the most appropriate assignment.

Step-by-Step Solution

1
Analyze the scope of practice for a practical nurse (PN).
Identify that PNs are assigned to care for stable clients with predictable outcomes and are permitted to perform routine therapeutic procedures.
Understanding scope of practice is essential for safe delegation and assignment.
2
Evaluate the clinical stability and requirements of each client option.
Identify that the newly admitted client is unstable, the client needing IV push medications requires advanced interventions, and the client needing surgical explanation requires a provider.
Matching client needs with the correct team member's legal boundaries prevents unsafe care.
3
Select the client assignment that perfectly aligns with the PN's capabilities.
The 3-day post-operative client needing a sterile dressing change is the safest and most appropriate assignment.
This client has a predictable recovery trajectory and the required task is within the established PN scope of practice.

Key Concept

Client Care Assignments and Collaboration
Estimated Time:1m 0s
Question 1166Question →

A client who sustained deep partial-thickness facial burns in a residential fire three weeks ago is preparing for discharge. While the practical nurse is changing the facial dressings, the client turns away from the mirror and says, 'Just cover it up quickly. I look like a monster. My life is completely ruined and nobody will ever accept me like this.' Which of the following responses by the nurse use therapeutic communication techniques? Select all that apply.

Select all that apply

Show answer & explanation

Answer: It must be overwhelming to think about facing people right now.; Would you like to talk more about these concerns you have regarding your future?; I will sit here with you for a while, and we do not have to talk unless you want to.

Answer

The correct therapeutic responses include acknowledging the client's overwhelming feelings, offering to talk more about their concerns, and offering self by sitting with them in silence.
Therapeutic communication focuses on validating the client's feelings and providing a safe space for expression. Acknowledging that the situation is overwhelming validates their emotional pain. Asking if they would like to talk more uses the technique of exploring to encourage dialogue. Offering to sit with the client without the pressure to talk demonstrates the technique of offering self, which conveys unconditional support and acceptance.

Step-by-Step Solution

1
Analyze the client's statement and current emotional state.
The client is exhibiting severe body image disturbance, grief, and fear of rejection due to their facial burns.
Understanding the core emotion is necessary to select a response that validates the client's feelings rather than minimizing them.
2
Evaluate each response for therapeutic communication techniques.
Three options use validating, exploring, and offering self. The other three use communication blocks.
Therapeutic communication facilitates expression, while blocks (like false reassurance, giving advice, or asking 'why') shut down communication.
3
Identify the non-therapeutic communication blocks to eliminate them.
Eliminate the responses that give advice, ask 'why', or provide false reassurance about the healing process of the scars.
Non-therapeutic techniques violate the principles of psychosocial integrity by invalidating the client's experience.

Key Concept

Therapeutic communication techniques vs. non-therapeutic blocks
Question 1167Question →

A practical nurse (PN) is asked to witness a client's signature on an informed consent form for an upcoming surgery. As the PN approaches with the form, the client states, 'I still do not really understand what the surgeon is going to do.' Which of the following is the best action by the PN?

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Answer: Notify the surgeon that the client requires further explanation before signing.

Answer

Notify the surgeon that the client requires further explanation before signing.
The correct action is to notify the surgeon. The practical nurse's role in informed consent is to act as a witness to ensure the client is competent and signing voluntarily. If the client states they do not understand the procedure, the nurse must act as a client advocate by halting the process and notifying the provider. The provider is legally responsible for explaining the procedure and answering the client's questions before consent is given.

Step-by-Step Solution

1
Identify the client's knowledge deficit regarding the upcoming surgery.
The client explicitly states a lack of understanding about what the surgeon is going to do.
Valid informed consent legally requires the client to fully understand the procedure, its risks, and alternatives prior to signing.
2
Recall the practical nurse's scope of practice regarding informed consent.
The nurse recognizes that their role is strictly to act as a witness to the voluntary signature of a competent client.
Explaining surgical procedures falls outside the nursing scope of practice and belongs exclusively to the healthcare provider.
3
Determine the appropriate advocacy action.
The nurse pauses the consent process and contacts the surgeon to return and speak with the client.
This action protects the client's right to informed consent and ensures safe, ethical care.

