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Question 1181Question →

The practical nurse (PN) is caring for a 68-year-old client who has been in a private room on contact precautions for five days. The client suddenly points upward, appears visibly frightened, and states, 'The people on the ceiling are whispering to me.' Which actions should the PN take to support this client? Select all that apply.

Select all that apply

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Answer: State that the voices are not real while acknowledging the client's feelings of fear.; Ensure the room has adequate lighting and open the window blinds during daylight hours.; Place a large-faced clock and the current calendar directly in the client's line of sight.

Answer

The correct actions involve presenting reality, acknowledging the client's fear, providing appropriate environmental lighting, and promoting reorientation with a clock and calendar.
For a client experiencing sensory deprivation and hallucinations, the practical nurse must prioritize safety, reorientation, and therapeutic communication. Acknowledging the client's fear while gently presenting reality helps build trust without reinforcing the false perception. Optimizing the environment with adequate lighting reduces shadows that can contribute to illusions or hallucinations. Providing concrete orienting tools, such as a clock and calendar, helps ground the client in reality.

Step-by-Step Solution

1
Analyze the client's presentation.
The client is experiencing a visual and auditory hallucination, likely triggered by sensory deprivation from prolonged isolation.
Identifying the root cause of the perceptual alteration guides appropriate nursing interventions.
2
Determine therapeutic communication strategies.
The nurse must validate the client's fear without reinforcing the hallucination.
Arguing with the client or playing into the hallucination increases agitation, whereas presenting reality builds trust.
3
Identify environmental modifications.
Increasing natural light and providing orienting tools (clock, calendar) should be implemented.
These modifications combat sensory deprivation and help ground the client in reality.

Key Concept

Sensory Deprivation and Hallucination Management
Question 1182Question →

The practical nurse (PN) is reviewing room assignments and infection control protocols for clients on a medical-surgical unit. Which action by the PN demonstrates the correct application of transmission-based precautions?

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Answer: Cohorting two clients with confirmed influenza A in the same room and wearing a standard surgical mask when providing direct care.

Answer

Cohorting two clients with confirmed influenza A in the same room and wearing a standard surgical mask when providing direct care.
The correct answer identifies that influenza A requires droplet precautions. According to standard infection control protocols, a standard surgical mask is required when providing care within 3 feet of the client. Furthermore, cohorting (placing clients with the exact same confirmed active infection in the same room) is a safe and accepted practice when private rooms are at capacity.

Step-by-Step Solution

1
Evaluate the pathogen and required precautions for influenza A.
Influenza A is transmitted via large respiratory droplets, requiring droplet precautions.
Identifying the exact transmission route determines the correct PPE (surgical mask) and room assignment parameters.
2
Determine the safety of cohorting clients with influenza A.
Clients with the exact same confirmed pathogen can share a room if private rooms are unavailable.
Cohorting clients with identical infections does not pose a cross-contamination risk for that specific pathogen.
3
Analyze the infection control actions in the remaining options for procedural errors.
Norovirus requires soap and water. Rubeola requires N95 removal outside the room. Bacterial meningitis requires a surgical mask, not an N95.
Identifying the specific errors in the distractors confirms that the influenza A action is the only correct application of precautions.

Key Concept

Transmission-Based Precautions and Cohorting
Question 1183Question →

Match each clinical task with the healthcare team member who has the appropriate scope of practice to perform it.

Click a left item, then click its matching right item

Items

Formulating the initial nursing care plan
Administering scheduled oral antibiotics to a stable client
Emptying a urinary catheter drainage bag and recording output
Prescribing a new dosage of pain medication

Matches

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Answer

Formulating the initial nursing care plan matches with Registered Nurse (RN); Administering scheduled oral antibiotics matches with Licensed Practical/Vocational Nurse (LPN/VN); Emptying a urinary catheter drainage bag matches with Unlicensed Assistive Personnel (UAP); Prescribing a new dosage of pain medication matches with Health Care Provider (HCP).
Each healthcare team member has a specific scope of practice. RNs handle initial assessments and care planning. LPN/VNs provide care and administer medications to stable clients. UAPs perform routine, non-invasive tasks like measuring output. HCPs possess prescriptive authority.

