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Question 121Question →

A practical nurse (PN) is caring for a client on a telemetry unit who is scheduled for a permanent pacemaker insertion in one hour. The client has already signed the informed consent document. While the PN is checking the client's morning vital signs, the client states, "I cannot go through with this. I do not want the pacemaker." Place the following nursing actions in the correct chronological order.

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Answer

The correct sequence is to first explore the client's statement, then withhold preoperative sedatives, followed by notifying the healthcare provider and charge nurse, and finally documenting the events in the medical record.
The correct sequence follows the nursing process and legal guidelines for informed consent. The PN first assesses the situation (data collection), implements immediate safety measures (withholding sedatives), communicates the findings to the responsible provider (reporting), and finally records the events (documentation).

Step-by-Step Solution

1
Explore the client's statement
The PN understands the client's reasoning and confirms their intent to refuse.
Data collection is the first step in the nursing process.
2
Withhold preoperative sedatives
Client safety is maintained and cognitive function remains intact.
Preoperative medications can alter mental status, which must be clear for any subsequent discussions about consent with the provider.
3
Notify the healthcare provider and charge nurse
The appropriate personnel are informed to manage the clinical and scheduling implications.
The provider is legally responsible for discussing the risks of refusing the procedure with the client. The PN's scope is to report the refusal, not to counsel on risks.
4
Document the events in the medical record
A clear, legal timeline of the events is established.
Documentation should reflect the client's exact words, nursing actions taken, and who was notified.

Key Concept

A competent client has the right to withdraw informed consent at any time. The PN's role is to verify the refusal, ensure client safety, report the decision to the provider, and document the event accurately.
Estimated Time:1m 30s
Question 122Question →

An unconscious client requires morning oral hygiene. To prevent aspiration and ensure safety, in what order should the practical nurse complete the following steps? Arrange the actions in the correct chronological sequence.

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Answer

The correct sequence for providing oral care to an unconscious client begins with lateral positioning to prevent aspiration, followed by placing protective linens, safely opening the mouth with a padded blade, performing the cleaning, and finally suctioning excess fluids.
When providing oral care to an unconscious client, the absolute priority is preventing aspiration. Therefore, positioning the client laterally (side-lying) is the crucial first step. Once the airway is protected by gravity, the nurse protects the linens, safely opens the mouth using a padded instrument, cleans the oral cavity, and finally suctions the remaining fluids to ensure the mouth is clear and safe.

Step-by-Step Solution

1
Position the client in a side-lying (lateral) posture with the head turned to the side.
The airway is protected from introduced fluids.
This utilizes gravity to allow fluids to drain out of the mouth, significantly reducing the risk of pulmonary aspiration.
2
Place a waterproof pad and towel under the client's chin with an emesis basin nearby.
The client's gown and bed linens remain dry and clean.
Preparing the immediate area provides a receptacle for the draining fluids and maintains hygiene.
3
Carefully separate the client's upper and lower teeth using a padded tongue blade.
The oral cavity becomes accessible for the cleaning procedure.
Unconscious clients may exhibit a bite reflex; a padded blade protects both the client's dentition and the nurse's fingers.
4
Clean the teeth, gums, and oral mucosa using a moistened soft toothbrush.
Plaque, bacteria, and crusts are removed from the oral cavity.
Routine cleaning maintains oral tissue integrity and reduces the bacterial load that can cause aspiration pneumonia.
5
Use a Yankauer suction catheter to remove excess oral secretions and rinse fluid.
The oral cavity is left clean and free of pooled liquids.
Immediate removal of residual fluids ensures the airway remains unobstructed after the hygiene procedure is complete.

Key Concept

Aspiration Precautions and Hygiene
Question 123Question →

A client in a subacute respiratory care unit is experiencing severe confusion and repeatedly attempts to remove their tracheostomy tube. After determining that alternative measures and verbal redirection are ineffective, the healthcare provider prescribes bilateral soft limb restraints. In what order should the practical nurse (PN) perform the following actions to safely apply the devices? (Arrange the actions in the correct sequence, from first to last.)

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Answer

The correct sequence is: Explain the intervention, wrap the restraints around the wrists, attach the straps to the movable bed frame, check the fit with two fingers, and finally assess the distal neurovascular status.
The correct sequence prioritizes client communication and ethical care first, followed by the safe mechanical application of the devices. Once the devices are wrapped around the wrists and securely anchored to a movable frame with quick-release knots, the nurse must immediately verify the fit (two-finger space) to prevent constriction. Finally, a complete neurovascular assessment (pulses, color, temperature) must be performed and documented to ensure circulation and nerve function are intact.