Key Concept

Client Rights and Advocacy: Scope of Practice in Informed Consent
Estimated Time:45s
Question 1168Question →

A practical nurse (PN) in an outpatient clinic is handed a surgical consent form by the supervising registered nurse (RN). The RN states, "The provider explained the procedure earlier but had to step away. Please get the client's signature and answer any final questions they have about the risks." Upon entering the room, the client asks the PN, "What exactly are the risks of the anesthesia they will use?" Which of the following is the most appropriate legal and ethical action by the PN?

Show answer & explanation

Answer: Refuse the RN's directive to answer questions about the risks and ensure the provider is notified that the client requires further clarification before signing.

Answer

The correct action is to refuse the RN's directive to answer questions about the risks and ensure the provider is notified that the client requires further clarification before signing.
The practical nurse's role in informed consent is strictly limited to witnessing the client's signature and advocating for the client by verifying they fully understand the procedure. Explaining the risks, benefits, and alternatives is exclusively the legal responsibility of the healthcare provider performing the procedure. A nurse cannot accept a delegated task to explain surgical risks. Because the client has unresolved questions about anesthesia, the PN must halt the consent process and ensure the provider addresses the client's concerns.

Step-by-Step Solution

1
Evaluate the RN's delegation and the client's question against the PN scope of practice.
The RN asked the PN to explain surgical risks, a request the client then repeated.
Nurses must ensure that all delegated tasks fall within their legal scope of practice before acting.
2
Identify the legal parameters of informed consent.
Only the healthcare provider performing the procedure can legally explain the risks, benefits, and alternatives.
The practical nurse's role is strictly limited to witnessing the voluntary signature and verifying that the client has no remaining questions.
3
Determine the appropriate clinical intervention.
The PN must decline the out-of-scope delegation, halt the consent process, and contact the provider.
Because the client still has questions about the anesthesia risks, they do not have adequate understanding to give informed consent.

Key Concept

Informed Consent and PN Scope of Practice
Estimated Time:1m 30s
Question 1169Question →

A practical nurse (PN) is caring for an older adult client who is newly confused and repeatedly attempts to pull out their intravenous (IV) catheter. Which action should the PN take first to prevent injury?

Show answer & explanation

Answer: Cover the IV site with a long-sleeved hospital gown or stockinette.

Answer

Cover the IV site with a long-sleeved hospital gown or stockinette.
Covering the intravenous site with a long-sleeved gown or stockinette hides the site from the client's view, which often naturally reduces the urge to pull on the catheter. This is an effective, non-restrictive alternative that must be attempted before considering any form of physical restraint to ensure the client's safety while preserving their dignity.

Step-by-Step Solution

1
Assess the client's behavior and identify the immediate safety risk.
The client is confused and attempting to dislodge a necessary medical device.
Identifying the specific safety hazard is the first step in determining an appropriate intervention.
2
Select the least restrictive intervention to protect the client and the medical device.
The nurse chooses to cover the site to remove the visual trigger.
Nursing standards and legal guidelines mandate that the least restrictive alternatives must be attempted before any physical restraints are used.

Key Concept

Restraint Alternatives and Injury Prevention
Question 1170Question →

A practical nurse (PN) is providing home health care for an older adult client. During personal care, the PN observes multiple unexplained bruises in various stages of healing on the client's torso. The client appears unusually withdrawn and becomes visibly fearful when their primary family caregiver enters the room. The PN suspects elder abuse. Which of the following is the most appropriate legal and ethical action for the PN to take?

Show answer & explanation

Answer: Immediately report the suspected abuse to the appropriate state authority or adult protective services.