Step-by-Step Solution

1
Identify the scope of practice required for formulating an initial care plan.
Matches with Registered Nurse (RN).
Initial assessment and care planning are legally restricted to the RN's scope of practice.
2
Identify the appropriate role for administering scheduled oral medications.
Matches with Licensed Practical/Vocational Nurse (LPN/VN).
LPN/VNs are trained and licensed to administer oral medications to stable clients.
3
Identify the role capable of emptying a urinary drainage bag.
Matches with Unlicensed Assistive Personnel (UAP).
This is a routine, non-invasive, and standardized task that can be safely delegated to a UAP.
4
Identify the role with prescriptive authority.
Matches with Health Care Provider (HCP).
Prescribing medications falls under the scope of practice of a medical provider, not nursing staff.

Key Concept

Delegating tasks based on the distinct scope of practice and legal boundaries of the interprofessional healthcare team.
Question 1184Question →

After providing care to a client on transmission-based precautions, a nurse prepares to exit the room and must remove all personal protective equipment (PPE). Arrange the following PPE removal steps in the correct standard sequence from first to last.

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Answer

The correct sequence for removing PPE is: gloves first, followed by protective eyewear/goggles, then the isolation gown, and finally the face mask.
The standard sequence for removing (doffing) personal protective equipment ensures that the healthcare worker does not contaminate their own skin, clothing, or mucous membranes. Gloves are typically the most contaminated and are removed first. Eyewear is removed next, followed by the gown. The mask is always removed last to provide continuous respiratory protection during the doffing process.

Step-by-Step Solution

1
Identify the most contaminated PPE.
Gloves are removed first.
To avoid spreading pathogens to the hair, face, or uniform while removing other items.
2
Identify the next contaminated item that protects the face.
Eyewear or goggles are removed second.
The outside of the goggles is contaminated and should be handled with clean hands.
3
Identify the item covering the body.
The gown is removed third.
It must be removed carefully, peeling away from the body, to prevent contamination of underlying clothing.
4
Identify the final item to remove.
The mask is removed last.
Respiratory protection must be maintained until all other contaminated items are removed and the nurse is ready to leave the room.

Key Concept

Standard Sequence for Removing (Doffing) Personal Protective Equipment
Question 1185Question →

A surgeon completes an explanation of a bowel resection to an older adult client who has mild cognitive impairment. The surgeon then leaves the room, instructing the practical nurse (PN) to witness the client's signature on the informed consent form. The client looks at the form and says, "I will sign it, but I do not really understand what they are going to cut out." Before the PN can respond, the client's adult child forcefully grabs the client's hand, physically guides the pen to sign the document, and whispers threateningly, "If you do not do this, I am putting you in a state home." A neighbor who is visiting the room then turns to the PN and asks, "What kind of surgery are they having?" Which of the following is the most appropriate legal and ethical action for the PN to take?

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Answer: Decline to witness the coerced signature, inform the neighbor that the client's information is confidential, and immediately report the suspected elder abuse to the nursing supervisor and state authorities.

Answer

The practical nurse must decline to witness the coerced signature, maintain confidentiality by refusing to share information with the neighbor, and immediately report the suspected elder abuse.
The practical nurse must immediately halt the informed consent process because the client explicitly stated a lack of understanding and was physically coerced, rendering the consent legally invalid. Furthermore, the nurse must uphold confidentiality by refusing to disclose medical information to the visiting neighbor without the client's explicit permission. Most importantly, the adult child's physical threat and forced signature constitute elder abuse, which requires immediate, mandatory reporting to authorities and the nursing supervisor.

Step-by-Step Solution

1
Evaluate the validity of the informed consent process.
The consent is determined to be invalid.
The client explicitly stated a lack of understanding, and the signature was physically forced by the adult child, negating voluntary comprehension.
2
Determine the appropriate response to the visiting neighbor's question.
Refuse to disclose the requested surgical details.
The neighbor does not have explicit authorization to receive the client's protected health information, making disclosure a breach of confidentiality.
3
Identify the legal obligation regarding the adult child's abusive behavior.
Immediate reporting to the nursing supervisor and appropriate state authorities is required.
The physical coercion and threats constitute elder abuse, and the practical nurse is a mandated reporter who cannot delay notification.

Key Concept

The practical nurse must navigate intersecting legal duties by halting invalid consent procedures, strictly maintaining client confidentiality, and immediately fulfilling mandatory reporting requirements for suspected abuse.
Estimated Time:2m 0s
Question 1186Question →

A practical nurse (PN) is preparing to remove personal protective equipment (PPE) after providing care to a client requiring airborne and contact precautions. Arrange the steps for safely removing the PPE in the correct sequence from first to last.

