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Question 1201Question →

A client is scheduled for an elective cardiac catheterization in 30 minutes and has previously signed the informed consent document. The client suddenly appears highly anxious and tells the practical nurse (PN), "I changed my mind and do not want to go through with this, but my daughter insists that I have to." The daughter is standing at the bedside. In what order should the PN perform the following interventions? (Arrange the actions from first to last.)

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Answer

The correct sequence is to first halt the preparation, then reassure the client of their rights, inquire about their specific concerns, notify the healthcare provider, and finally document the event.
In any situation involving the withdrawal of informed consent and potential family coercion, the nursing process dictates that immediate harm or unwanted intervention must be stopped first (halting preparation). Next, the nurse addresses the psychosocial threat by advocating for the client's rights (reassuring the client). Once the client is safe and supported, the nurse collects data (inquiring about fears) to understand the root cause. This information is then communicated to the primary healthcare provider, who is responsible for the medical management of the refusal. Finally, the entire sequence of events is legally documented.

Step-by-Step Solution

1
Halt any further preoperative preparation and delay the transport process.
The immediate progression toward the procedure is stopped.
The fundamental right to refuse treatment requires the immediate cessation of any interventions leading up to the procedure to prevent battery and respect client autonomy.
2
Reassure the client that they retain the right to withdraw informed consent without penalty.
The client feels supported and their legal rights are validated.
Because the client is experiencing family coercion, the nurse must immediately act as an advocate to empower the client and neutralize the external pressure.
3
Ask open-ended questions to determine the client's specific fears about the procedure.
The practical nurse gathers relevant clinical data about the refusal.
The PN must collect data regarding the cause of the refusal (e.g., fear of pain, misunderstanding of the procedure) to report an accurate and complete clinical picture to the provider.
4
Contact the primary healthcare provider to report the client's decision to revoke consent.
The provider is made aware of the situation and the client's concerns.
Only the primary healthcare provider can formally address complex medical concerns, explain alternative treatments, and officially cancel the procedure.
5
Document the client's exact verbal refusal and the subsequent notifications in the health record.
A permanent, legal record of the event is created.
Accurate, objective documentation of the client's quotes, family dynamics, and provider notifications provides legal protection and ensures continuity of care.

Key Concept

The practical nurse's role in client advocacy and informed consent withdrawal involves prioritizing immediate safety, validating client autonomy, collecting preliminary data, escalating to the provider, and maintaining accurate legal documentation.
Question 1202Question →

A client with moderate dementia is admitted to a medical-surgical unit and repeatedly attempts to get out of bed unassisted. The client has an unsteady gait and is at high risk for falls. Which intervention should the practical nurse (PN) implement to prevent injury while utilizing the least restrictive environment?

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Answer: Place a pressure-sensitive bed alarm under the client's mattress.

Answer

Place a pressure-sensitive bed alarm under the client's mattress.
Placing a bed alarm is the most appropriate and direct intervention because it promotes safety by alerting staff to the client's movement while strictly maintaining the least restrictive environment possible.

Step-by-Step Solution

1
Identify the primary safety risk and the client's clinical profile.
The client is at high risk for falls due to an unsteady gait and moderate dementia.
Understanding the specific risk and cognitive status is necessary to select a safe, targeted intervention.
2
Evaluate the available interventions against the principle of least restrictive care.
A bed alarm provides an early warning system without restricting the client's physical freedom.
Physical and chemical restraints should only be used as a last resort after less restrictive alternatives have failed.

Key Concept

Implementing least restrictive alternatives to prevent falls and client injury.
Estimated Time:1m 0s
Question 1203Question →

A practical nurse (PN) is working the night shift on a medical-surgical unit. The PN observes the charge nurse (a registered nurse) stumbling, slurring words, and smelling faintly of alcohol. The registered nurse is preparing to administer an intravenous (IV) push medication to a client. In what order should the PN perform the following actions? (Arrange from first action to last).

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Answer

The correct sequence is to first intervene to stop the medication administration, remove the nurse from the area, notify the supervisor, collaborate on reassigning client care, and finally complete an incident report.
When encountering an impaired colleague, the correct sequence prioritizes immediate client safety (stopping the medication administration and removing the impaired nurse), followed by initiating the chain of command (notifying the supervisor). Because the PN cannot independently reassign the RN's clients, they must collaborate with the supervisor to ensure continuity of care. Finally, an objective incident report is completed to document the event for administrative and legal purposes.