Answer

Immediately report the suspected abuse to the appropriate state authority or adult protective services.
The correct action is to report the suspected abuse immediately. As licensed healthcare professionals, practical nurses are legally mandated reporters. When there is a reasonable suspicion of abuse, neglect, or exploitation of a vulnerable individual (such as an older adult), the nurse has a legal duty to report these findings to the designated state authority or adult protective services. Prompt reporting prioritizes the client's safety and fulfills the nurse's ethical duty of advocacy.

Step-by-Step Solution

1
Identify the clinical cues present in the scenario.
The client has unexplained bruises in various stages of healing and displays fearful behavior around their caregiver, which are classic red flags for potential elder abuse.
Recognizing signs of abuse is the first step in protecting vulnerable populations.
2
Determine the legal role and ethical responsibility of the practical nurse.
The practical nurse is legally designated as a mandated reporter in the healthcare system.
State laws require healthcare professionals to report suspected abuse or neglect of vulnerable individuals (children, older adults, disabled persons).
3
Select the intervention that aligns with legal mandates and client safety.
The PN must promptly report the suspicion to the appropriate state agency or adult protective services.
Immediate reporting initiates an official investigation by trained authorities to ensure the client is safe from further harm.

Key Concept

Mandatory Reporting of Suspected Abuse
Estimated Time:1m 0s
Question 1171Question →

An older adult client with chronic obstructive pulmonary disease (COPD) and hypertension is admitted for a severe respiratory exacerbation. Current assessment findings include a blood pressure of 158/92 mmHg, a heart rate of 112 beats/min, a respiratory rate of 28 breaths/min, and an oxygen saturation of 88% on room air. The provider's orders include a one-time dose of intravenous (IV) push methylprednisolone, a stat albuterol nebulizer treatment, and a scheduled dose of oral amlodipine. Which of the following actions best demonstrates the appropriate role of the practical nurse (PN) in managing this client's pharmacological therapies?

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Answer: Initiate the albuterol nebulizer treatment, administer the oral amlodipine, and monitor the client's respiratory status while the registered nurse administers the intravenous push methylprednisolone.

Answer

The practical nurse should safely administer the oral and inhaled medications, but must defer the administration of the intravenous push medication to the registered nurse.
The correct action demonstrates strict adherence to the practical nurse's legal scope of practice while appropriately prioritizing care. Administering oral and inhaled medications is safely within the practical nurse scope. However, intravenous push medications require the advanced assessment skills of a registered nurse. By initiating the respiratory treatment promptly, the practical nurse addresses the client's most critical airway needs while legally and safely delegating the intravenous medication.

Step-by-Step Solution

1
Analyze the client's clinical presentation and the prescribed pharmacological interventions.
The client is in a respiratory crisis (hypoxia, tachypnea) requiring immediate intervention with a bronchodilator (albuterol) and a corticosteroid (methylprednisolone), alongside management of hypertension (amlodipine).
Understanding the clinical priorities ensures that the most critical needs (Airway and Breathing) are addressed first.
2
Evaluate the practical nurse scope of practice regarding the prescribed medication routes.
Oral (amlodipine) and inhaled (albuterol) medication administration are within the practical nurse's scope of practice. However, intravenous push administration (methylprednisolone) is restricted and falls under the registered nurse's scope of practice.
Adhering strictly to the legal scope of practice is mandatory for client safety and professional licensure compliance.
3
Determine the safest and most effective plan for pharmacological management.
The practical nurse should initiate the albuterol nebulizer to address the immediate airway compromise, give the oral amlodipine, and collaborate with the registered nurse to administer the intravenous push methylprednisolone.
This collaborative approach ensures all medications are administered promptly while maintaining strict adherence to safety protocols and scope of practice limitations.

Key Concept

Practical Nurse Scope of Practice and Prioritization in Pharmacological Therapies
Question 1172Question →

A practical nurse (PN) is preparing to witness a client's signature on an informed consent form for a lumbar puncture. The provider has just left the room after discussing the procedure. The client holds the pen and asks the PN, "Can you explain again what happens if they hit a nerve during the procedure? I didn't quite understand what the doctor said." Which action should the practical nurse take?