Step-by-Step Solution

1
Communicate with the client and family.
The rationale for the restraints is understood.
Ethical nursing practice requires informing the client and family about the need for protective devices prior to application, even if the client is confused or agitated.
2
Apply the soft limb restraints.
The restraints are physically placed on the client's wrists.
The device is applied to safely restrict movement that threatens the tracheostomy tube.
3
Secure the straps using quick-release knots.
The restraints are anchored to the movable part of the bed frame.
Securing the straps to the movable frame prevents injury when the bed's head or foot is adjusted. Quick-release knots allow for immediate removal during an emergency.
4
Check the tightness of the restraints.
Two fingers can slide beneath the restraint.
Verifying the fit prevents the mechanical compression of nerves and blood vessels, which could cause permanent damage.
5
Perform a neurovascular assessment.
Distal pulses, color, and temperature are evaluated.
A baseline post-application assessment ensures that the restraints have not compromised circulation or neurologic function to the extremities.

Key Concept

The safe application of physical restraints involves a systematic sequence prioritizing communication, correct mechanical application to a movable bed frame, and immediate neurovascular verification.
Question 124Question →

A practical nurse is assisting with the preparation of a client with severe hepatic cirrhosis who is scheduled for a bedside paracentesis. In what order should the nurse perform the following actions to minimize the risk of procedural complications, such as bladder perforation?

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Answer

The correct sequence prioritizes administrative safety (verifying consent), followed by physiological risk reduction (emptying the bladder), obtaining accurate baseline data, optimal client positioning, and finally, establishing the sterile field.
Preparing for a paracentesis requires a strategic sequence to ensure client safety. Consent must be verified first. The client must then empty their bladder to drastically reduce the risk of a bladder perforation when the needle is inserted. Baseline vitals, weight, and abdominal girth must be measured immediately after voiding for accuracy. The client is then placed upright so gravity pools the ascites in the lower abdomen, safely away from vital organs. Finally, the sterile field is established.

Step-by-Step Solution

1
Verify informed consent.
Legal and administrative safety is established.
No preparatory actions should begin until the client has officially consented to the procedure.
2
Have the client empty their bladder.
The bladder is decompressed and moves safely down into the pelvis.
A full bladder extends upward into the abdominal cavity, greatly increasing the risk of accidental puncture by the paracentesis needle.
3
Obtain baseline vital signs, weight, and abdominal girth.
Accurate physiological baseline data is recorded.
Measurements must be taken after the bladder is emptied so that the weight and girth solely reflect the body mass and ascitic fluid, ensuring accurate post-procedure evaluation.
4
Position the client upright (high Fowler's or sitting).
The ascitic fluid pools in the lower abdominal cavity.
Gravity forces the fluid downward, making it easier to drain and naturally shifting the intestines away from the planned puncture site.
5
Prepare the sterile tray and equipment.
The sterile field is ready for the provider.
Supplies should be opened and prepared immediately before the procedure begins to reduce the risk of environmental contamination.

Key Concept

Client Preparation and Risk Reduction for Invasive Procedures (Paracentesis)
Question 125Question →

A practical nurse (PN) is preparing to provide care for a newly admitted client with suspected avian influenza. Facility infection control protocols mandate airborne, contact, and eye precautions. In what order should the PN don the required personal protective equipment (PPE) before entering the client's room? Arrange the actions from first to last.

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Answer

The correct sequence for donning PPE is: perform hand hygiene, put on the isolation gown, apply the N95 respirator, position the face shield, and finally don the gloves.
The Centers for Disease Control and Prevention (CDC) strictly defines the PPE donning sequence to minimize cross-contamination and ensure proper fit of barrier equipment. Hand hygiene is always the required first step. The gown is applied next to cover the torso. Facial protection follows, beginning with the N95 respirator so it can be securely fitted and seal-checked against the skin, followed by the face shield which rests securely over the respirator. Finally, gloves are applied last and extended over the gown cuffs to create a sealed barrier right before patient care begins.

Step-by-Step Solution

1
Initiate the donning process with hand hygiene.
Hands are decontaminated.
Prevents contamination of clean PPE items during the application process.
2
Apply the isolation gown.
Torso and uniform are completely covered.
Provides a primary barrier against contact transmission. Tying it securely prepares the upper body before facial gear limits visibility or mobility.
3
Apply the N95 respirator.
Respiratory tract is protected from airborne particles.
Securing the respirator to the face and checking the seal is crucial for airborne precautions and must be done before eye protection is added to ensure an uninterrupted seal against the skin.
4
Apply the face shield.
Eyes and mucous membranes are protected.
Eye protection goes over the upper edge of the respirator to shield from splashes or respiratory sprays.
5
Apply clean gloves.
Hands and wrists are covered.
Gloves are applied last and pulled over the gown cuffs to maintain a continuous barrier and ensure the gloves remain entirely clean immediately prior to client contact.