Step-by-Step Solution

1
Intervene immediately to stop the registered nurse from administering the medication.
The client is protected from a potentially dangerous medication error.
Client safety is the highest priority. The PN must stop the unsafe action before taking any other steps.
2
Remove the registered nurse from the client care area to a private location.
The RN is no longer a threat to other clients on the unit.
This protects all clients on the unit and maintains the confidentiality of the impaired coworker.
3
Notify the nursing supervisor on duty about the objective observations.
The formal chain of command is activated to handle the impaired employee.
The PN does not have the authority to dismiss or formally discipline the RN; leadership must intervene immediately.
4
Collaborate with the nursing supervisor to ensure continuous care is arranged for the clients.
The RN's assigned clients continue to receive necessary nursing care.
The PN cannot independently reassign clients, but must ensure they are not abandoned while the RN is removed.
5
Submit an objective incident report detailing the registered nurse's behavior.
The facility has a formal, written administrative record of the event.
Factual documentation of the event is required for risk management, legal protection, and potential regulatory reporting.

Key Concept

Prioritization in impaired practice reporting: Immediate client safety first, followed by chain of command notification, continuity of care, and documentation.
Estimated Time:2m 0s
Question 1204Question →

An older adult client receiving home health services for wound care presents with bilateral bruising on the upper arms shaped like handprints. The client, who lives with a primary caregiver who struggles with alcohol use, tearfully tells the visiting practical nurse, 'Please do not tell anyone about how I got these. If they find out, I will be forced into a nursing home and I would rather die.' Which action by the practical nurse correctly upholds legal and ethical advocacy standards?

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Answer: Contact adult protective services immediately to report the suspected abuse regardless of the client's plea for secrecy.

Answer

Contact adult protective services immediately to report the suspected abuse regardless of the client's plea for secrecy.
Nurses are mandated reporters for suspected elder abuse. This legal obligation supersedes the client's right to confidentiality and self-determination, even if the client explicitly requests that the abuse be kept secret. The nurse's primary advocacy role in this situation is ensuring the vulnerable client's safety through appropriate legal channels.

Step-by-Step Solution

1
Identify the client's physical findings and statements as indicative of suspected elder abuse.
Recognize that the situation falls under mandatory reporting laws.
Bruising shaped like handprints and statements expressing fear of the caregiver are strong clinical indicators of physical abuse.
2
Evaluate the conflict between the client's request for confidentiality and the nurse's legal obligations.
Determine that mandatory reporting laws override the client's right to privacy and self-determination in this specific scenario.
Vulnerable adult protection laws require healthcare workers to report suspected abuse to prevent further harm, regardless of the client's wishes.
3
Select the most appropriate advocacy action that complies with legal requirements.
Choose to contact adult protective services immediately.
This fulfills the nurse's legal duty as a mandated reporter and initiates the process of securing the client's safety without conducting an out-of-scope investigation.

Key Concept

Mandatory Reporting and Client Confidentiality Exceptions
Question 1205Question →

A client is scheduled for a surgical biopsy and has already signed the informed consent form. While a practical nurse (PN) is collecting baseline vital signs, the client states, "I signed the paper, but I still do not understand exactly what they are going to do to me." Which of the following is the most appropriate action for the PN to take?

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Answer: Notify the healthcare provider that the client requires further explanation of the procedure.

Answer

Notify the healthcare provider that the client requires further explanation of the procedure.
The correct answer advocates for the client's right to true informed consent. Even if a physical signature is on the form, informed consent is invalid if the client does not understand what they are consenting to. Because explaining the procedure is strictly the legal responsibility of the healthcare provider, the nurse must halt the preoperative process and notify the provider to return and answer the client's questions.

Step-by-Step Solution

1
Analyze the client's statement regarding the signed consent form.
The client has signed the form but openly admits to not understanding the medical procedure.
A signature alone does not constitute valid informed consent if the client lacks comprehension of the medical intervention.
2
Determine the legal boundaries of the practical nurse's role in this scenario.
The nurse's role is to act as a client advocate and halt the preoperative process, as nurses cannot legally explain surgical procedures or risks.
Explaining the procedure is strictly the legal responsibility of the healthcare provider performing the surgery.
3
Select the safest and most ethical intervention.
The PN must notify the healthcare provider so they can return and clarify the procedure with the client.
This ensures the client's legal right to informed consent is protected before the surgery begins.