Show answer & explanation

Answer: Withhold witnessing the signature and notify the provider to return to clarify the risks.

Answer

The correct action is to withhold witnessing the signature and notify the provider to return to clarify the risks.
The correct answer requires the nurse to halt the signing process and contact the provider. A client must have a complete understanding of a procedure, including its risks, before providing informed consent. If a client expresses confusion or asks targeted questions about the risks, the practical nurse must advocate for the client by ensuring they get accurate information from the authorized practitioner. It is the legal responsibility of the provider performing the procedure to explain these risks and ensure full understanding.

Step-by-Step Solution

1
Evaluate the client's statement regarding their understanding of the procedure.
The client explicitly states they do not understand the risks associated with the lumbar puncture.
Informed consent requires the client to be fully informed and comprehend the risks, benefits, and alternatives before signing.
2
Identify the practical nurse's legal scope of practice regarding informed consent.
The PN's role is limited to witnessing the signature, ensuring the client is competent, and verifying the client is signing voluntarily.
Nursing staff cannot assume the provider's legal duty to explain the procedure and its medical risks.
3
Determine the appropriate advocacy intervention based on the client's knowledge deficit.
The PN must stop the consent process and contact the provider to return and re-explain the risks.
Advocating for the client's right to informed decision-making requires ensuring the provider fulfills their legal obligation before any documents are signed.

Key Concept

Client Rights and Advocacy
Question 1173Question →

A charge nurse on a medical-surgical unit is creating shift assignments for a team consisting of Registered Nurses (RNs) and Licensed Practical Nurses (LPNs/VNs). Which assignment is most appropriate to delegate to an LPN/VN?

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Answer: Administering scheduled oral analgesics and performing focused data collection on the incision site of a client who is 3 days post-operative.

Answer

The most appropriate assignment for the LPN/VN is administering scheduled oral analgesics and performing focused data collection on the incision site of a stable, 3-day post-operative client.
The LPN/VN is safely assigned to care for stable clients with predictable outcomes. Administering scheduled oral medications and performing focused data collection (such as observing a 3-day post-operative incision) fall squarely within the LPN/VN legal scope of practice. This explicitly contrasts with the RN's responsibility for comprehensive assessments.

Step-by-Step Solution

1
Analyze the legal scope of practice for the Licensed Practical Nurse (LPN/VN).
LPNs/VNs care for stable clients with predictable outcomes, administer routine medications, and perform focused data collection.
Understanding scope boundaries is required to identify safe delegation.
2
Evaluate the option regarding admission assessment and care planning.
This is outside the LPN/VN scope; comprehensive assessment and initial care planning are exclusively RN responsibilities.
RNs must establish the baseline assessment and plan of care upon admission.
3
Evaluate the option regarding the evaluation of a complex pain regimen.
This is outside the LPN/VN scope; evaluating complex, new interventions requires RN-level clinical judgment.
LPNs/VNs participate in evaluation by collecting data, but the RN completes the comprehensive evaluation of complex regimens.
4
Evaluate the option regarding explaining surgical risks.
This is outside the nursing scope entirely; the healthcare provider must explain risks and benefits for informed consent.
The nurse's role in informed consent is to act as a witness to the signature, not to provide the primary clinical explanation.
5
Evaluate the option regarding oral analgesics and focused data collection.
This is within the LPN/VN scope; the client is stable (3 days post-op), the medication is routine, and the data collection is focused.
This task aligns perfectly with the LPN/VN's capability to care for stable clients with predictable outcomes.

Key Concept

Delegation and LPN/VN Scope of Practice
Question 1174Question →

The practical nurse (PN) is reviewing the client care assignments for the upcoming shift. Which of the following client assignments is most appropriate for the PN to accept?