Drag items to arrange them in the correct order

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Answer

The correct sequence for doffing personal protective equipment is: gloves, followed by goggles or face shield, then the gown, and finally the N95 respirator or mask.
According to standard infection control guidelines, personal protective equipment (PPE) must be removed in a specific order to minimize the risk of self-contamination. The sequence progresses from the most contaminated items to the least contaminated, prioritizing the maintenance of respiratory protection. Gloves are removed first, followed by the goggles or face shield, then the gown, and lastly the mask or respirator.

Step-by-Step Solution

1
Identify the most highly contaminated PPE item.
Gloves are identified as the most contaminated.
Gloves have direct contact with the client and environmental surfaces.
2
Determine the next piece of PPE to remove that protects the face but not the respiratory tract.
Goggles or face shield.
The front of the eyewear is contaminated and must be removed before the gown to avoid reaching up over a potentially contaminated gown later.
3
Identify the remaining large body covering.
The gown.
The gown's front and sleeves are contaminated. It is removed by touching only the inside and rolling it away from the body.
4
Determine the final piece of PPE to remove.
The N95 respirator or mask.
Airway protection must be maintained until all other contaminated items are removed and discarded safely.

Key Concept

Proper Sequence for Doffing Personal Protective Equipment (PPE)
Question 1187Question →

A client informs the practical nurse (PN) that they will not take their scheduled antihypertensive medication. To respect the client's right to refuse while ensuring safe care, arrange the following nursing actions in the correct chronological order.

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Answer

The correct sequence is to first assess the client's reason for refusal, then reinforce education about the medication's importance, subsequently report the refusal to the RN or provider, and finally document the incident.
When a client exercises their right to refuse care, the nursing process dictates that data collection comes first. The PN must first understand the root cause of the refusal. Next, the PN ensures informed refusal by reinforcing education about the medication. Then, the PN communicates with the supervising RN or provider for continuity of care. Finally, accurate and complete documentation provides a legal record of the client's choice and the appropriate nursing response.

Step-by-Step Solution

1
Gather data regarding the refusal
Understanding the client's perspective and any underlying issues
To identify if the refusal stems from a manageable problem, such as nausea or a knowledge deficit, before escalating the situation.
2
Reinforce client education
The client makes an informed decision regarding their care
Clients have a legal right to refuse treatment, but they must be fully aware of the potential health consequences of doing so.
3
Communicate with the healthcare team
The RN and prescribing provider are made aware of the missed medication
To maintain safety and allow the provider to consider alternative treatments or evaluate the client if necessary.
4
Document the event
The client's medical record accurately reflects the refusal and nursing response
To meet legal standards of nursing practice and ensure continuity of care.

Key Concept

Client Rights: Refusal of Treatment
Question 1188Question →

A practical nurse (PN) enters a client's room and observes an unlicensed assistive personnel (UAP) forcefully grabbing the client's arm and stating, "If you don't stay still, you will not get any lunch." To protect the client's rights and ensure safety, arrange the following actions the PN should take in the correct priority order.

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Answer

The PN must first intervene to stop the behavior, then assess the client for injury, report the incident to the charge nurse, and finally document the event in an incident report.
When advocating for a client whose rights are being violated (e.g., facing abuse or coercion), the nurse's primary responsibility is client safety. Intervening to stop the abuse must happen first. Once the threat is removed, the nurse assesses the client's physical and emotional status. After the client is stabilized and deemed safe, the nurse follows the chain of command to report the incident to management. Finally, formal documentation is completed via an incident report, which is an administrative task that should never delay direct client care.

Step-by-Step Solution

1
Intervene immediately to stop the behavior.
The client is protected from further physical and emotional abuse.
Immediate safety and client protection take precedence over all other actions.
2
Assess the client.
The PN identifies any injuries or distress caused by the UAP.
Determines the needed care post-incident and ensures the client's physical stability.
3
Report to the supervisor.
The chain of command is activated.
Leadership must be made aware to address the UAP's actions and ensure facility-wide safety.
4
Complete an incident report.
An official administrative record is created.
Provides factual, objective documentation of the event for risk management and legal purposes.

Key Concept

Client Rights and Advocacy: Protecting clients from abuse and proper incident reporting sequence
Question 1189Question →

Match each client care task to the most appropriate healthcare team member and corresponding scope of practice principle.

Click a left item, then click its matching right item

Items

Completing the initial comprehensive admission assessment for a newly admitted client.
Administering scheduled oral pain medication to a stable client.
Emptying a surgical drain and recording the output amount.
Formulating and updating the client's initial nursing care plan.