Key Concept

Informed Consent and the Scope of Nursing Practice
Question 1206Question →

Following the morning handoff on a respiratory care unit, the nursing staff divides the pending clinical tasks. The team includes a registered nurse (RN), a licensed practical nurse (LPN), and assistive personnel (AP). Which specific action is most appropriate for the LPN to accept and perform independently?

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Answer: Reinforcing previous dietary teaching and administering scheduled oral medications to a client with chronic obstructive pulmonary disease (COPD)

Answer

The most appropriate action is reinforcing previous dietary teaching and administering scheduled oral medications to a client with chronic obstructive pulmonary disease (COPD).
The correct answer involves reinforcing previous teaching and administering scheduled oral medications. Both of these actions are fundamental components of the LPN's legal scope of practice when caring for stable clients. The LPN can reinforce education that an RN has already initiated and safely administer routine oral medications.

Step-by-Step Solution

1
Analyze the roles and legal scope of practice for the Licensed Practical Nurse (LPN) within the interprofessional healthcare team.
The LPN is authorized to provide care to stable clients, administer standard medications, and reinforce teaching previously initiated by a Registered Nurse.
National guidelines and state nurse practice acts delineate clinical tasks based on educational preparation and clinical judgment levels.
2
Evaluate each available option against the LPN's scope of practice, the RN's scope, and the healthcare provider's scope.
Providing IV push medications to unstable clients requires an RN. Explaining procedural complications is the provider's duty. Discussing health information in public violates confidentiality standards.
Recognizing unauthorized actions prevents unsafe client care assignments and legal liabilities.
3
Select the task that safely falls within the LPN's legal responsibilities and capabilities.
Reinforcing previous dietary teaching and administering scheduled oral medications is the correct and safe assignment.
These actions do not require the comprehensive assessment, independent clinical judgment, or initial teaching skills reserved for the RN.

Key Concept

Delegation and LPN Scope of Practice
Question 1207Question →

During a busy shift on a medical-surgical unit, a practical nurse receives four new client transfer requests. To maintain standard and transmission-based precautions, which client requires the nurse to secure a negative-pressure airborne infection isolation room prior to arrival?

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Answer: A client diagnosed with a disseminated varicella-zoster infection

Answer

A client diagnosed with a disseminated varicella-zoster infection
Disseminated varicella-zoster (chickenpox/shingles) is highly contagious and transmitted via small-particle aerosols that can remain suspended in the ambient air. Therefore, the client requires airborne precautions, which specifically mandates placement in a negative-pressure infection isolation room to safely vent the contaminated air to the outside, alongside the use of an N95 respirator.

Step-by-Step Solution

1
Identify the primary mode of transmission for each infectious condition presented in the client transfer list.
Varicella is airborne/contact; meningitis is droplet; Clostridioides difficile is contact; RSV is contact/droplet.
Accurate identification of transmission modes is required to determine the specific isolation room requirements.
2
Determine which transmission mode strictly requires a negative-pressure isolation room.
Airborne precautions require negative-pressure rooms.
Negative pressure prevents small, aerosolized infectious particles from drifting outward into public hallways.
3
Select the client whose diagnosis matches the airborne transmission requirement.
The client with disseminated varicella-zoster.
Disseminated varicella-zoster produces small-particle aerosols that remain suspended in the air, necessitating airborne isolation.

Key Concept

Airborne Precautions and Isolation Room Assignments
Question 1208Question →

An older adult client is admitted to the medical-surgical unit from their home, where they reside with a primary family caregiver. During routine hygiene care, the practical nurse discovers bilateral wrist abrasions and patterned contusions on the client's torso in various stages of healing. When asked about the marks, the client avoids eye contact and remains completely silent. Which action is the priority for the practical nurse?

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Answer: Report the assessment findings immediately to the nursing supervisor and the designated protective services agency.

Answer

The practical nurse must immediately report the suspected abuse to the nursing supervisor and the appropriate protective agency.
Nurses serve as essential client advocates and are legally mandated reporters of suspected abuse or neglect. Patterned bruising, wrist abrasions, and a withdrawn demeanor in an older adult are critical red flags for potential elder abuse. The practical nurse is required to immediately report these suspicions to the facility leadership and the appropriate state protective agency to secure the client's safety. Concrete proof is not required to fulfill this legal and ethical obligation.