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Answer: A client who is 2 days postoperative following an open cholecystectomy and requires a sterile dressing change.

Answer

The most appropriate assignment for the practical nurse (PN) is the client who is 2 days postoperative and requires a sterile dressing change.
The correct answer identifies a stable client with predictable outcomes. A client who is 2 days postoperative and requires a sterile dressing change does not need the advanced clinical judgment or assessment of a registered nurse (RN). Performing sterile dressing changes on stable clients is a fundamental competency within the practical nurse (PN) scope of practice.

Step-by-Step Solution

1
Analyze each client's condition and required care against the practical nurse (PN) scope of practice.
Identified that three of the four clients require RN-level care, such as continuous IV insulin, initial assessments, and IV push medications.
The PN scope of practice requires distinguishing between stable clients with predictable outcomes and unstable clients requiring advanced clinical judgment.
2
Select the assignment that involves a stable client and tasks within the PN's legal boundaries.
The 2 days postoperative client requiring a sterile dressing change is identified as the only appropriate choice.
This client is recovering predictably, and the required task (sterile dressing change) is a standard PN competency.

Key Concept

Delegation and Scope of Practice for the Practical Nurse (PN)
Question 1175Question →

A practical nurse (PN) is preparing to enter the room of a client who is on contact and droplet precautions. The required personal protective equipment (PPE) includes a disposable gown, a surgical mask, a face shield, and clean gloves. What is the correct sequence for donning this PPE?

Show answer & explanation

Answer: Put on the gown, apply the surgical mask, put on the face shield, and don the gloves.

Answer

The correct sequence for donning PPE is to put on the gown first, followed by the surgical mask, then the face shield, and finally the gloves.
According to the Centers for Disease Control and Prevention (CDC), the proper sequence for donning PPE begins with the gown to protect the torso and clothing. Next, the mask or respirator is applied to protect the respiratory tract. Third, goggles or a face shield are put on to protect the eyes and mucous membranes. Finally, clean gloves are donned last, ensuring they extend over the cuffs of the gown for complete, overlapping coverage.

Step-by-Step Solution

1
Identify the required PPE for contact and droplet precautions.
A gown, surgical mask, face shield, and gloves are needed.
To protect the nurse from infectious microorganisms spread by direct contact and respiratory droplets.
2
Determine the correct donning sequence according to standard infection control guidelines.
The sequence is gown, mask, face shield, and gloves.
This sequence ensures that the most vulnerable areas (respiratory tract and mucous membranes) are protected, and allows the gloves to be placed over the cuffs of the gown to create a continuous barrier.

Key Concept

Proper Sequence for Donning Personal Protective Equipment (PPE)
Question 1176Question →

A toddler weighing 35.235.2 lb is prescribed oral acetaminophen 1515 mg/kg every 44 hours as needed for fever. The medication available is an oral suspension with a concentration of 160160 mg/55 mL. How many milliliters should the practical nurse administer for one dose? (Record answer to the nearest tenth. Do not include units in answer.)

Show answer & explanation

Answer: 7.5

Answer

7.5
The calculation requires three clinical math steps: first converting the client's weight to kilograms (35.2÷2.2=1635.2 \div 2.2 = 16 kg), determining the weight-based dose (16×15=24016 \times 15 = 240 mg), and then calculating the liquid volume using the available concentration of 160160 mg per 55 mL (240160×5=7.5\frac{240}{160} \times 5 = 7.5 mL). The correct final amount to administer is 7.57.5 mL.