Matches

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Answer

Initial comprehensive admission assessment matches RN responsibility for comprehensive assessment; administering scheduled oral pain medication matches PN scope of practice; emptying a surgical drain matches UAP delegation; formulating the care plan matches RN responsibility for care plan development.
Safe delegation requires matching the task complexity and client stability to the caregiver's legal scope of practice. The RN is responsible for the nursing process's assessment and planning phases. The PN is responsible for implementing routine care for stable clients, and the UAP handles standard, routine tasks that do not require nursing judgment.

Step-by-Step Solution

1
Analyze the task: Completing the initial comprehensive admission assessment.
Matches Registered Nurse (RN) responsibility - Comprehensive Assessment.
The RN is legally responsible for the initial comprehensive assessment; the PN can only gather subsequent data.
2
Analyze the task: Administering scheduled oral pain medication to a stable client.
Matches Practical Nurse (PN) scope of practice - Routine Implementation.
Medication administration for stable clients is a fundamental PN responsibility.
3
Analyze the task: Emptying a surgical drain and recording the output amount.
Matches Unlicensed Assistive Personnel (UAP) delegation - Routine Task.
This is a standard procedure that does not require nursing judgment and is safely delegated to UAPs.
4
Analyze the task: Formulating and updating the client's initial nursing care plan.
Matches Registered Nurse (RN) responsibility - Care Plan Development.
Care plan formulation requires synthesis and advanced judgment, which falls outside the PN and UAP scopes of practice.

Key Concept

Scope of practice and safe delegation principles for the RN, PN, and UAP.
Estimated Time:1m 0s
Question 1190Question →

A practical nurse (PN) is caring for a client who suddenly packs their belongings, becomes upset, and states, 'I am leaving this hospital right now without treatment.' In which order should the PN perform the following actions? Arrange the actions in the correct sequence from first to last.

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Answer

First, the PN assesses the client's reasons for leaving. Second, the PN notifies the charge nurse and provider. Third, the PN reinforces the provider's explanation of the risks. Fourth, the PN witnesses the AMA signature. Finally, the PN documents the entire event in the medical record.
When a client wishes to leave against medical advice, the practical nurse must prioritize actions based on the nursing process and scope of practice. Assessing the client's reasons comes first to determine if a resolvable issue exists. If the client insists on leaving, the chain of command must be activated to involve the provider, who is responsible for explaining the medical risks. Following the provider's explanation, the PN reinforces the information, witnesses the legal AMA document, and concludes by thoroughly documenting the entire encounter.

Step-by-Step Solution

1
Assess the underlying reason for the client's distress.
The PN identifies exactly why the client wants to leave.
Addressing an immediate need (such as fear, anger, or pain) might resolve the underlying issue and prevent an unsafe departure.
2
Notify the healthcare provider and charge nurse.
The primary provider is alerted to intervene.
It is outside the PN's scope to provide the initial disclosure of complex medical risks; the provider must be present to fulfill this legal requirement.
3
Reinforce the provider's explanation of medical risks.
The client receives consistent information confirming the dangers of leaving.
While the PN cannot initiate the primary risk disclosure, reinforcing the provider's education falls squarely within the PN scope of practice.
4
Witness the signature on the AMA form.
The client signs the legal document refusing care.
Competent clients have the legal right to refuse treatment. Witnessing the signature validates that the client signed it voluntarily after being informed of the consequences.
5
Document the event thoroughly.
A clear legal record is created in the client's chart.
Documentation should occur after the situation is fully handled to ensure all client statements, provider notifications, and signed forms are captured accurately.

Key Concept

Client Rights and Advocacy: Leaving Against Medical Advice (AMA)
Question 1191Question →

While reviewing the care plan for a newly admitted client with a confirmed *Clostridioides difficile* (C. diff) infection, the practical nurse notes that the client is on contact precautions. Which of the following hand hygiene practices must the nurse follow when exiting this client's room?

Show answer & explanation

Answer: Washing hands thoroughly with soap and water

Answer

Washing hands thoroughly with soap and water
Washing hands with soap and water is required because *Clostridioides difficile* forms spores that are highly resistant to the bactericidal effects of alcohol-based hand sanitizers. The mechanical friction of washing with soap and water physically removes the spores from the nurse's hands, preventing cross-contamination.