Step-by-Step Solution

1
Analyze the client's physical findings and behavioral cues.
The patterned contusions, bilateral wrist abrasions, and evasive behavior strongly suggest physical abuse or non-accidental trauma.
Identifying signs of abuse is the first step in fulfilling the nurse's role in client advocacy and protection.
2
Determine the legal and ethical responsibility of the practical nurse.
Nurses are mandated reporters of suspected abuse for vulnerable populations, including older adults.
The law requires reporting based on reasonable suspicion, without needing concrete proof or waiting for further incidents to occur.
3
Select the priority intervention.
Reporting the findings to facility leadership and state protective services is the immediate priority.
This action officially initiates the process to ensure the client's ongoing physical safety and protects their legal rights.

Key Concept

Mandated Reporting and Client Advocacy
Estimated Time:1m 0s
Question 1209Question →

A practical nurse receives a transfer client from the emergency department who has a confirmed diagnosis of seasonal influenza. Which infection control interventions should the nurse implement? Select all that apply.

Select all that apply

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Answer: Place the client in a standard private room.; Put on a surgical mask before entering the client's room.; Apply a surgical mask to the client when transport to another department is necessary.

Answer

The nurse should place the client in a standard private room, put on a surgical mask before entering, and apply a surgical mask to the client if transport outside the room is necessary.
Seasonal influenza is transmitted via large respiratory droplets. To prevent transmission, droplet precautions require placing the client in a private room and the use of a standard surgical mask by healthcare workers when entering the room. Furthermore, if the client must leave the isolation environment, they must wear a surgical mask to contain their respiratory secretions.

Step-by-Step Solution

1
Identify the mode of transmission for the specified pathogen.
Seasonal influenza is transmitted via large respiratory droplets.
Knowing the transmission route determines the specific category of transmission-based precautions required.
2
Select the appropriate barrier precautions and room assignments for droplet transmission.
Droplet precautions require a private room and a surgical mask for healthcare workers.
Large droplets typically travel only short distances (about 3 to 6 feet) before settling, requiring standard masking rather than specialized ventilation.
3
Differentiate droplet requirements from airborne and contact precautions to eliminate incorrect interventions.
N95 respirators, negative pressure rooms, and routine gown/glove use are ruled out.
Applying the wrong precautions demonstrates a misunderstanding of specific infection control protocols.

Key Concept

Droplet Precautions Protocol
Estimated Time:1m 0s
Question 1210Question →

Following the shift handoff, a practical nurse (PN) must organize the morning workflow for a newly assigned group of clients. Prioritize the order in which the PN should evaluate the following clients, from most urgent (first) to least urgent (last).

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Answer

The correct sequence prioritizes the acute physiological emergency (shortness of breath) first, followed by urgent symptom management (pain), routine clinical maintenance (dressing change), and finally administrative tasks (discharge).
Safe client care assignments require the nurse to prioritize based on the ABCs (Airway, Breathing, Circulation) and Maslow's Hierarchy of Needs. The client with shortness of breath has an acute breathing compromise and must be evaluated first. The client experiencing post-operative pain requires urgent symptom management, making them the second priority. The routine dressing change is a necessary clinical task but is not immediately urgent, placing it third. Finally, the client awaiting an afternoon discharge is stable and requires only administrative preparation, making them the lowest priority.

Step-by-Step Solution

1
Identify any clients with life-threatening airway, breathing, or circulation (ABC) issues.
The client with sudden shortness of breath and wheezing is identified as the highest priority.
Airway and breathing are the most critical physiological needs because failure can lead to rapid systemic deterioration.
2
Evaluate the remaining clients for urgent but non-life-threatening physiological needs.
The client requesting post-operative pain medication is identified as the second priority.
Unrelieved pain is an urgent physiological and psychological need that impacts recovery, taking precedence over routine scheduled tasks.
3
Differentiate between routine clinical care and non-clinical or administrative tasks.
The client needing a routine dressing change is prioritized over the client awaiting an afternoon discharge.
Clinical maintenance tasks must take precedence over administrative tasks for stable clients.

Key Concept

Prioritization of Care Assignments
Question 1211Question →

A licensed practical nurse (LPN) in a rehabilitation facility is planning to delegate morning ambulation for a medically stable client to an unlicensed assistive personnel (UAP). Place the following steps of the delegation process in the correct chronological order.

