Examkin

All practice questions

2933 questions

All types2,933Multiple choice1,506Multiple select653Numeric68Matching70Ordering636
Question 1221Question →

During morning rounds on a geriatric rehabilitation floor, the nursing staff coordinates care for multiple individuals. Which client is best suited for the licensed practical nurse (LPN) to take primary responsibility for?

Show answer & explanation

Answer: An older adult who requires a scheduled subcutaneous insulin injection and routine blood glucose monitoring

Answer

The most appropriate assignment for the licensed practical nurse is the older adult who requires a scheduled subcutaneous insulin injection and routine blood glucose monitoring.
The licensed practical nurse (LPN) is responsible for providing care to stable clients with predictable clinical outcomes. Administering a scheduled subcutaneous insulin injection and performing routine blood glucose monitoring are standard, predictable tasks that fall perfectly within the legal scope of practice for an LPN.

Step-by-Step Solution

1
Analyze the legal scope of practice for the licensed practical nurse (LPN).
The LPN is responsible for providing care to stable clients with predictable outcomes, performing routine procedures, and administering standard medications.
To determine the boundaries of safe delegation and assignment acceptance.
2
Evaluate the clinical needs and acuity of each client in the given options.
Sudden confusion and shortness of breath indicate an unstable client requiring RN assessment. Developing initial teaching plans is an RN duty. Explaining surgical risks is the provider's duty. Routine insulin administration is a stable, expected LPN task.
To match the client's specific needs with the appropriate healthcare team member's scope of practice.
3
Select the assignment that safely aligns with the LPN's capabilities and legal role.
The client needing insulin and blood glucose monitoring is selected.
This assignment presents the lowest risk and involves predictable, routine interventions.

Key Concept

LPN/VN Scope of Practice and Safe Assignment Delegation
Question 1222Question →

While providing care in a continuous care facility, a practical nurse collaborates with registered nurses and unlicensed assistive personnel to manage clients in isolation. Which clinical actions by the practical nurse demonstrate correct application of precautions and scope of practice? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Donning an isolation gown, followed by a surgical mask, face shield, and clean gloves before entering a droplet precautions room.; Leaving dedicated reusable equipment, such as a stethoscope and pulse oximeter, inside the room of a client with a Vancomycin-resistant enterococci (VRE) infection.; Reinforcing previous education with family members about the necessity of keeping the door completely closed for a client on airborne precautions.

Answer

The correct actions include following the proper sequence for donning personal protective equipment, dedicating reusable equipment to clients on contact precautions, and reinforcing established teaching regarding airborne isolation.
The appropriate actions adhere to CDC infection control guidelines by correctly sequencing the donning of personal protective equipment, restricting reusable equipment to a single contaminated room, and properly operating within the scope of practice by reinforcing established client education.

Step-by-Step Solution

1
Evaluate each option against the standard sequence for donning and doffing personal protective equipment.
Donning sequence (gown, mask, shield, gloves) is correct. Doffing the N95 inside an airborne room is incorrect.
Correct sequence and location of removal prevent cross-contamination and pathogen exposure.
2
Analyze the transmission-based precaution rules for the specific pathogens mentioned.
VRE requires contact precautions with dedicated equipment. Airborne precautions require a closed door to maintain negative pressure.
Pathogen-specific protocols disrupt the chain of infection.
3
Assess each nursing action against the practical nurse scope of practice.
Reinforcing education is within scope. Creating initial care plans and delegating assessments to unlicensed personnel are out of scope.
Maintaining practice boundaries ensures safe and legal client care.

Key Concept

Application of Infection Control Protocols and Nursing Scope of Practice
Question 1223Question →

A client is in an outpatient clinic awaiting a minor surgical excision. The healthcare provider has discussed the procedure, and the practical nurse brings the printed consent document for the client's signature. Before signing, the client hesitates and asks, 'I forgot what the doctor said about the risk of scarring. Can you explain that to me?' Which action is most appropriate for the practical nurse to take?

Show answer & explanation

Answer: Withhold the document and notify the healthcare provider to return and clarify the risk of scarring.