Key Concept

Standardized sequence for donning personal protective equipment (PPE)
Estimated Time:1m 30s
Question 126Question →

While rounding on a medical unit, the practical nurse (PN) encounters a conscious client with a history of diabetes mellitus who is trembling and visibly diaphoretic. Place the following nursing interventions in the correct chronological sequence to appropriately manage this acute situation.

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Answer

The correct sequence is to verify the blood glucose first, immediately treat with a fast-acting carbohydrate, recheck the glucose in 15 minutes to evaluate effectiveness, and finally provide a sustaining snack once stable.
The standard management for acute hypoglycemia in a conscious client follows the 'rule of 15'. The nurse must first collect data by checking the blood glucose to confirm the condition. Next, the nurse administers 15 grams of a fast-acting carbohydrate (such as juice) to rapidly correct the low blood sugar. The nurse then waits 15 minutes and reassesses the blood glucose to ensure the intervention was effective. Finally, once the blood glucose is in a safe range, providing a snack with complex carbohydrates and protein helps sustain the blood glucose level and prevents it from dropping again.

Step-by-Step Solution

1
Assess capillary blood glucose.
Confirms the presence and severity of hypoglycemia.
Data collection must precede intervention to ensure the symptoms are not caused by a different physiological issue.
2
Give 15 grams of simple carbohydrates.
Rapidly increases the blood sugar level.
Addresses the acute physiological deficit immediately.
3
Recheck blood glucose in 15 minutes.
Evaluates the client's response to the intervention.
Determines if the hypoglycemia has resolved or if the treatment step must be repeated.
4
Provide a complex carbohydrate and protein snack.
Maintains a stable blood glucose level.
Prevents a recurrent drop in blood sugar after the simple sugars have been rapidly metabolized.

Key Concept

Management of acute hypoglycemia using the 'rule of 15'
Question 127Question →

A practical nurse has finished providing care for a client who requires both airborne and contact precautions. The nurse is currently wearing an isolation gown, gloves, and an N95 respirator. Arrange the steps for doffing the personal protective equipment (PPE) and exiting the area in the correct sequential order to prevent contamination.

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Answer

The correct sequence is to first remove the gloves, then remove the gown, exit the client's room, remove the N95 respirator in the hallway, and finally perform hand hygiene.
Established infection control and safety protocols dictate that the most contaminated items (gloves and gown) must be removed first while the nurse is still inside the isolation room. Because the client is on airborne precautions, the nurse must remain protected against airborne particles until they have completely exited the room and the door is closed. Therefore, the N95 respirator is removed in the hallway or anteroom, followed by final hand hygiene to ensure complete decontamination.

Step-by-Step Solution

1
Remove and discard the gloves.
The most contaminated PPE is discarded safely.
Removing gloves first prevents the highly contaminated hands from spreading pathogens to the neck, face, or hair when untying the gown or reaching for the respirator.
2
Remove the isolation gown.
Contact precaution garments are fully removed inside the isolation environment.
The gown's front and sleeves are contaminated. Rolling it inside out traps the pathogens. This must be done inside the room before opening the door.
3
Exit the isolation room and close the door.
The nurse transitions to a clean environment while airborne protection is still active.
Airborne precautions require the door to remain closed to maintain negative pressure. The nurse must be safely outside the contaminated airspace before removing the respirator.
4
Remove the N95 respirator.
Respiratory protection is safely discarded without exposing the nurse to airborne particles.
Handling only the elastic straps prevents contamination of the hands from the front of the mask, which acts as a filter for pathogens.
5
Perform thorough hand hygiene.
Hands are completely clean and safe.
This final step ensures that any accidental contamination that occurred during the doffing process is eliminated before the nurse moves on to other tasks.

Key Concept

Personal Protective Equipment (PPE) doffing sequence for combined airborne and contact precautions.
Question 128Question →

A practical nurse (PN) working in a long-term care facility witnesses another staff member aggressively grabbing a resident's arm and shouting at them. Arrange the following actions the PN should take in the correct chronological order.

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Answer

The correct sequence is to first intervene to ensure safety, assess the resident for injuries, notify management to remove the staff member, and finally document the event.
In any scenario involving active harm, the nursing process dictates that immediate safety intervention is the first priority. This is followed by assessment of the client, notifying the chain of command to manage the offending staff member and initiate legal reporting, and finally creating an objective medical record of the event.