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Answer

The correct chronological sequence is: Assess the client, determine UAP competency, provide clear instructions, verify understanding, and finally evaluate the outcome.
According to the NCSBN National Guidelines for Nursing Delegation, the delegation process must follow a logical sequence. The nurse must first assess the client to ensure stability (Right Circumstance). Next, the nurse verifies the competence of the delegatee (Right Person). After matching the person to the task, the nurse must communicate clear expectations and parameters (Right Direction/Communication). The nurse then verifies that the delegatee understands and accepts the task. Finally, the nurse must follow up to evaluate the client's response and the outcome of the task (Right Supervision/Evaluation).

Step-by-Step Solution

1
Prioritize client safety by performing a clinical assessment.
The nurse confirms the client is stable and suitable for delegation.
Delegation must always begin with evaluating the client's current condition.
2
Match the task to the appropriate healthcare team member.
The nurse verifies the UAP is competent to perform the ambulation.
The delegatee must have the demonstrated knowledge and skills to perform the task safely.
3
Communicate the specific requirements of the task.
The nurse provides exact parameters, such as distance to walk and specific signs to report.
Clear communication prevents errors and sets concrete expectations.
4
Confirm two-way communication.
The UAP acknowledges understanding and accepts the task.
This ensures the delegatee is confident and prepared to proceed without confusion.
5
Perform supervision and evaluation.
The nurse follows up on the client's status after the ambulation is completed.
The delegating nurse retains accountability for the outcome and must evaluate the results.

Key Concept

The National Council of State Boards of Nursing (NCSBN) delegation process follows a sequential framework: assessing the client, verifying delegatee competency, providing clear communication, confirming understanding, and evaluating the final outcome.
Question 1212Question →

While preparing a client for a scheduled colonoscopy in an ambulatory care center, the physician completes the procedural briefing and leaves the room. The physician directs the practical nurse to witness the client's signature on the consent document. Immediately before signing, the client remarks, "I am so relieved this surgery will finally fix my gallbladder." Which action is legally required of the practical nurse?

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Answer: Halt the signing process and require the physician to return to address the client's fundamental misconception.

Answer

Halt the signing process and require the physician to return to address the client's fundamental misconception.
Informed consent is only valid if the client understands the specific procedure being performed. Because the client demonstrates a fundamental misconception (believing they are having gallbladder surgery instead of a colonoscopy), the practical nurse must not witness the signature. The nurse's legal obligation is to act as a patient advocate by halting the process and requiring the primary healthcare provider to return to re-evaluate and re-explain the procedure. Correcting major misconceptions about the procedure itself is strictly within the provider's scope of practice.

Step-by-Step Solution

1
Analyze the client's statement regarding the procedure.
The client believes they are having gallbladder surgery instead of a colonoscopy, indicating a complete lack of informed understanding.
Informed consent requires the client to accurately understand the specific nature and purpose of the scheduled procedure.
2
Evaluate the practical nurse's legal role in the informed consent process.
The nurse acts only as a witness to the voluntary nature of the signature and to the client's apparent understanding of the provider's explanation.
Explaining the procedure, discussing risks and benefits, or correcting major medical misconceptions falls strictly under the healthcare provider's scope of practice, not the nurse's.
3
Determine the correct, legally sound intervention.
The nurse must stop the process and notify the provider to return and re-educate the client.
This protects the client's rights, ensures true informed consent, and prevents an unauthorized procedure from occurring.

Key Concept

Scope of Practice and Informed Consent
Question 1213Question →

An adult client with a confirmed diagnosis of disseminated varicella-zoster requires an urgent transfer from the medical-surgical unit to the intensive care unit. Which action by the practical nurse is most appropriate regarding infection control during this transport?

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Answer: Place a standard surgical mask on the client, cover all active fluid-filled lesions with clean linens, and alert the receiving unit about the isolation status.

Answer

Place a standard surgical mask on the client, cover all active fluid-filled lesions with clean linens, and alert the receiving unit about the isolation status.
The correct answer safely addresses both the airborne and contact transmission risks of disseminated varicella. A standard surgical mask provides adequate source control for the client's respiratory secretions, and covering the lesions prevents direct contact transmission. Alerting the receiving unit ensures they can prepare a negative-pressure room and don appropriate personal protective equipment before the client arrives.