Answer

Withhold the document and notify the healthcare provider to return and clarify the risk of scarring.
The correct action is to pause the consent process and contact the primary healthcare provider. A client must have all their questions answered by the provider performing the procedure before they can give valid informed consent. The practical nurse acts as an advocate and a witness to the signature, but it is outside their scope of practice to explain procedural risks, alternatives, or outcomes.

Step-by-Step Solution

1
Assess the client's statement regarding the consent document.
The client indicates a lack of understanding about a specific procedural risk (scarring).
Identifying knowledge gaps ensures the client is truly informed before signing.
2
Determine the scope of practice for the practical nurse regarding informed consent.
The nurse's role is strictly to witness the voluntary signature, not to explain risks or the procedure itself.
Explaining surgical risks falls exclusively under the healthcare provider's scope of practice.
3
Take action to advocate for the client's right to informed consent.
Delay the signing process and contact the healthcare provider to return and address the client's questions.
This guarantees the client's legal rights are protected and valid consent is obtained.

Key Concept

The practical nurse's role in informed consent is limited to witnessing the signature voluntarily given by a fully informed client; addressing questions about risks or the procedure itself requires the provider.
Question 1224Question →

A client is at an ambulatory surgery center preparing for a scheduled cataract extraction. The surgeon has previously discussed the procedure with the client. When the practical nurse (PN) presents the consent form for the client to sign, the client states, "I know the doctor explained it, but I forgot if this laser will also correct my astigmatism." Which action should the PN take?

Show answer & explanation

Answer: Hold the consent form and notify the surgeon to address the client's question.

Answer

Hold the consent form and notify the surgeon to address the client's question.
The correct action is to delay the signing of the consent form and contact the surgeon. For informed consent to be legally valid, the client must fully understand the procedure. The practical nurse's role is strictly to witness the voluntary signature and verify client comprehension. If the client has specific questions about the surgery itself, the nurse must advocate for the client by having the provider return to answer them.

Step-by-Step Solution

1
Analyze the client's statement.
The client is indicating a lack of full understanding regarding the surgical procedure's outcomes.
Informed consent requires the client to fully understand the procedure, risks, benefits, and alternatives.
2
Determine the practical nurse's scope of practice regarding informed consent.
The nurse acts only as a witness to the signature and an advocate who ensures the client has no remaining questions.
Nurses are not legally authorized to explain medical or surgical procedure details.
3
Select the action that aligns with legal requirements.
The PN must stop the consent process and contact the primary healthcare provider (surgeon) to answer the client's specific medical question.
Only the provider performing the procedure can clarify these details before the client signs the document.

Key Concept

Informed Consent and the Nurse's Role
Estimated Time:1m 0s
Question 1225Question →

A practical nurse (PN) is caring for an older adult client in a long-term care facility. The client suddenly becomes agitated and states, "The voices are telling me to hide under the bed." Which of the following is the best initial response by the nurse?

Show answer & explanation

Answer: I do not hear any voices, but I can see that you are frightened.

Answer

The nurse should present reality by stating they do not hear the voices, while simultaneously validating the client's feelings of fear.
The correct response effectively acknowledges the client's underlying emotion (fear) and grounds them by calmly presenting reality. This is the standard of care for a client experiencing an active hallucination.

Step-by-Step Solution

1
Analyze the client's statement and behavior.
The client is experiencing an active auditory hallucination and is displaying visible agitation and fear.
Identifying the nature of the perceptual alteration helps determine the safest and most therapeutic response.
2
Select the appropriate therapeutic communication technique.
The nurse chooses to present reality and validate feelings without arguing.
Arguing with the client or asking 'why' questions increases agitation, whereas presenting reality while validating fear builds trust and promotes safety.

Key Concept

Therapeutic communication for sensory and perceptual alterations
Question 1226Question →

A client in an outpatient clinic is preparing for a minor surgical procedure. The healthcare provider has finished discussing the risks and benefits of the surgery. Which action is the specific responsibility of the practical nurse (PN) regarding the informed consent process?