Step-by-Step Solution

1
Intervene immediately to separate the staff member from the resident.
The resident is protected from further physical or emotional harm.
According to the hierarchy of nursing actions, immediate client safety and preventing further injury always takes absolute precedence.
2
Assess the resident for any physical injuries and provide necessary care.
The resident's clinical status is determined.
After securing the environment, the nurse must evaluate the resident to treat any injuries sustained during the incident.
3
Notify the nursing supervisor about the witnessed incident.
The chain of command is activated.
The supervisor must be alerted to remove the accused staff member from the premises and to fulfill the facility's legal obligation for mandatory reporting.
4
Document the objective, factual details of the event in the medical record.
A legal record of the incident is created.
Accurate, objective documentation is required for the client's health record and for the inevitable investigation by adult protective services.

Key Concept

Procedural escalation for suspected client abuse and prioritizing client safety.
Question 129Question →

A practical nurse (PN) is preparing to delegate the routine task of obtaining morning vital signs on a stable adult client to an assistive personnel (AP). Arrange the steps of the delegation process in the correct chronological sequence.

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Answer

The correct sequence follows the standard delegation process: first assessing the client's stability (Right Circumstance/Task), then verifying the AP's competence (Right Person), followed by giving clear instructions (Right Direction/Communication), and finally evaluating the outcome (Right Supervision/Evaluation).
The NCSBN delegation model requires a systematic approach. The nurse must first assess the client and the appropriateness of the task, then ensure the right person is selected. Only after these factors are confirmed can the nurse provide specific directions. Finally, the nurse must supervise and evaluate the outcome, as accountability for the task's outcome always remains with the delegating nurse.

Step-by-Step Solution

1
Determine task appropriateness.
The PN verifies the client is stable.
Delegation requires a stable client and a routine, predictable task to ensure safety.
2
Verify competence.
The PN selects an AP who is trained for the specific task.
The delegatee must be legally permitted and individually competent to perform the skill.
3
Provide instructions.
The PN tells the AP exactly what to do and when to report.
Clear, specific, two-way communication prevents errors and ensures the AP knows when to escalate concerns.
4
Supervise and evaluate.
The PN checks the vital signs and follows up with the AP.
The PN retains ultimate accountability for the task's outcome and must ensure it was completed properly.

Key Concept

Five Rights of Delegation in Nursing Practice
Question 130Question →

A practical nurse is changing the abdominal dressing of a client who is four days postoperative from an exploratory laparotomy. When the client forcefully coughs, the nurse observes internal organs protruding through the opened incision line. In which sequential order should the practical nurse prioritize the following interventions? Arrange the actions from first to last.

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Answer

The correct sequence of actions is to first call for help while staying with the client, position the client to reduce abdominal tension, cover the exposed organs with moist sterile dressings, assess vital signs for shock, and maintain NPO status for emergency surgery.
In an acute evisceration, the practical nurse must prioritize actions that protect the client and the exposed organs while expediting emergency medical intervention. First, the nurse must never leave the client; activating the emergency system brings necessary personnel and sterile supplies to the bedside. Next, positioning the client in a low-Fowler's position with flexed knees is a critical mechanical intervention that instantly reduces intra-abdominal pressure and prevents further protrusion of the bowel. Once sterile supplies are available, the nurse must cover the exposed viscera with sterile, saline-moistened dressings to prevent tissue necrosis and severe infection. After the site is physically protected, obtaining vital signs is essential to monitor for hypovolemic shock, a major systemic complication of evisceration. Finally, because evisceration requires immediate operative repair, the nurse must ensure the client is kept strictly NPO to prevent aspiration during anesthesia.

Step-by-Step Solution

1
Activate the emergency response while staying with the client.
Ensures the client remains safe while necessary sterile supplies and personnel are brought to the bedside.
The practical nurse must not leave an unstable client; leaving could lead to further injury or severe complications.
2
Place the client in a low-Fowler's position with knees flexed.
Minimizes intra-abdominal pressure.
Relieving tension on the abdominal wall physically prevents further evisceration of internal organs.
3
Apply sterile, saline-moistened dressings over the evisceration.
Protects the exposed bowel from the external environment.
Exposed viscera are highly susceptible to drying and infection, which can cause tissue necrosis. Sterile normal saline maintains moisture safely.
4
Assess and document the client's vital signs.
Provides baseline hemodynamic data.
Evisceration can trigger a massive stress response and fluid shifts, leading to hypovolemic shock. Tachycardia and hypotension require immediate medical intervention.
5
Reinforce NPO status and prepare for surgery.
Prevents aspiration during future anesthesia.
Wound evisceration is a surgical emergency requiring operative closure. Maintaining strict NPO status is critical for safe intubation.

Key Concept

Wound Evisceration Emergency Management
Question 131Question →

A practical nurse (PN) is monitoring a client who is receiving a continuous infusion of packed red blood cells (PRBCs). Fifteen minutes after the transfusion begins, the client suddenly reports severe lower back pain, chills, and shortness of breath. Arrange the PN's interventions in the correct order of priority.