Step-by-Step Solution

1
Identify the required transmission-based precautions for disseminated varicella-zoster.
Airborne and Contact precautions are required.
The virus is transmitted through respiratory aerosols and direct contact with fluid from open lesions.
2
Determine the appropriate source control for the respiratory (Airborne) component during transport.
The client must wear a standard surgical mask.
Surgical masks trap large expelled droplets and reduce aerosol emission from the source. Clients do not wear N95 respirators because they require specialized fit testing and significantly increase the work of breathing.
3
Determine the appropriate source control for the physical (Contact) component during transport.
All active, fluid-filled skin lesions must be covered with clean linens or dressings.
Covering the lesions prevents direct contact transmission and prevents environmental contamination of the stretcher and hallways.
4
Evaluate the nurse's transport requirements.
The nurse communicates with the receiving unit and avoids wearing contaminated gowns/gloves in the hallway.
Advance notification allows the intensive care unit to prepare a negative-pressure room. Wearing contaminated PPE in public areas violates infection control standards.

Key Concept

Standard and Transmission-Based Precautions
Question 1214Question →

Before entering the isolation room of a pediatric client diagnosed with respiratory syncytial virus (RSV), a practical nurse gathers the necessary personal protective equipment (PPE). The infection control protocol requires both contact and droplet precautions. Which item of PPE should the nurse put on first?

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Answer: A clean isolation gown

Answer

A clean isolation gown
According to standardized infection control procedures, the correct sequence for donning personal protective equipment is to first apply the isolation gown. This ensures the nurse's uniform is fully covered and provides a clean, safe base before applying the mask, eye protection, and gloves. Gloves are always applied last so they can be pulled securely over the cuffs of the gown.

Step-by-Step Solution

1
Identify the required PPE for contact and droplet precautions.
The required PPE includes a gown, surgical mask, face shield or goggles, and gloves.
RSV transmission requires barriers against both direct contact and respiratory droplets.
2
Recall the standard sequence for donning PPE.
The correct sequence is: gown, mask or respirator, goggles or face shield, and then gloves.
This specific sequence prevents contamination of the equipment and ensures full coverage.
3
Determine the first item to be applied.
The clean isolation gown is selected as the initial item.
Applying the gown first provides a protective base layer over the uniform before handling facial PPE or applying gloves.

Key Concept

Sequence for Donning Personal Protective Equipment (PPE)
Question 1215Question →

A practical nurse (PN) is assigned to care for a resident in a long-term care facility who recently fell while walking to the bathroom at night. The resident has a history of osteoarthritis and frequent nighttime urination (nocturia). Which of the following interventions should the PN implement to prevent future injuries? Select all that apply.

Select all that apply

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Answer: Maintain a clear, unobstructed walkway between the resident's bed and the bathroom.; Keep a low-level light on in the bathroom during the nighttime hours.; Position a portable commode directly next to the resident's bed.

Answer

The correct interventions are maintaining an unobstructed walkway, keeping a low-level light on, and positioning a portable commode next to the bed.
Interventions that address environmental hazards directly reduce the incidence of falls. Providing a clear pathway, utilizing nightlights, and offering a bedside commode directly accommodate the resident's mobility deficits and nighttime elimination needs without restricting their freedom of movement.

Step-by-Step Solution

1
Identify the resident's specific risk factors for falling.
The resident has mobility issues from osteoarthritis and wakes frequently at night to urinate.
Understanding the root causes of the fall risk directs the appropriate preventative interventions.
2
Select non-restrictive, environmental safety modifications.
Clearing the pathway, improving visibility with a nightlight, and shortening the travel distance with a bedside commode are chosen.
These actions directly mitigate the identified risks without violating the client's rights or restricting movement.
3
Eliminate inappropriate nursing actions.
Actions involving unauthorized delegation, physical restraints, and privacy breaches are excluded.
The PN must practice within legal and ethical boundaries, ensuring tasks are delegated properly and client rights are protected.

Key Concept

Environmental safety modifications and fall prevention
Question 1216Question →

A practical nurse is supervising an unlicensed assistive personnel (UAP) on a medical-surgical unit. The practical nurse must immediately intervene if the UAP is observed performing which action?

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Answer: Applying a fit-tested N95 respirator to a client with active pulmonary tuberculosis prior to transporting the client to the radiology department.

Answer

The practical nurse must intervene when the UAP attempts to apply an N95 respirator to the client with active tuberculosis for transport. The client should be provided a standard surgical mask for source control.
The practical nurse must intervene because a client with active pulmonary tuberculosis should wear a standard surgical mask, not an N95 respirator, during transport outside their negative-pressure room. A standard surgical mask provides effective source control by trapping large respiratory droplets and preventing the expulsion of infectious droplet nuclei into the environment. Placing an N95 respirator on a client is unnecessary for source control, cannot be properly fit-tested for the client, and can significantly increase their work of breathing.