Show answer & explanation

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

Answer

Witnessing the client's voluntary signature on the consent document
In the informed consent process, the primary responsibility of the practical nurse is to act as a witness. This involves verifying that it is the correct client, that the client is signing voluntarily, and that the client appears competent to sign. The nurse does not obtain the consent or explain the medical procedure itself.

Step-by-Step Solution

1
Identify the practical nurse's designated role in the informed consent process.
The provider is legally responsible for obtaining informed consent and explaining the procedure, while the nurse acts as an advocate and witness.
To differentiate between provider and nursing scopes of practice regarding consent.
2
Evaluate the given choices against the practical nurse's scope of practice.
Explaining complications, discussing alternative treatments, and performing comprehensive clearance assessments are all outside the practical nurse's scope.
Ensures the selected action is legally appropriate and safe for the practical nurse to perform.

Key Concept

The practical nurse's role in informed consent is limited to witnessing the signature, ensuring the client is competent, and verifying that the client has spoken with the provider.
Question 1227Question →

A practical nurse (PN) is providing care for a young adult client admitted to a behavioral health unit under a temporary involuntary hold following a substance overdose. The client is highly agitated, pacing the hallway, and stating, 'I know my rights, I want to leave right now, and I want a copy of my medical chart!' Simultaneously, the client's parent calls the nursing station requesting the latest toxicology lab results. Which actions by the PN are appropriate? (Select all that apply.)

Select all that apply

Show answer & explanation

Answer: Decline to confirm the client's presence at the facility or provide any laboratory results to the calling parent.; Calmly inform the client that they are legally required to remain at the facility due to the involuntary hold status.; Communicate the client's request to view their medical record to the supervising registered nurse.

Answer

The appropriate actions are to decline sharing information with the calling parent, inform the client of their legal hold status, and report the medical record request to the supervising registered nurse.
The practical nurse acts as a client advocate by protecting strict confidentiality (refusing the parent's request), informing the client of their legal rights and restrictions (explaining the involuntary hold), and escalating complex requests (like accessing a psychiatric medical record) to the registered nurse. Providing factual information about the hold manages the client's expectations, while declining the parent's request strictly adheres to HIPAA guidelines.

Step-by-Step Solution

1
Evaluate the parent's phone request for lab results against HIPAA regulations.
Determine that without explicit client authorization, no information, including confirmation of the client's presence, can be disclosed.
Protects client confidentiality and complies with federal privacy laws.
2
Analyze the client's demand to leave the facility against their legal admission status.
Identify that the temporary involuntary hold legally supersedes the general right to leave against medical advice.
Ensures the client is safely and truthfully informed of their legal boundaries.
3
Assess the client's request to immediately view their medical chart in the context of the PN scope of practice.
Determine that while clients have a right to their records, the provider must often review psychiatric records first, requiring escalation to the RN.
Maintains safe practice boundaries, avoids out-of-scope clinical judgment, and follows proper chain of command.
4
Evaluate the appropriateness of applying physical restraints or obtaining informed consent.
Recognize that restraints require prior less restrictive alternatives and provider orders, and obtaining initial informed consent is strictly a provider responsibility.
Prevents severe scope of practice violations and client rights infringements.

Key Concept

Client Rights and Advocacy
Question 1228Question →

A client diagnosed with both Neisseria meningitidis and Clostridioides difficile requires immediate transport to the radiology department for a computerized tomography (CT) scan. Which actions should the practical nurse take to ensure proper transmission-based precautions? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Place a standard surgical mask on the client before leaving the isolation room.; Clean any shared medical equipment used during transport with a bleach-based sporicidal wipe.; Perform hand hygiene exclusively with soap and water after providing direct client care.

Answer

The correct actions are placing a surgical mask on the client, cleaning equipment with a bleach-based wipe, and performing hand hygiene using soap and water.
The scenario requires synthesizing multiple infection control protocols. Neisseria meningitidis is spread via large respiratory droplets, mandating that the client wear a surgical mask outside the room to prevent transmission during transport. Clostridioides difficile is spread via contact and produces highly resilient spores. Therefore, alcohol-based hand sanitizers are completely ineffective; nurses must use the mechanical friction of soap and water for hand hygiene. Furthermore, standard sanitizing wipes do not kill C. difficile spores, meaning any shared equipment must be rigorously disinfected using a bleach-based sporicidal solution.