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Answer

The correct priority sequence for a suspected hemolytic transfusion reaction is to first stop the transfusion, secure the IV line with normal saline using new tubing, notify the supervising RN, assess vital signs, and finally send the blood product to the blood bank.
In the event of a blood transfusion reaction, the immediate priority is to stop the cause of the reaction (following Airway, Breathing, Circulation principles by stopping the harmful agent first). Next, IV access must be maintained for potential emergency drug administration, which requires entirely new tubing primed with normal saline. Following this, the PN must notify the RN to escalate the emergency. Assessing vital signs is the next priority to monitor for shock and respiratory distress. Finally, administrative and diagnostic steps, such as returning the blood to the lab, are completed.

Step-by-Step Solution

1
Stop the blood transfusion immediately.
The infusion of the potentially incompatible blood product is halted.
This is the most critical first step to minimize the volume of reactive blood entering the client's circulation.
2
Connect new tubing primed with 0.9% normal saline.
Intravenous access is maintained without infusing residual blood.
Emergency medications may be needed, so the IV site must be kept open, but flushing the old tubing would worsen the reaction.
3
Notify the supervising RN.
The healthcare team is alerted to the medical emergency.
The RN will contact the healthcare provider for emergency orders and assist with advanced assessments.
4
Assess vital signs and respiratory status.
Objective data regarding the client's hemodynamic stability is collected.
Vital signs help determine the severity of the reaction and guide further therapeutic interventions.
5
Return the blood bag and tubing to the blood bank.
The blood and tubing are sent for laboratory analysis.
This administrative step allows the facility to investigate the cause of the reaction, but it only occurs after the client is stable.

Key Concept

Management of acute blood transfusion reactions.
Estimated Time:1m 30s
Question 132Question →

A practical nurse is completing care for a client on airborne and contact precautions due to disseminated herpes zoster. The nurse is wearing an isolation gown, gloves, a face shield, and an N95 respirator. Assuming the nurse removes each piece of equipment separately, arrange the following steps for safely doffing the personal protective equipment (PPE) and exiting the room in the correct chronological sequence.

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Answer

The correct sequence is: 1) Remove gloves, 2) Remove face shield, 3) Remove gown, 4) Exit the isolation room, 5) Remove N95 respirator, and 6) Perform hand hygiene.
According to standard CDC infection control guidelines, personal protective equipment (PPE) must be removed in a specific sequence to prevent self-contamination. The most contaminated items are removed first. Gloves are removed first, followed by the face shield (handled by the clean back straps), and then the gown (rolled inside out to contain pathogens). For airborne precautions, it is a critical safety requirement that the N95 respirator remains firmly in place until the nurse has safely exited the negative-pressure isolation room and closed the door. Finally, thorough hand hygiene is performed after all PPE is entirely removed.

Step-by-Step Solution

1
Remove gloves
Hands are freed from the most heavily contaminated PPE.
Gloves are typically the most contaminated items and must be removed first to prevent cross-contamination to the face or clean areas.
2
Remove face shield
Eye and face protection is safely discarded.
The face shield is removed next by handling only the clean back straps, protecting the nurse's face while still in the contaminated environment.
3
Remove gown
The gown is bundled inside out and discarded.
The gown is removed third. Rolling it inside out traps contact pathogens (like those from herpes zoster lesions) safely inside the bundle.
4
Exit the room
The nurse leaves the contaminated airborne environment.
The nurse must exit the negative-pressure room before removing respiratory protection to prevent inhalation of airborne infectious particles.
5
Remove N95 respirator
The respirator is discarded safely in the hallway.
Removing the N95 outside the isolation environment ensures the nurse's airway remains protected during the transition out of the room.
6
Perform hand hygiene
Any residual pathogens on the bare hands are eradicated.
Hand hygiene is strictly required as the final step of the doffing process to ensure complete decontamination.

Key Concept

PPE Doffing Sequence for Airborne and Contact Precautions
Question 133Question →

A client is scheduled for a peripherally inserted central catheter (PICC) placement. The client states they are ready to complete the legal paperwork. Place the following steps the practical nurse (PN) must take to properly witness the informed consent in the correct chronological order.

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Answer

The correct sequence is to first ask if the provider explained the procedure, then confirm the client is alert, observe the client sign, sign as a witness, and finally place the document in the medical record.
The proper sequence aligns with the PN's legal scope of practice. First, verify the provider completed their duty. Next, ensure the client is competent to sign. Then, directly observe the signing. Afterward, sign as the witness. Finally, secure the document in the chart for the procedural team.