Step-by-Step Solution

1
Analyze the transmission-based precautions required for each client scenario presented in the options.
Identifies Droplet precautions for Mycoplasma pneumoniae, Airborne precautions for tuberculosis, and Contact precautions for MRSA and RSV.
Correct infection control requires specific, targeted interventions based on the distinct mode of pathogen transmission.
2
Evaluate the UAP's action regarding the client with active pulmonary tuberculosis.
Determines that placing an N95 respirator on the infectious client is clinically incorrect and requires immediate intervention.
Clients with airborne infections must wear a standard surgical mask during transport to trap expelled respiratory secretions (source control). N95 respirators are designed to filter inhaled air to protect healthcare workers; placing them on clients is unnecessary, not properly fit-tested for the client, and can dangerously increase the client's work of breathing.

Key Concept

Source Control and Proper PPE Utilization in Transmission-Based Precautions
Question 1217Question →

A float Licensed Practical Nurse (LPN) has just arrived for a shift on an acute medical-surgical unit. The charge nurse hands the LPN a list of proposed client assignments. Which client assignment must the LPN immediately question and decline because it falls outside the legal scope of practice?

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Answer: A client admitted 2 hours ago with a fractured femur who has become increasingly restless, reports a sudden onset of dyspnea, and exhibits a new petechial rash on the upper chest

Answer

The client with a fractured femur who is exhibiting restlessness, dyspnea, and a petechial rash.
The client with a fractured femur who suddenly develops restlessness, dyspnea, and a petechial rash is exhibiting classic signs of fat embolism syndrome (FES), a life-threatening medical emergency. This client is acutely unstable and requires immediate, comprehensive assessment and advanced clinical judgment, which are strictly within the Registered Nurse (RN) scope of practice. The LPN must recognize this instability and decline the assignment.

Step-by-Step Solution

1
Analyze the role and scope of practice of the Licensed Practical Nurse (LPN) in client assignments.
LPNs care for clients with stable, predictable outcomes and perform tasks with established procedures. Unstable clients or those requiring comprehensive initial assessments must be assigned to an RN.
Identifying the boundaries of the LPN scope of practice is essential for safe delegation and assignment acceptance.
2
Evaluate the stability and acuity of each client described in the options.
The client with Alzheimer's disease, the client with a pressure injury, and the client needing a consent witness are all stable with predictable, chronic, or routine needs. The client with a femur fracture is showing sudden respiratory and neurological changes.
Determining client stability is the primary factor in deciding if an assignment is appropriate for an LPN.
3
Identify the underlying complication for the unstable client and determine the required level of care.
The client with a fractured femur is exhibiting the classic triad of fat embolism syndrome (respiratory distress, neurological changes like restlessness, and a petechial rash). This is an acute medical emergency requiring immediate RN-level assessment and intervention.
Recognizing life-threatening complications ensures the LPN knows when to immediately escalate care and decline unsafe assignments.

Key Concept

Delegation and Scope of Practice for the LPN/VN: Unstable Clients
Question 1218Question →

A licensed practical nurse (LPN) on a medical-surgical unit receives simultaneous requests for assistance regarding four assigned clients. Arrange the clients in the order the LPN should evaluate them and report findings to the supervising registered nurse (RN), from first (highest priority) to last (lowest priority).

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Answer

The correct priority sequence evaluates airway/breathing first, then circulation, then metabolic needs, and finally comfort needs. The order is: 1) Asthma with retractions, 2) Postoperative client with saturated dressing, 3) Diabetic client with hypoglycemia signs, 4) Client with bladder spasms.
The correct sequence utilizes the ABC (Airway, Breathing, Circulation) prioritization framework and Maslow's Hierarchy of Needs. The client with asthma is experiencing severe respiratory distress (airway/breathing), making them the absolute highest priority. The postoperative client has an active hemorrhage (circulation), which is the second priority. The client with signs of hypoglycemia has an urgent metabolic need, placing them third. Finally, the client with bladder spasms has a comfort/pain issue, which is the lowest priority among this group. The LPN must evaluate them in this order, implement immediate basic interventions, and rapidly collaborate with the RN.