Step-by-Step Solution

1
Identify the pathogen and its unique characteristics.
The client has a C. diff infection, which produces spores.
Different pathogens require specific infection control measures based on how they spread and their resistance to cleaning agents.
2
Determine the appropriate hand hygiene method for spores.
Spores are highly resistant to the bactericidal effects of alcohol.
Because alcohol cannot destroy the spores, a mechanical method is required to physically remove them from the skin.
3
Select the correct nursing action.
The nurse must use soap and water for hand hygiene.
The friction of scrubbing with soap and rinsing with water is the only effective way to wash spores down the drain.

Key Concept

Standard and Transmission-Based Precautions
Question 1192Question →

A practical nurse (PN) is tasked with witnessing a client's signature on an informed consent form for an upcoming elective procedure. Arrange the steps the PN should take in the correct chronological order.

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Answer

The correct sequence is to first verify the client's identity, then determine their cognitive status and ensure no sedatives were given, followed by confirming their understanding of the procedure, and finally witnessing the signature.
The proper legal sequence for witnessing informed consent requires establishing identity first to prevent wrong-person errors, ensuring the client is legally competent to sign (alert and unmedicated), confirming the provider has fulfilled their duty to inform, and lastly, witnessing the actual physical signature.

Step-by-Step Solution

1
Identify the primary role of the practical nurse in the informed consent process.
The PN acts as an advocate and a witness, ensuring legal and facility requirements are met.
Understanding the PN scope of practice ensures the nurse does not overstep by attempting to explain the procedure themselves.
2
Determine the fundamental first action before initiating any procedure or legal documentation.
Verify the client's identity using two acceptable identifiers.
Accurate identification is a critical safety measure to prevent wrong-person errors.
3
Evaluate the client's legal and cognitive capacity to provide consent.
Assess the client's cognitive status to ensure they are alert and have not received sedating medications.
A consent form signed after the administration of mind-altering medications is considered legally invalid.
4
Verify that the healthcare provider has fulfilled their legal duty.
Confirm with the client that the provider has adequately explained the procedure and answered questions.
The PN must ensure the client genuinely understands the procedure before witnessing the signature.
5
Complete the legal documentation process.
Observe the client voluntarily sign the document and provide a witness signature.
This finalizes the consent process and formally documents that the client signed voluntarily.

Key Concept

The practical nurse's legal responsibilities and sequential steps when witnessing informed consent.
Question 1193Question →

A practical nurse (PN) working the night shift on a medical-surgical unit observes a colleague exhibiting slurred speech, an unsteady gait, and the smell of alcohol on their breath while preparing to administer scheduled intravenous medications. Arrange the following actions the PN must take in the correct order of priority.

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Answer

The correct priority sequence is: first, intervene to stop the colleague from giving medications; second, notify the nursing supervisor; third, ensure the colleague's clients are safely reassigned; and fourth, document the incident in a facility report.
In any ethical or legal dilemma involving suspected impaired practice, the nurse's first duty is to protect the client from immediate harm. Therefore, stopping the impaired colleague from administering medications is the first mandatory step. Next, the nurse must activate the chain of command by notifying the nursing supervisor, who has the authority to formally remove the colleague from the clinical area. Once the colleague is removed, the team must ensure that the colleague's clients receive continuous, safe care through reassignment. Finally, an objective, factual incident report is completed to document the event legally.

Step-by-Step Solution

1
Prioritize immediate client safety by stopping the colleague.
The impaired colleague is prevented from administering potentially dangerous medications.
Client safety is always the first ethical and legal priority in nursing practice. Immediate intervention prevents potential sentinel events.
2
Report the observations directly to the nursing supervisor.
The chain of command is activated.
The PN must report impaired practice to management so the facility can initiate appropriate disciplinary, safety, and testing protocols.
3
Establish continuity of care for the affected clients.
Client needs continue to be met safely by competent staff.
Clients cannot be abandoned; once an impaired nurse is removed, their care must be seamlessly transitioned to safe personnel.
4
Complete an objective facility incident report.
A formal, legal record of the event is created.
Accurate, factual documentation must be completed promptly, but only after immediate safety and client care needs are resolved.

Key Concept

Mandatory reporting and management of impaired nursing practice
Question 1194Question →

A healthcare team on a medical-surgical unit is coordinating care for a group of clients. Based on the principles of delegation, legal scope of practice, and interprofessional collaboration, match each clinical task with the most appropriate team member to perform it.

Click a left item, then click its matching right item

Items

Formulating the initial plan of care and identifying priority nursing diagnoses for a newly admitted client.
Auscultating lung sounds to gather focused clinical data on a stable client with a history of chronic asthma.
Emptying, measuring, and documenting the drainage volume from a client's Jackson-Pratt (JP) drain.
Conducting a comprehensive swallowing evaluation to recommend the safest diet consistency.