Step-by-Step Solution

1
Analyze the transmission routes for the diagnosed infections.
Neisseria meningitidis requires droplet precautions. Clostridioides difficile requires contact precautions and special enteric precautions.
Identifying the correct isolation categories dictates the required personal protective equipment and environmental controls.
2
Determine the requirements for patient transport.
The client must wear a surgical mask to contain respiratory droplets.
During transport, the client acts as the primary source of droplet transmission, which is mitigated by source control (masking the client).
3
Identify the proper hand hygiene and equipment sanitation methods for enteric pathogens.
Hand hygiene must be performed with soap and water; equipment must be cleaned with a sporicidal (bleach) agent.
C. difficile spores are not destroyed by standard alcohol-based sanitizers or quaternary ammonium wipes.

Key Concept

Synthesizing simultaneous droplet and enteric contact precautions, including appropriate personal protective equipment selection, doffing sequences, and specialized disinfection.
Question 1229Question →

A practical nurse (PN) is reviewing daily responsibilities and communicating with the interprofessional team on a step-down unit. Which of the following actions represents safe and appropriate practice by the PN?

Show answer & explanation

Answer: Measuring the drainage from a client's surgical wound drain and recording the volume in the electronic health record.

Answer

Measuring the drainage from a client's surgical wound drain and recording the volume in the electronic health record.
Measuring and recording drainage is a standard data collection task that falls safely within the legal scope of practice for a practical nurse (PN). It involves objective measurement without requiring the initial, comprehensive assessment reserved for registered nurses.

Step-by-Step Solution

1
Analyze the practical nurse (PN) scope of practice regarding data collection versus assessment.
PNs are authorized to collect routine data, such as measuring and recording drainage, but cannot perform initial, comprehensive assessments.
To determine if the clinical action is legally permissible for the PN.
2
Evaluate the task of administering an IV push medication.
IV push medications are outside the standard scope of practice for a PN and require a registered nurse (RN).
IV push medications have rapid, systemic effects that require advanced assessment and evaluation.
3
Review the PN's role in the informed consent process.
The PN can witness a signature but cannot be the one to describe the risks, benefits, or complications of a procedure.
Providing the initial explanation of surgical risks is the responsibility of the healthcare provider.
4
Assess the communication scenario for privacy compliance.
Discussing client information in a public elevator violates HIPAA and client confidentiality regulations.
Client information must only be discussed in secure environments with authorized team members.

Key Concept

Scope of Practice and Safe Care Environment
Estimated Time:1m 0s
Question 1230Question →

A client in a rehabilitation facility tells the practical nurse (PN) that they are packing their bags and leaving immediately, despite not being medically discharged. Arrange the following actions the PN should take in the correct priority order, from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first listen to the client's concerns, then notify the supervising RN and provider, reinforce the risks of leaving, request a signature on the AMA form, and finally document the event.
When a client decides to leave against medical advice, the practical nurse's first priority is to advocate for the client by exploring their concerns. If the client insists on leaving, the PN must utilize the chain of command by notifying the RN and provider so the medical risks can be officially explained. The PN then reinforces this education, asks the client to sign the AMA form to legally acknowledge the risks, and completes thorough, objective documentation of the entire departure process.

Step-by-Step Solution

1
Assess the situation by listening to the client.
The PN understands why the client wants to leave.
Advocacy begins with understanding the client's perspective and attempting to resolve immediate concerns.
2
Notify the RN and healthcare provider.
The healthcare team is alerted to the situation.
The provider must be informed so they can explain the specific medical risks of leaving against medical advice.
3
Reinforce the provider's explanation of the risks.
The client fully understands the potential consequences.
The PN reinforces education provided by the RN or physician, ensuring informed decision-making.
4
Present the AMA form for signature.
The client's informed refusal is formally captured.
The AMA form provides legal documentation that the client was informed of risks but chose to leave anyway.
5
Document the entire incident.
The medical record reflects a complete account of the event.
Thorough documentation is legally required to show that the facility and nursing staff provided safe, appropriate care and advocacy.