Step-by-Step Solution

1
Apply the primary ABC (Airway, Breathing, Circulation) framework.
Identify the client with asthma exhibiting retractions and wheezing as having an immediate airway and breathing threat.
Airway and breathing compromise is the most rapid cause of deterioration and death. This client must be evaluated and reported to the RN first.
2
Evaluate the remaining clients for severe circulatory threats.
Identify the postoperative client with a blood-saturated dressing as having active hemorrhage.
Circulatory collapse from severe bleeding is the next most immediate threat to life after airway issues, making this the second priority.
3
Assess the remaining clients for urgent metabolic or systemic needs.
Identify the client with diabetes experiencing diaphoresis and jitteriness as having symptomatic hypoglycemia.
Hypoglycemia is a critical metabolic state that can lead to neurological damage if untreated, but physiological survival (ABCs) must be secured first.
4
Assign the lowest priority to non-life-threatening comfort or routine needs.
Identify the client with bladder spasms as the final priority.
While pain requires management and catheter troubleshooting is necessary, it is a physiologically stable condition compared to the other emergencies.

Key Concept

Prioritization of Client Care Assignments using the ABC and Maslow's Frameworks
Estimated Time:1m 30s
Question 1219Question →

Prior to initiating care for a newly admitted client placed on contact and droplet precautions, the practical nurse must don appropriate protective gear. In what sequence should the nurse apply the following items? Arrange the steps in the correct order from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence for donning personal protective equipment is: gown, mask, goggles or face shield, and finally gloves.
The standardized sequence for donning personal protective equipment maximizes protection and minimizes the risk of contamination. The gown is applied first to cover the torso and arms. Next, the mask is secured to protect the respiratory tract. Eye protection is then added. Finally, gloves are donned and extended over the gown cuffs to complete the protective barrier.

Step-by-Step Solution

1
Put on the isolation gown.
The nurse's torso and clothing are protected.
The gown forms the largest barrier and must be secured before other facial PPE is applied.
2
Apply the surgical mask.
The nurse's respiratory tract is protected from large droplets.
The mask must be placed and adjusted before eye protection to ensure a proper fit over the bridge of the nose.
3
Place goggles or a face shield.
The nurse's eyes are protected from potential splashes or sprays.
Eye protection is placed over the mask and face to complete mucous membrane coverage.
4
Don clean gloves.
The nurse's hands are protected, and the wrist area is sealed.
Gloves are put on last so they can be pulled up securely over the cuffs of the gown, creating a continuous barrier.

Key Concept

The sequence for donning personal protective equipment (PPE) moves systematically from the largest body coverage to the face, ending with the hands.
Question 1220Question →

A practical nurse (PN) is assigned to care for a client who has active pulmonary tuberculosis and a secondary wound infection with methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the practical nurse take? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Apply a fit-tested N95 respirator, gown, and gloves before entering the client's room.; Keep the door to the client's room closed to maintain negative-pressure airflow.; Place a standard surgical mask on the client if transport to the radiology department is required.

Answer

The practical nurse should apply an N95 respirator, gown, and gloves before entry; keep the negative-pressure room door closed; and place a standard surgical mask on the client during transport.
Active pulmonary tuberculosis requires airborne precautions (using an N95 respirator, maintaining a negative-pressure room with the door closed, and placing a surgical mask on the client during transport). MRSA requires contact precautions (donning a gown and gloves upon entry). The correct interventions accurately combine these two transmission-based precaution protocols while remaining within the practical nurse's scope of practice.

Step-by-Step Solution

1
Identify the transmission-based precautions required for the pathogens.
Active pulmonary tuberculosis requires Airborne Precautions. MRSA requires Contact Precautions.
Understanding the mode of transmission determines the necessary personal protective equipment (PPE) and room assignments.
2
Determine appropriate PPE and environmental controls.
The nurse must use a fit-tested N95 respirator, negative-pressure room with the door closed (Airborne), and a gown and gloves (Contact).
When a client has multiple infections, the precautions must be combined to prevent transmission of all present pathogens.
3
Determine protocol for client transport.
The client must wear a standard surgical mask during transport.
A standard surgical mask effectively contains the client's respiratory droplets and protects the environment outside the negative-pressure room.
4
Evaluate distractors against LPN/LVN scope of practice and ethical standards.
Developing initial teaching plans and posting specific diagnoses on doors are incorrect actions.
Initial teaching is an RN responsibility. Posting diagnoses breaches patient confidentiality.

Key Concept

Clients with multiple transmissible infections require a synthesis of isolation protocols. Care must also align with the LPN/LVN scope of practice and confidentiality standards.
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