Matches

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Answer

The RN formulates the initial care plan; the LPN/VN auscultates lung sounds for focused data collection; the UAP empties and records the JP drain volume; and the Speech-Language Pathologist performs the swallowing evaluation.
Delegation and interprofessional collaboration require a thorough understanding of each team member's scope of practice. The RN is solely responsible for comprehensive assessments and the formulation of the nursing care plan. The LPN/VN is legally permitted to gather focused data, such as auscultating lung sounds on a stable client, to report to the RN. The UAP is trained to perform routine, standard procedures that do not require nursing judgment, such as emptying a surgical drain and recording output. Finally, complex evaluations of swallowing function to prevent aspiration are within the specialized scope of the Speech-Language Pathologist.

Step-by-Step Solution

1
Identify the legal scope of practice for the Registered Nurse (RN).
The RN must handle comprehensive assessments, formulation of care plans, and initial education.
These tasks require advanced clinical judgment and cannot be delegated to LPNs/VNs or UAPs.
2
Determine the appropriate tasks for the Licensed Practical Nurse (LPN/VN).
The LPN/VN can perform focused data collection, such as auscultating lung sounds on a stable client.
The LPN/VN scope includes assisting the RN by gathering data and contributing to the care of stable clients with predictable outcomes.
3
Evaluate the tasks suitable for Unlicensed Assistive Personnel (UAP).
The UAP can safely empty, measure, and record output from a Jackson-Pratt drain.
This is a routine, standard task that does not require nursing judgment or specialized assessment skills.
4
Recognize the role of interprofessional team members, such as the Speech-Language Pathologist (SLP).
The SLP is the expert designated to conduct swallowing evaluations.
Collaboration with specialists ensures safe, evidence-based care for clients with high-risk conditions like dysphagia.

Key Concept

Delegation and interprofessional collaboration require matching client needs with the specific legal scope of practice and documented competencies of each team member (RN, LPN/VN, UAP, and specialists).
Estimated Time:1m 30s
Question 1195Question →

After performing nasotracheal suctioning on a client colonized with methicillin-resistant Staphylococcus aureus (MRSA) in the sputum, the practical nurse is standing near the room exit. The nurse is currently wearing a fluid-resistant isolation gown, disposable gloves, a surgical mask, and a protective face shield. To adhere to strict infection control protocols and prevent self-contamination, in what exact chronological sequence must the nurse execute the removal of these items?

Drag items to arrange them in the correct order

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Answer

The correct sequence for doffing full personal protective equipment is to first remove the gloves, followed by the face shield, then the gown, then the surgical mask, and finally concluding with hand hygiene.
According to standardized infection control guidelines, the removal of personal protective equipment must proceed from the most contaminated item to the least, protecting the respiratory tract until the very end. The exact sequence is: gloves, goggles/face shield, gown, mask/respirator, and hand hygiene. This specific order ensures that contaminated items are not brought near the unprotected face and that any airborne particles disturbed during gown removal do not enter the respiratory tract.

Step-by-Step Solution

1
Remove and discard the disposable gloves.
The hands are freed from the most heavily soiled barrier.
This prevents transferring gross contamination to the face, neck, or uniform during the subsequent removal steps.
2
Remove the face shield by handling only the back straps.
Eye protection is safely taken off without touching the contaminated front surface.
This eliminates splash hazards while keeping the nurse's respiratory tract protected during the next steps.
3
Unfasten and remove the isolation gown by rolling it inside out.
The gown is safely contained in an inside-out bundle and discarded.
Rolling the gown inside out prevents pathogens on the exterior from transferring to the nurse's uniform or skin.
4
Remove the surgical mask by handling only the ear loops or ties.
The respiratory barrier is taken off as the final piece of apparel.
The mask must remain on during gown removal in case any pathogens become aerosolized while manipulating the contaminated gown fabric.
5
Perform thorough hand hygiene.
The hands are completely sanitized.
This eradicates any microorganisms that may have incidentally contacted the bare skin during the doffing procedure.

Key Concept

Standardized CDC Sequence for Doffing Personal Protective Equipment (PPE)
Estimated Time:1m 30s
Question 1196Question →

After completing a wound dressing change for a client with disseminated herpes zoster, the practical nurse prepares to leave the airborne infection isolation room (AIIR). The nurse is currently wearing an N95 respirator, a face shield, an isolation gown, and gloves. What is the correct sequence for safely removing the personal protective equipment (PPE) and exiting the area?