Step-by-Step Solution

1
Ask the client if the healthcare provider has explained the procedure and answered all their questions.
The PN ensures the provider has fulfilled the legal obligation of informing the client.
The PN cannot witness consent if the provider has not yet explained the risks, benefits, and alternatives.
2
Confirm that the client is alert, oriented, and not under the influence of sedating medications.
The PN establishes that the client has the cognitive capacity to sign a legal document.
Consent is invalid if the client is sedated, confused, or coerced.
3
Observe the client physically signing and dating the consent document.
The PN fulfills the core requirement of being a witness.
A witness must visually confirm that the specific client is the one signing the document voluntarily.
4
Sign the designated witness line on the consent document.
The PN legally documents their presence and observation of the client's signature.
The witness signature authenticates that the client's signature was obtained properly.
5
Place the fully executed consent document into the client's medical record.
The document is secured for the healthcare team.
The completed consent must be on the chart before any procedure can legally and safely commence.

Key Concept

The practical nurse's role in informed consent is strictly limited to ensuring the provider gave the explanation, assessing client competency, and witnessing the voluntary signature.
Estimated Time:1m 0s
Question 134Question →

A client with severe cognitive impairment is hospitalized for pneumonia and repeatedly attempts to forcefully remove their intravenous (IV) catheter. Place the following nursing interventions in the correct sequential order, starting with the initial least-restrictive assessment and ending with the action of absolute last resort, to ensure client safety.

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Answer

The correct sequence prioritizes client safety by escalating from the least restrictive intervention to the most restrictive: Assess physiological triggers, Conceal the IV site, Relocate the client for observation, Contact the provider for a prescription, and finally Secure the restraints.
The correct sequence follows the evidence-based nursing standard for restraint application: it begins with independent nursing assessments to rule out physiological causes, progresses to least-restrictive bedside interventions (camouflaging), escalates to increased supervision (room relocation), and only then seeks a provider prescription to implement the most restrictive measure (physical restraints).

Step-by-Step Solution

1
Evaluate the client for reversible physiological triggers such as hypoxia, pain, or a distended bladder.
Underlying causes of agitation are identified and addressed.
Agitation is often a symptom of an unmet physical need; resolving the root cause is the least restrictive and most effective primary intervention.
2
Conceal the intravenous insertion site and tubing by applying a loose, soft stockinette over the client's forearm.
The medical device is obscured from the client's line of sight.
If agitation persists, camouflaging the site is a low-risk, non-restrictive bedside modification that often prevents the client from fixating on the IV.
3
Relocate the client to a room directly visible from the nurses' station to facilitate constant observation.
The client receives enhanced environmental supervision.
When bedside modifications fail, moving the client to a highly visible area increases safety without restricting their physical freedom.
4
Contact the primary healthcare provider to report the ongoing safety risk and obtain a prescription for physical restraints.
Legal authorization for restraints is obtained.
Mechanical restraints cannot be applied without a documented medical order, which should only be requested after all less restrictive alternatives have proven ineffective.
5
Secure padded extremity restraints to the movable segment of the bed frame.
The client is physically prevented from removing the life-sustaining IV.
Applying physical restraints is strictly a measure of absolute last resort to prevent imminent harm, and they must be secured safely to avoid injury during bed adjustments.

Key Concept

Hierarchy of Restraint Alternatives and Client Safety
Question 135Question →

A client receiving continuous enteral nutrition via a nasogastric tube suddenly begins to cough forcefully. The practical nurse observes that the client is experiencing severe dyspnea and has developed circumoral cyanosis. In what order should the practical nurse prioritize the following immediate actions? Arrange the actions in chronological order from first to last.

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Answer

The correct sequence is to first stop the feeding, then position the client laterally, suction the airway, administer oxygen, and finally notify the registered nurse.
When a client receiving continuous enteral feeding exhibits signs of acute aspiration (such as coughing, dyspnea, and cyanosis), the practical nurse must follow a strict prioritization sequence. The absolute first priority is to stop the source of the aspiration by turning off the feeding pump; failing to do so allows further fluid to compromise the lungs. Second, the airway must be protected physically by turning the client to a lateral position, which uses gravity to drain secretions and prevent further inhalation. Third, the nurse suctions the oropharynx to actively clear the airway of aspirated formula. Fourth, with a clear airway established, supplemental oxygen is administered to treat the resulting hypoxia. Finally, after resolving the immediate life-threatening crisis at the bedside, the nurse reports the event to the registered nurse (RN) to coordinate ongoing evaluation, such as diagnostic imaging and provider notification.