Key Concept

Client Rights and Advocacy
Question 1231Question →

A practical nurse is preparing to administer scheduled medications to a newly admitted client. Which of the following actions should the nurse take to prevent a medication administration error?

Show answer & explanation

Answer: Ask the client to state their full name and date of birth.

Answer

Ask the client to state their full name and date of birth.
To prevent medication errors, the nurse must always verify at least two distinct patient identifiers before administration. Asking the client to state their full name and date of birth is an active, reliable method that complies with established patient safety goals.

Step-by-Step Solution

1
Identify the primary goal of the clinical scenario.
The goal is to safely administer medication by ensuring it is given to the correct client.
Correct patient identification is the critical first step in the 'rights of medication administration'.
2
Evaluate the safety and validity of the proposed identification methods.
Acceptable identifiers are specific to the individual, such as full name and date of birth.
Location-based identifiers (like room number) or subjective methods (like visual recognition) are highly prone to error.
3
Select the option that utilizes approved client identifiers.
Asking the client to state their full name and date of birth meets national patient safety standards.
This method uses two distinct, reliable pieces of information to actively verify identity before administration.

Key Concept

Rights of Medication Administration: Client Identification
Question 1232Question →

The charge nurse on a medical-surgical floor is creating client assignments for the upcoming shift. Which of the following clients are most appropriate to assign to a licensed practical nurse (LPN)? (Select all that apply.)

Select all that apply

Show answer & explanation

Answer: A client with chronic obstructive pulmonary disease (COPD) scheduled to receive a routine inhaled bronchodilator.; A client three days postoperative following an appendectomy who is tolerating a regular diet.; A client with type 2 diabetes mellitus requiring scheduled blood glucose monitoring and subcutaneous insulin.

Answer

The most appropriate clients to assign to the LPN are the client with COPD receiving a routine inhaler, the client who is three days postoperative, and the client with diabetes requiring insulin.
Licensed practical nurses (LPNs) are assigned to care for clients whose conditions are chronic, stable, and have predictable outcomes. The correct selections involve clients requiring routine medication administration (inhalers and subcutaneous insulin) and a client progressing as expected after an uncomplicated surgery, all of which fall within the LPN scope of practice.

Step-by-Step Solution

1
Analyze each client's condition for stability and predictability.
The COPD client, postoperative client, and diabetic client have stable, predictable conditions. The clients with chest pain, sepsis, and a heparin infusion have unstable or complex conditions.
The LPN scope of practice is limited to caring for clients with stable conditions and predictable outcomes.
2
Determine if the required care interventions fall within the LPN scope of practice.
Administering routine inhalers and subcutaneous insulin are within the LPN scope. Conducting initial assessments for acute chest pain, initiating IV antibiotics for sepsis, and titrating continuous IV heparin are outside the LPN scope.
Assigning clients requiring complex RN-level assessment or advanced intravenous therapies to an LPN is unsafe.

Key Concept

Delegating and accepting client care assignments based on the licensed practical nurse (LPN) scope of practice
Question 1233Question →

A competent adult client is in the preoperative holding area awaiting an elective surgical procedure. The surgeon has previously discussed the risks and benefits with the client and obtained verbal agreement. The practical nurse brings the informed consent document for the client's signature. The client pushes the paper away and states, "I have changed my mind. I am too frightened and I do not want the surgery anymore." The client's spouse becomes visibly angry and loudly insists, "You are going to sign that paper right now! We already paid a large deposit for this!" Which action is the priority for the practical nurse?

Show answer & explanation

Answer: Withhold the consent document, remain present to support the client, and immediately notify the registered nurse and the surgeon.

Answer

The practical nurse should withhold the consent document, remain present to support the client, and immediately notify the registered nurse and the surgeon.
The correct action directly advocates for the client's autonomy and right to refuse treatment. By withholding the form and staying in the room, the practical nurse protects the client from further coercion by the spouse. Notifying the registered nurse and surgeon is necessary because the provider must address the refusal and discuss the medical implications directly with the client.