Step-by-Step Solution

1
Convert the child's weight from pounds (lb) to kilograms (kg).
1616 kg
The medication dosage is prescribed in mg/kg, requiring the client's weight to be converted using the factor 11 kg = 2.22.2 lb (35.2÷2.2=1635.2 \div 2.2 = 16).
2
Calculate the total required dose in milligrams (mg).
240240 mg
Multiply the weight in kilograms by the prescribed dosage amount (16 kg×15 mg/kg=240 mg16 \text{ kg} \times 15 \text{ mg/kg} = 240 \text{ mg}).
3
Calculate the volume of liquid to administer in milliliters (mL).
7.57.5 mL
Use the formula: (Desired / Have) × Quantity. Here, (240 mg160 mg\frac{240 \text{ mg}}{160 \text{ mg}}) × 5 mL=1.5×5 mL=7.5 mL5 \text{ mL} = 1.5 \times 5 \text{ mL} = 7.5 \text{ mL}.

Key Concept

Weight-based pediatric dosage calculation and liquid medication volume computation
Question 1177Question →

A licensed practical nurse (LPN/VN) is collaborating with a registered nurse (RN) and assistive personnel (AP) on a progressive care unit. Which action by the LPN/VN demonstrates a correct understanding of scope of practice, delegation boundaries, and legal responsibilities?

Show answer & explanation

Answer: Declining to initiate the primary discharge education for a client with a new diagnosis of heart failure, but offering to reinforce the low-sodium dietary guidelines after the RN completes the initial teaching.

Answer

The LPN/VN should decline to perform the initial discharge education but appropriately offer to reinforce the teaching once the RN has completed the primary instruction.
The correct action demonstrates an accurate understanding of the boundaries of LPN/VN practice. Initial, comprehensive client education requires the clinical judgment and assessment skills of a registered nurse (RN). However, once the RN has completed the primary teaching and established the care plan, the LPN/VN can safely and legally reinforce that information, such as reviewing low-sodium dietary guidelines with the client.

Step-by-Step Solution

1
Analyze the LPN/VN scope of practice regarding client education.
Initial teaching requires comprehensive assessment of learning needs and readiness, which is restricted to the RN.
To determine if initiating the discharge teaching is a legally appropriate task to accept.
2
Analyze the LPN/VN scope regarding reinforcement of teaching.
Reinforcing previously taught information from an established care plan is well within the LPN/VN scope of practice.
To identify tasks that can be safely and legally performed by the practical nurse.
3
Evaluate the distractor actions against legal and ethical nursing standards.
The other actions represent violations: caring for an unstable client (scope of practice violation), explaining surgical risks (informed consent violation), and checking an unassigned client's chart (confidentiality breach).
To eliminate incorrect options based on safety, legal, and ethical non-compliance.

Key Concept

LPN/VN Scope of Practice, Delegation, and Ethical Care Boundaries
Question 1178Question →

A practical nurse (PN) is asked to obtain a client's signature on an informed consent form for an elective surgery. When the PN hands the form to the client, the client states, 'The doctor talked to me, but I still do not understand what the risks of this surgery are.' Which of the following is the appropriate action by the PN?

Show answer & explanation

Answer: Notify the health care provider that the client needs further clarification before signing the form.

Answer

Notify the health care provider that the client needs further clarification before signing the form.
The correct action is to notify the health care provider. For informed consent to be legally valid, the client must fully comprehend the risks, benefits, and alternatives of the procedure. It is the legal responsibility of the health care provider performing the procedure to explain these elements. The practical nurse serves only as a witness to the signature and must advocate for the client by halting the signing process and notifying the provider if the client expresses confusion.

Step-by-Step Solution

1
Analyze the client's statement regarding the upcoming surgery.
The client indicates a lack of understanding of the surgical risks, meaning informed consent is not currently valid.
To sign an informed consent form, a client must have a clear understanding of the procedure, its risks, and available alternatives.
2
Determine the scope of practice for a practical nurse regarding informed consent.
The PN's role is to witness the voluntary signature of a competent, fully informed client. It is the provider's legal duty to explain the risks.
Nurses cannot provide the primary education or explanation for surgical procedures; this is outside their legal scope of practice.
3
Select the clinical intervention that best protects the client's rights.
The nurse must withhold the signature and notify the health care provider.
Advocating for the client ensures their right to self-determination and safety is upheld before undergoing an invasive procedure.