Step-by-Step Solution

1
Stop the continuous enteral feeding pump.
The source of the aspiration is halted.
Prior to addressing the airway directly, the nurse must eliminate the active cause of the aspiration to prevent further respiratory compromise.
2
Turn the client to a lateral, side-lying position.
Secretions and formula are drained away from the trachea.
Positioning utilizes gravity to protect the airway and prevent further inhalation of gastric contents.
3
Suction the client's oropharynx.
The airway is cleared of visible formula and respiratory secretions.
Direct removal of aspirated material is necessary to restore airway patency once the client is positioned securely.
4
Administer supplemental oxygen as prescribed.
Oxygenation levels are improved, resolving cyanosis.
After securing a patent airway, treating the hypoxia caused by the aspiration event is the next physiological priority.
5
Report the acute event to the registered nurse (RN).
Further medical evaluation and interventions are initiated.
Once the client is stabilized from the immediate threat, the RN must be notified to coordinate a chest radiograph and healthcare provider notification.

Key Concept

Prioritization during acute aspiration: Stop the causative agent first, followed by Airway, Breathing, and Notification.
Question 136Question →

A practical nurse (PN) is admitting a client for an elective procedure at an ambulatory care center. As the PN prepares the paperwork, the client states, "I thought about it all night, and I absolutely refuse to go through with this today." In what order should the PN take the following actions? Arrange the actions in the correct chronological sequence.

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Answer

The correct sequence is to first stop the admission process, then clarify the client's intent, followed by notifying the provider and RN, and finally documenting the event.
A client has the right to withdraw informed consent at any time. The PN must immediately prioritize client safety by halting the procedure preparation. Next, the PN clarifies the statement to ensure accurate data collection. The PN then advocates for the client by notifying the provider, who is responsible for explaining the medical consequences of refusal. Finally, the PN documents the chronological events to maintain an accurate legal health record.

Step-by-Step Solution

1
Stop preparations and withhold medications.
Prevents unwanted and potentially irreversible interventions.
The client has a legal right to refuse treatment or withdraw consent at any time.
2
Clarify the client's decision.
Confirms the exact nature of the refusal.
Ensures accurate communication and verifies that the client is refusing the procedure, rather than simply expressing general anxiety.
3
Notify the provider and RN.
Alerts the surgical team to the change in status.
The healthcare provider must address the revoked consent, discuss alternatives with the client, and adjust the medical plan.
4
Document the event.
Creates a legal record of the encounter.
Fulfills legal and ethical nursing responsibilities regarding informed consent and client advocacy.

Key Concept

Client's Right to Revoke Consent
Question 137Question →

A practical nurse (PN) is reviewing new orders for a client and notes a prescription for an antibiotic. The client's medical record clearly indicates a severe anaphylactic allergy to this specific medication class. Arrange the actions the PN should take in the correct priority order.

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Answer

First, withhold the medication. Next, contact the prescribing provider. Then, escalate to the nursing supervisor if necessary. Finally, document the event in the client's record.
The correct order prioritizes immediate client safety, followed by communication, escalation, and finally documentation. The PN must first withhold the medication to prevent a life-threatening anaphylactic reaction. Next, the PN clarifies the order with the provider. If the provider refuses to change the order, the PN must ethically advocate for the client by following the chain of command and notifying the nursing supervisor. Finally, all actions and communications must be thoroughly documented in the medical record.

Step-by-Step Solution

1
Withhold the medication.
The client is protected from an anaphylactic reaction.
Immediate client safety is the highest priority in legal and ethical nursing practice.
2
Contact the healthcare provider.
The provider is informed of the severe allergy.
The provider must be notified immediately so they can clarify, change, or cancel the erroneous prescription.
3
Escalate to the nursing supervisor.
The situation is brought to nursing leadership for further intervention.
If the provider refuses to alter an unsafe order, the chain of command must be used to protect the client and the nurse's license.
4
Document the incident.
A formal, objective record of the event is created.
Accurate medical records are a legal requirement and must reflect all interventions and communications after the client is safe.

Key Concept

Chain of Command and Medication Safety in PN Scope of Practice
Question 138Question →

A practical nurse is gathering supplies to assist a healthcare provider with an aerosol-generating procedure for a client diagnosed with a severe acute respiratory pathogen. The nurse must apply full personal protective equipment (PPE) prior to entering the negative-pressure isolation room. Arrange the following steps for donning the required PPE in the correct chronological order.

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Answer

The correct sequence for donning PPE is: 1) Perform hand hygiene, 2) Put on the isolation gown, 3) Don the N95 respirator, 4) Place the face shield, and 5) Put on clean gloves.
Following the standardized Centers for Disease Control and Prevention (CDC) sequence for donning PPE ensures maximum protection and prevents gaps in the barrier. Hand hygiene always occurs first to prevent contaminating clean supplies. The gown provides foundational body coverage and is applied next. The N95 respirator must then be applied to ensure a proper, unobstructed seal directly against the face. This is followed by the face shield, which sits externally to protect the mask and eyes from splashes. Finally, gloves are applied last so they can be securely pulled over the gown cuffs, eliminating exposed skin at the wrists.