Step-by-Step Solution

1
Identify the client's right to refuse.
The nurse recognizes that a competent client has the legal and ethical right to withdraw consent for a procedure at any time, even after initial verbal agreement.
Client autonomy is a foundational principle of nursing ethics and client rights.
2
Assess the validity of the informed consent environment.
The nurse identifies that the spouse's aggressive demand creates a coercive environment, meaning any subsequent signature would not be voluntary.
For informed consent to be legally valid, it must be given freely and without duress or external coercion.
3
Determine the appropriate scope of practice and priority action.
The nurse determines that counseling the client on medical risks is beyond the practical nurse scope. The immediate priority is to halt the consent process, protect the client, and escalate to the provider.
Practical nurses advocate by protecting the client's rights in the moment and ensuring the provider addresses any complex clinical decision-making regarding treatment refusal.

Key Concept

Client Rights and Advocacy regarding Informed Consent and Treatment Refusal
Estimated Time:1m 30s
Question 1234Question →

An alert and oriented client is scheduled for a lumbar puncture. The attending physician has completed the initial discussion regarding the procedure. As the practical nurse hands the client a pen to sign the informed consent document, the client states, "I am still not entirely sure what other options I have besides this test." Which action should the nurse take next?

Show answer & explanation

Answer: Withhold the consent form and notify the physician that the client requires further explanation of alternative options.

Answer

The correct action is to withhold the consent form and notify the physician that the client requires further explanation of alternative options.
For informed consent to be legally valid, the client must fully understand the procedure, including its risks, benefits, and any alternative options. Providing this detailed medical explanation is strictly the responsibility of the healthcare provider. The practical nurse's role is to witness the signature voluntarily given by a competent, informed client. Because the client expressed uncertainty about alternative options, the nurse must advocate for the client by stopping the consent process and notifying the provider to return and answer the client's questions.

Step-by-Step Solution

1
Identify the client's statement as a knowledge deficit regarding the procedure's alternatives.
The client does not have sufficient information to provide a truly informed consent.
Informed consent legally requires the client to fully understand the risks, benefits, and alternative options prior to signing.
2
Determine the practical nurse's scope of practice in the informed consent process.
The nurse's role is strictly to act as a witness to the signature and advocate for the client.
Explaining primary medical alternatives is exclusively the responsibility of the healthcare provider.
3
Select the action that protects the client's rights while remaining within the practical nursing scope.
The nurse must halt the signing process and contact the physician to return.
This advocates for the client's right to full disclosure and ensures safe, ethical, and legal care.

Key Concept

The practical nurse's role in informed consent is to act as an advocate and a witness. If a client demonstrates a lack of understanding regarding the procedure, risks, benefits, or alternatives, the nurse must halt the signing process and notify the healthcare provider.
Question 1235Question →

A practical nurse (PN) in a long-term care facility enters a resident's room and witnesses an assistive personnel (AP) roughly pulling the resident by the arm and yelling at them. Arrange the following actions the PN should take in the correct priority order, from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first intervene to stop the action, then assess the resident, next report the incident to the supervisor, and finally document the objective findings.
In any situation involving client abuse or an immediate safety threat, the nurse must prioritize actions based on immediate client safety. The very first action must always be to intervene and stop the active harm. Immediately following intervention, the nurse must assess the client for injuries. Once the client is safe and stable, the nurse must act as a mandatory reporter by notifying the supervisor. Finally, the nurse completes the ethical and legal requirement of factual, objective documentation.

Step-by-Step Solution

1
Intervene immediately to stop the assistive personnel's actions.
The immediate threat to the resident's safety is removed.
According to safety principles, protecting the client from active harm is always the primary nursing responsibility.
2
Assess the resident for physical injuries and signs of distress.
The resident's physical and emotional condition is evaluated.
The nurse must determine if the resident sustained any injuries that require immediate medical treatment or further monitoring.
3
Report the incident to the charge nurse or nursing supervisor.
Facility management is informed of the suspected abuse.
Nurses are mandatory reporters. The chain of command must be notified promptly so that the AP can be removed from client care and formal investigations can begin.
4
Document the objective observations and the resident's condition in the medical record.
A legal, factual record of the event is created.
Objective documentation must be completed according to facility policy to ensure a legal record exists, but only after immediate safety, assessment, and reporting steps are complete.