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Answer

The correct sequence is to first remove the gloves, then the face shield, followed by the gown. After removing these items, the nurse must exit the room and close the door. Once outside in the clean hallway, the nurse removes the N95 respirator and finally performs hand hygiene.
The correct sequence prioritizes removing the most contaminated items first (gloves), followed by the face shield and gown, all while remaining inside the client's room. Because the client has disseminated herpes zoster (requiring airborne and contact precautions), the N95 respirator must be kept on until the nurse has fully exited the negative-pressure room and closed the door. Furthermore, safely removing the N95 requires pulling the bottom strap first. Finally, hand hygiene is universally performed immediately after all PPE is removed.

Step-by-Step Solution

1
Identify the most contaminated items to remove first.
The gloves are removed.
Gloves have directly touched the client and environmental surfaces, making them the most contaminated item. Removing them first prevents transferring pathogens to the head or face during other doffing steps.
2
Protect the mucous membranes while maintaining body protection.
The face shield is removed by the back strap.
The traditional CDC doffing sequence dictates removing eyewear before the gown. Touching only the back strap ensures the hands remain clean.
3
Remove the remaining body protection.
The gown is untied, pulled away, and rolled inside out.
Rolling the gown inside out contains the contaminated front and sleeves, protecting the nurse's uniform and the environment.
4
Maintain the integrity of the airborne isolation environment.
The nurse exits the AIIR and closes the door.
To prevent inhalation of airborne particles (like aerosolized varicella-zoster virus), respiratory protection must remain firmly in place until the nurse is outside the negative pressure environment.
5
Remove respiratory protection safely.
The N95 respirator is removed using the straps, starting with the bottom strap.
Removing the bottom strap first prevents the contaminated front of the mask from falling against the nurse's body. Touching only the straps prevents hand contamination.
6
Eradicate any residual pathogens.
Hand hygiene is performed.
This is the universal final step of standard precautions to ensure hands are safe for the next client interaction.

Key Concept

Standard CDC PPE doffing sequence for combined Airborne and Contact precautions
Question 1197Question →

A practical nurse enters a client's room and observes the client's adult child reading through the client's open medical record, which was inadvertently left on the bedside table. The client is currently sleeping. Which action should the practical nurse take to uphold the client's rights?

Show answer & explanation

Answer: Secure the medical record and explain that healthcare information cannot be viewed without the client's explicit authorization.

Answer

The practical nurse should immediately secure the medical record and inform the family member that explicit client permission is required to view health information.
The Health Insurance Portability and Accountability Act (HIPAA) mandates that a client's medical information remains strictly confidential. Even immediate family members do not possess an automatic right to access a client's chart unless the client explicitly authorizes it or the family member holds a designated legal proxy. The nurse's immediate duty is to advocate for the client by securing the private information and respectfully educating the visitor about privacy regulations.

Step-by-Step Solution

1
Identify the immediate threat to the client's rights.
Recognize that an unauthorized individual is viewing confidential health information.
Protecting client privacy is a fundamental nursing responsibility.
2
Intervene to stop the breach of confidentiality.
Remove and secure the medical record from the bedside table.
Immediate action prevents further unauthorized disclosure of protected health information.
3
Educate the family member about confidentiality laws.
Explain that even close relatives require the client's explicit consent to access medical records.
Clarifying facility policies and federal privacy laws helps prevent future violations and maintains a therapeutic environment.

Key Concept

Client Confidentiality and Health Information Privacy
Question 1198Question →

The clinical team leader is auditing the proposed morning shift delegations and assignments for a multidisciplinary nursing team. Match each of the following specific task allocations (Left) with the most accurate regulatory justification regarding the boundaries of practice (Right).

Click a left item, then click its matching right item

Items

Assigning a Licensed Practical/Vocational Nurse (PN/VN) to evaluate the clinical effectiveness of a newly implemented pain management regimen for a client in an acute sickle cell crisis.
Delegating the initial oral feeding of a client who suffered an ischemic cerebrovascular accident 24 hours ago to Unlicensed Assistive Personnel (UAP).
Assigning a Licensed Practical/Vocational Nurse (PN/VN) to perform a sterile dressing change and administer scheduled medications via an established gastrostomy tube for a client who is 4 days post-operative.
Delegating the task of demonstrating the correct application technique for newly prescribed anti-embolism stockings to Unlicensed Assistive Personnel (UAP).