Step-by-Step Solution

1
Perform hand hygiene using an alcohol-based hand rub or antimicrobial soap and water.
Hands are decontaminated prior to handling clean PPE.
This reduces the risk of transferring transient flora to the protective equipment before it is worn.
2
Put on the fluid-resistant isolation gown and secure the ties at the neck and waist.
The torso, arms, and uniform are protected from contamination.
The gown is the largest piece of PPE and provides the primary barrier; securing it first establishes foundational body coverage.
3
Don the N95 respirator, securing the elastic headbands, and perform a seal check.
The respiratory tract is protected from airborne infectious particles.
The respirator requires precise strap placement around the head and a critical seal check, which is significantly easier to accomplish before bulky eye protection is applied.
4
Place the face shield over the eyes and face, adjusting the headband to fit securely.
The eyes and face are protected from aerosolized respiratory secretions and procedural splashes.
The face shield rests externally over the respirator, preventing contaminated fluids from saturating the mask material.
5
Put on clean gloves and pull the edges carefully over the wrists of the isolation gown.
The hands are protected and the gap between the gown and gloves is completely sealed.
Applying gloves as the final step allows the nurse to pull them over the gown cuffs, creating a continuous barrier without exposing the wrists.

Key Concept

Standard CDC Sequence for Donning Personal Protective Equipment (PPE)
Question 139Question →

A practical nurse enters a client's room and finds the client lying on the floor beside the bed. Arrange the following actions in the priority order the nurse should perform them, from first to last.

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Answer

The correct sequence is: Assess the client, call for assistance, obtain vital signs, assist the client to bed, notify the provider, and finally complete the incident report.
When a client falls, the nurse must prioritize actions based on the nursing process (assessment first) and Maslow's hierarchy of needs. The absolute first step is to assess the client for any immediate life-threatening injuries or changes in consciousness. Second, the nurse calls for help because moving the client or conducting further assessment requires additional personnel. Third, the nurse obtains vital signs to ensure hemodynamic stability. Fourth, once cleared of contraindicating injuries, the client is safely returned to bed. Fifth, the primary health care provider is notified of the incident and assessment findings to obtain further orders. Finally, the nurse completes the facility's incident report, as administrative tasks are always the lowest priority in an emergency or acute event.

Step-by-Step Solution

1
Determine the immediate priority using the nursing process.
Assessment always comes first.
Before acting, the nurse must know the client's status to avoid causing further harm.
2
Identify the next most critical action for safety.
Calling for assistance.
The nurse needs help to manage the situation, take vitals, and safely lift the client.
3
Sequence the remaining clinical actions.
Obtain vital signs, then move the client.
Checking vital signs confirms stability before physically moving the client back to bed.
4
Sequence the communication and administrative tasks.
Notify the provider, then complete the incident report.
Clinical communication for ongoing care takes precedence over administrative paperwork.

Key Concept

The nursing process and prioritization guide post-fall management, emphasizing immediate assessment and client safety over administrative tasks.
Question 140Question →

Prior to entering the negative-pressure isolation room of a client admitted with disseminated varicella-zoster virus, the healthcare provider must put on appropriate personal protective equipment (PPE). Arrange the following actions in the correct sequential order to safely prepare for patient care according to standard infection control guidelines.

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Answer

The correct sequence for donning personal protective equipment is: perform hand hygiene, don the isolation gown, apply the N95 respirator, place the eye protection, and finally put on the gloves.
Following the Centers for Disease Control and Prevention (CDC) guidelines, PPE must be donned in a sequence that minimizes contamination and ensures all barrier components function together effectively. Hand hygiene must occur first. The gown is applied to cover the body, followed by the respirator and eye protection to secure the face. Gloves are applied last specifically so they can extend over the gown cuffs, completing the physical barrier.

Step-by-Step Solution

1
Perform hand hygiene.
Removes baseline pathogens from the hands.
Prevents the contamination of clean PPE components during the application process.
2
Don the isolation gown.
Covers the torso and arms.
Provides the primary structural barrier against contact transmission before applying smaller facial items.
3
Apply the N95 respirator.
Secures respiratory protection.
Must be applied directly to the face and fit-checked before eye protection is added to guarantee an airtight seal.
4
Place the face shield or goggles.
Protects the ocular mucous membranes.
Fits appropriately over the upper portion of the respirator without interfering with the respirator's structural integrity.
5
Put on gloves.
Seals the gap at the wrists.
Applying gloves last allows the provider to stretch the glove cuffs entirely over the gown sleeves, preventing skin exposure.

Key Concept

Correct sequential donning of Personal Protective Equipment (PPE)
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