Key Concept

Mandatory Reporting and Client Safety Prioritization
Question 1236Question →

A practical nurse (PN) working in a long-term care facility enters the medication preparation area and observes a coworker consuming a client's prescribed liquid opioid medication. Arrange the actions the PN must take in the correct chronological order of priority.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first prevent the coworker from providing care, then report to the supervisor, followed by ensuring continuity of care for the clients, and finally documenting the incident.
In situations involving impaired practice, the nursing process dictates that client safety is the paramount concern. The PN must first intervene to stop the impaired individual from providing care. Immediately following this, the PN must report up the chain of command so leadership can address the employee. Ensuring that the affected clients receive their care from an alternative nurse follows next. Finally, a factual incident report must be completed to legally document the event.

Step-by-Step Solution

1
Prioritize immediate client safety.
The impaired coworker is prevented from interacting with clients.
Client safety is always the primary concern in nursing practice; an impaired nurse cannot safely administer care.
2
Activate the chain of command.
The nursing supervisor is notified of the objective findings.
Management must handle the impaired employee, arrange for drug testing if appropriate, and secure the facility.
3
Maintain continuity of care.
Another qualified nurse is assigned to the coworker's clients.
Clients must continue to receive their scheduled medications and safe care without interruption.
4
Document the event.
An objective incident report is filed.
Factual documentation provides a legal record of the observation, which must be completed after the situation is stabilized.

Key Concept

Impaired Practice and Mandatory Reporting Procedures
Question 1237Question →

A practical nurse (PN) is assigned to a busy surgical step-down unit. The charge nurse delegates preoperative preparations for a client scheduled for a partial bowel resection. The provider has documented that the procedure was explained, but the consent form remains unsigned. Which of the following actions by the PN represents legally and ethically sound practice?

Show answer & explanation

Answer: Witnessing the client's signature on the consent form and notifying the provider if the client expresses confusion about the surgical outcome.

Answer

The practical nurse should witness the client's signature on the surgical consent form and notify the healthcare provider if the client exhibits any confusion regarding the surgery.
The legally and ethically sound action is for the practical nurse to witness the client's signature on the consent form. If the client expresses any confusion or misunderstanding about the procedure, the nurse's ethical duty is to halt the signing process and advocate for the client by notifying the provider, as only the provider can legally clarify surgical risks and outcomes.

Step-by-Step Solution

1
Evaluate the delegated task regarding informed consent.
Identify that the PN may witness the client's signature but cannot provide the medical explanation of the procedure or its risks.
Obtaining informed consent is a non-delegable duty of the provider. The nurse's role is solely advocacy and witnessing.
2
Evaluate the delegated task regarding the nursing care plan.
Recognize that creating the initial postoperative care plan is outside the PN scope of practice.
The RN is legally responsible for the initial assessment and formulation of the care plan; the PN contributes to and implements it.
3
Evaluate the action regarding telephone communication.
Determine that confirming client location or status to a caller without authorization violates confidentiality laws.
HIPAA requires strict protection of patient information, and an 'emergency contact' status does not automatically grant telephone access to protected health information without verification.

Key Concept

Practical Nurse Scope of Practice, Informed Consent, and Confidentiality
Question 1238Question →

A practical nurse prepares to obtain routine vital signs for a newly admitted client who has a suspected case of pertussis and is experiencing severe paroxysmal coughing. Which infection control action must the nurse complete prior to stepping inside the client's room?

Show answer & explanation

Answer: Secure a standard surgical face mask over the nose and mouth.

Answer

The nurse must secure a standard surgical face mask over the nose and mouth.
Pertussis (whooping cough) is transmitted through large respiratory droplets. According to standard infection control guidelines, droplet precautions require healthcare workers to wear a surgical face mask when entering the client's room or coming within 3 feet of the client to protect against infectious respiratory secretions.