Matches

Show answer & explanation

Answer

Properly align the PN/VN evaluation task to the RN scope limitation; the UAP initial feeding task to the 'Right Circumstance' violation; the PN/VN wound and gastrostomy care to the appropriate stable assignment; and the UAP stocking demonstration to the education limitation.
Safe delegation and assignment require adherence to the NCSBN Five Rights of Delegation and the specific legal scopes of practice for the healthcare team. The PN/VN scope focuses on stable clients with predictable outcomes and assisting with the nursing process, whereas the RN retains ultimate responsibility for comprehensive assessment, evaluation of outcomes, and initial client education. UAP tasks are strictly limited to routine, non-complex care with minimal risk for harm.

Step-by-Step Solution

1
Analyze the assignment of evaluating a new pain regimen for a sickle cell crisis to a PN/VN.
Identify this as an inappropriate assignment.
Evaluating clinical effectiveness and analyzing outcomes for unstable clients requires advanced nursing judgment, which falls exclusively under the Registered Nurse's scope of practice.
2
Analyze the delegation of feeding a 24-hour post-stroke client to a UAP.
Identify this as an inappropriate delegation due to safety risks.
Initial feeding after a stroke carries a high risk of aspiration and requires active assessment of swallowing. This makes the client unstable and violates the 'Right Circumstance' for UAP delegation.
3
Analyze the assignment of a sterile dressing change and gastrostomy meds for a 4-day post-op client to a PN/VN.
Identify this as an appropriate assignment.
The client's physiological status is stable and predictable. Sterile dressing changes and tube feedings are standard procedures within the PN/VN legal scope of practice.
4
Analyze the delegation of demonstrating anti-embolism stocking application to a UAP.
Identify this as an inappropriate delegation.
Demonstrating a new procedure constitutes initial client education. Under delegation rules, teaching and health education cannot be delegated to unlicensed personnel.

Key Concept

NCSBN Five Rights of Delegation and PN/VN Scope of Practice
Question 1199Question →

During the morning huddle, tasks are being distributed among the nursing staff. Which activity should the Licensed Practical Nurse (LPN) safely accept?

Show answer & explanation

Answer: Performing a sterile dressing change on a client's stage 2 pressure injury.

Answer

Performing a sterile dressing change on a client's stage 2 pressure injury.
The LPN scope of practice includes performing standard, predictable procedures such as sterile dressing changes on stable clients, as it relies on following established protocols.

Step-by-Step Solution

1
Identify the scope of practice for the Licensed Practical Nurse (LPN).
The LPN scope includes reinforcing teaching, administering routine medications, and performing predictable procedures like sterile dressing changes on stable clients.
Understanding professional boundaries is necessary to evaluate the assigned tasks.
2
Evaluate each task against the established LPN scope of practice.
Establishing nursing diagnoses, providing primary risk explanations for consent, and analyzing unstable conditions all require RN or provider-level judgment. Dressing changes do not.
Delegation and task acceptance must strictly adhere to safe practice guidelines.

Key Concept

Scope of Practice and Delegation for the Licensed Practical Nurse
Question 1200Question →

A registered nurse (RN) preceptor is observing a newly licensed practical nurse (PN) providing care on a medical-surgical unit. Which action by the PN indicates a violation of legal and ethical standards and requires immediate intervention by the preceptor?

Show answer & explanation

Answer: Using a personal mobile device to photograph a client's complex wound to consult with the wound care specialist.

Answer

The action that requires immediate intervention is using a personal mobile device to photograph a client's complex wound to consult with the wound care specialist.
The correct answer describes a significant breach of client confidentiality. Utilizing a personal mobile device to photograph and transmit protected health information (PHI), even for the purpose of a medical consultation, violates the Health Insurance Portability and Accountability Act (HIPAA) privacy laws and ethical nursing standards. Facilities require the use of secure, approved clinical devices for taking medical photographs.

Step-by-Step Solution

1
Analyze each action performed by the PN to determine if it falls within the legal scope of practice and ethical guidelines.
Three actions are legally and ethically appropriate; one is a violation.
Identifying the single violation requires evaluating scope of practice, mandated reporting laws, informed consent roles, and HIPAA regulations.
2
Evaluate the use of a personal device for taking clinical photographs.
This is identified as a HIPAA violation.
Personal devices are not secure and using them to capture or transmit protected health information (PHI) breaches federal confidentiality laws.

Key Concept

Confidentiality and Information Security
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