Key Concept

The practical nurse acts as a witness for informed consent and must ensure the provider clarifies any client misunderstandings before the consent form is signed.
Question 1179Question →

A practical nurse has finished providing care for a client in an airborne infection isolation room who is diagnosed with active pulmonary tuberculosis. The nurse is wearing an isolation gown, clean gloves, a face shield, and a fit-tested N95 respirator. Which sequence correctly describes the appropriate steps for doffing this personal protective equipment (PPE) to minimize the risk of contamination?

Show answer & explanation

Answer: Remove the gloves, remove the face shield, remove the gown, exit the room, and finally remove the N95 respirator.

Answer

The correct sequence is to remove the gloves, then the face shield, then the gown while still inside the room, followed by exiting the room and closing the door before safely removing the N95 respirator.
The correct sequence strictly follows the Centers for Disease Control and Prevention (CDC) guidelines for doffing PPE. The most heavily contaminated item (the gloves) is removed first. The face shield and gown are then safely removed while the nurse is still inside the room. Because the client has active tuberculosis (which requires Airborne Precautions), the N95 respirator must remain securely in place until the nurse has fully exited the room and the door is closed to prevent inhalation of suspended droplet nuclei.

Step-by-Step Solution

1
Identify the transmission-based precautions required for pulmonary tuberculosis.
The client is on Airborne Precautions, meaning infectious particles remain suspended in the air inside the room.
Understanding the mode of transmission dictates where respiratory protection can be safely removed.
2
Determine the most contaminated pieces of PPE that must be removed first.
Gloves are considered the most heavily contaminated, followed by the front of the face shield and the front of the gown.
PPE must be removed from most contaminated to least contaminated to protect the healthcare worker from self-inoculation.
3
Apply the standard CDC doffing sequence for the body and face.
The gloves are removed first, followed by the face shield (handling only the clean straps behind the head), and then the isolation gown.
This sequence prevents cross-contamination of the nurse's hands, uniform, and mucous membranes.
4
Determine the safest location to remove the N95 respirator.
The nurse must exit the patient's room and ensure the door is closed before grasping the bottom strap, then the top strap, to remove the N95 respirator.
The N95 respirator protects the airway and must remain securely in place until the nurse is completely out of the airborne isolation environment.

Key Concept

Personal Protective Equipment (PPE) Doffing Sequence and Airborne Precautions
Question 1180Question →

A practical nurse (PN) working in a rehabilitation unit observes a colleague with an unsteady gait, slurred speech, and the odor of alcohol while preparing to administer a narcotic to a client. Arrange the following actions in the chronological order the PN should perform them. All options must be used.

Drag items to arrange them in the correct order

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Answer

The correct sequence prioritizes immediate client safety, followed by removing the risk, notifying management, and finally documenting the event.
When dealing with an impaired colleague, the absolute first priority is client safety. The PN must intervene immediately to stop care delivery. Next, the colleague must be removed from the area to secure the environment. Third, management must be notified to take official administrative action. Finally, objective documentation is completed as a permanent legal record.

Step-by-Step Solution

1
Ensure immediate client safety by stopping the medication administration.
The client is protected from a potentially dangerous medication error.
The core tenet of nursing practice is to do no harm; preventing an immediate physical threat to the client takes precedence over all other actions.
2
Remove the impaired colleague from the clinical area.
The colleague can no longer access medications or interact with clients.
This secures the environment and prevents the impaired nurse from attempting to provide care to other clients on the unit.
3
Report the situation to the nursing supervisor.
Facility leadership is activated to manage the impaired employee.
Supervisors have the authority to relieve the nurse of duty, arrange for mandatory testing, and ensure the unit remains adequately staffed.
4
Document the incident objectively.
A factual, legal record of the event is created.
Thorough documentation is legally and ethically required, but must wait until the immediate safety and administrative steps are successfully completed.

Key Concept

Reporting Impaired Practice and Prioritizing Client Safety
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