Step-by-Step Solution

1
Identify the mode of transmission for the specified pathogen (pertussis).
Pertussis is a respiratory infection spread through large respiratory droplets generated by coughing or sneezing.
Determining the transmission route is the first step in selecting the appropriate isolation precautions.
2
Select the correct transmission-based precautions based on the pathogen.
Droplet precautions are required for clients with suspected or confirmed pertussis.
Large droplets typically travel short distances (about 3 feet) and do not remain suspended in the air, requiring specific barrier protection.
3
Determine the correct personal protective equipment (PPE) required before entry.
A standard surgical mask is required to protect the nurse's mucous membranes from droplet exposure.
Airborne PPE (N95) or Contact PPE (gown/gloves) are not the primary requirement for standard droplet entry unless multiple precautions are active.

Key Concept

Droplet Precautions for Respiratory Pathogens
Question 1239Question →

A client with a diagnosis of early-stage vascular dementia is preparing for an elective cholecystectomy. The medical record includes a durable power of attorney for healthcare (DPOA-HC) naming the client's eldest child as the surrogate. The client accurately describes the surgical risks and benefits but firmly states, 'I have changed my mind; I do not want this surgery.' The eldest child presents the DPOA-HC document to the practical nurse (PN) and insists that preoperative preparations continue. Which action should the PN take?

Show answer & explanation

Answer: Halt all preoperative interventions and immediately notify the attending surgeon of the client's verbal refusal.

Answer

Halt all preoperative interventions and immediately notify the attending surgeon of the client's verbal refusal.
The correct action is to halt the preoperative interventions and notify the attending surgeon. Clients have the fundamental right to refuse medical treatment at any time, even after initially providing consent. A durable power of attorney for healthcare (DPOA-HC) is only activated when a client is deemed to lack decision-making capacity by a healthcare provider. Because this client is able to accurately articulate the risks and benefits of the surgery, they currently demonstrate capacity. The practical nurse must advocate for the client's expressed wishes and escalate the situation to the provider, who will address the family.

Step-by-Step Solution

1
Identify the client's current cognitive status and expressed wishes regarding the procedure.
The client accurately describes risks and benefits, demonstrating current capacity, and explicitly refuses the surgery.
Clients with capacity have the absolute right to refuse medical treatment at any time, regardless of prior consent.
2
Evaluate the legal standing of the durable power of attorney for healthcare (DPOA-HC).
The DPOA-HC is not currently active because the client is demonstrating the capacity to understand their decisions.
A healthcare proxy only makes decisions when the primary provider formally determines the client lacks decision-making capacity.
3
Determine the appropriate practical nurse (PN) advocacy action.
Stop preparations and escalate the situation to the provider.
The PN must advocate for the client's expressed wishes. The provider is legally responsible for discussing the refusal with the family and making any formal determinations regarding capacity.

Key Concept

Client Rights and Advocacy: Informed Refusal and Advance Directives
Question 1240Question →

Upon completing client care in an airborne infection isolation room, a nurse prepares to remove personal protective equipment (PPE). The nurse is currently wearing an N95 respirator, an isolation gown, and gloves. Which action represents the correct procedure for removing the N95 respirator?

Show answer & explanation

Answer: Remove the respirator after exiting the client's room and closing the door.

Answer

The respirator must be removed after exiting the client's room and closing the door.
The correct answer describes removing the respirator after exiting the client's room and closing the door. Because airborne pathogens are small enough to remain suspended in the air, the nurse must maintain continuous respiratory protection until completely outside of the contaminated environment.

Step-by-Step Solution

1
Identify the transmission risk associated with the precaution type.
Airborne precautions indicate that infectious particles remain suspended in the air of the patient's room.
Understanding how the pathogen spreads dictates how and where respiratory protection should be handled.
2
Recall the standardized sequence for doffing (removing) PPE.
The most contaminated items (gloves and gown) are removed inside the room, while respiratory protection (N95) is removed last.
This sequence minimizes self-contamination during the removal process.
3
Determine the safe location for respirator removal.
The N95 respirator is only removed after leaving the isolation room and ensuring the door is closed.
Removing the mask outside the room ensures the nurse does not inhale any infectious airborne particles that are still circulating in the client's environment.

Key Concept

Standard and Transmission-Based Precautions
PreviousPage 62 / 147Next
All practice questions — NCLEX-PN | Examkin