Examkin

All practice questions

2933 questions

All types2,933Multiple choice1,506Multiple select653Numeric68Matching70Ordering636
Question 1461Question →

A practical nurse (PN) is preparing to apply bilateral soft wrist restraints to a client to prevent the removal of essential medical devices. In what order should the PN perform the following actions? Arrange the steps in the correct chronological sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: Verify the prescription, explain the purpose, pad and apply the restraints, secure to the movable bed frame, and assess distal neurovascular status.
The proper application of restraints follows a strict legal and safety protocol. The nurse must first confirm the legal prescription. Next, psychosocial needs are addressed through explanation. Then, the physical application occurs with skin protection (padding). Once on the client, they must be safely anchored to a movable bed frame using a quick-release knot. Finally, the nurse must immediately evaluate for any circulatory or neurological impairment caused by the devices.

Step-by-Step Solution

1
Verify the healthcare provider's prescription.
Legal and facility requirements are met.
Restraints are a prescription intervention and cannot be applied without a valid provider order.
2
Explain the purpose of the restraints.
The client and family are informed.
Communication promotes cooperation and reduces psychosocial distress before physical contact is made.
3
Pad the wrists and apply the restraints.
The restraints are physically placed on the client.
Proper padding is necessary to prevent skin breakdown and friction injuries.
4
Secure the straps to the movable bed frame.
The restraints are safely anchored.
Attaching to the movable frame ensures the restraints move with the client when the bed is adjusted, preventing unintended tightening.
5
Assess distal pulses, skin color, and temperature.
Neurovascular status is confirmed to be intact.
Immediate assessment is required to ensure the restraints are not impeding blood flow or causing nerve damage.

Key Concept

Safe sequence for physical restraint application and monitoring.
Question 1462Question →

A licensed practical nurse (LPN) is prioritizing tasks for the upcoming shift on a medical-surgical unit. Which action is strictly within the LPN's scope of practice and legal responsibilities?

Show answer & explanation

Answer: Administering scheduled oral analgesics to a stable client with chronic lower back pain

Answer

Administering scheduled oral analgesics to a stable client with chronic lower back pain is the correct action.
The administration of routine oral medications to a stable client with a chronic condition falls safely and appropriately within the established scope of practice for a licensed practical nurse. This task involves predictable outcomes and does not require complex RN-level clinical judgment.

Step-by-Step Solution

1
Identify the basic scope of practice and legal boundaries for a licensed practical nurse.
The LPN cares for stable clients with predictable outcomes and safely administers standard therapies, such as oral medications.
Understanding scope of practice ensures safe and legal client care assignments.
2
Evaluate the distractors against LPN limitations regarding assessment, informed consent, and privacy.
Initial assessments, explaining surgical risks, and sharing private health information with unauthorized visitors all violate legal or scope-of-practice boundaries.
These actions either require the advanced judgment of an RN/provider or breach HIPAA regulations.
3
Select the option that reflects safe, routine care within the PN role.
Administering oral pain medication to a client with a chronic, stable condition is the correct choice.
This task does not require advanced initial assessment or complex clinical judgment.

Key Concept

Client Care Assignments and Collaboration
Question 1463Question →

A practical nurse (PN) is gathering focused data on a 78-year-old client residing in a long-term care facility. The assistive personnel (AP) reports that the client, who is typically calm, has suddenly begun pacing the halls, appearing disoriented, and crying out intermittently. Which of the following data collection techniques and actions are appropriate for the PN to implement? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Obtaining a midstream urine specimen to test for the presence of leukocytes or nitrites; Checking oxygen saturation using a pulse oximeter on a well-perfused digit; Measuring a complete set of vital signs, including blood pressure and core temperature

Answer

The correct actions are obtaining a midstream urine specimen, checking oxygen saturation, and measuring a complete set of vital signs.
Sudden-onset disorientation and agitation in an older adult strongly suggest acute delirium, which is frequently caused by physiological stressors like urinary tract infections, hypoxia, or systemic illness. Appropriate data collection involves immediately gathering physical data—such as vital signs, oxygen saturation, and a urinalysis—to identify the underlying physiological cause so it can be promptly reported to the registered nurse (RN) or provider.

Step-by-Step Solution

1
Differentiate between dementia and delirium based on the scenario.
The client's symptoms represent a sudden, acute change from their calm baseline, which is a hallmark indicator of delirium rather than chronic dementia.
Recognizing that sudden behavioral changes indicate an acute physiological issue dictates the need for immediate, targeted physical data collection.
2
Identify non-invasive data collection techniques to uncover physiological causes.
Techniques include assessing vital signs, pulse oximetry (for hypoxia), and urinalysis (for urinary tract infections).
Infection and hypoxia are two of the most common causes of acute delirium in the older adult population.
3
Eliminate inappropriate or unsafe data collection techniques.
Discarding options that suggest non-therapeutic communication ('why' questions), normalization of the symptom, or the premature use of physical restraints.
Safe and effective care requires therapeutic communication and adherence to legal guidelines regarding restrictive devices.

Key Concept

Data Collection Techniques for Acute Delirium in the Older Adult
Question 1464Question →

Management of a client diagnosed with an active Clostridioides difficile infection requires specific transmission-based precautions. Which interventions must be included in this client's care? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Perform hand hygiene using soap and water after removing personal protective equipment.; Don a disposable gown and clean gloves before entering the client's room.; Place the client in a private room with a dedicated commode or bathroom.

Answer

The correct interventions are placing the client in a private room with a dedicated commode, donning a gown and gloves upon entry, and washing hands with soap and water.
Clients with an active Clostridioides difficile infection require strict contact precautions to prevent the spread of the pathogen. This mandates placing the client in a private room with a dedicated bathroom, wearing a gown and gloves when entering the room, and performing hand hygiene specifically with soap and water, as alcohol-based sanitizers do not destroy C. difficile spores.

Step-by-Step Solution

1
Identify the specific pathogen and its mode of transmission.
Clostridioides difficile is transmitted via the fecal-oral route and direct contact with contaminated surfaces, and it produces hardy spores.
Understanding the pathogen dictates which specific isolation precautions are necessary.
2
Select the appropriate transmission-based precautions and hand hygiene method.
Contact precautions (gown, gloves, private room) and strict soap and water hand hygiene are selected.
Contact precautions prevent the physical transfer of the bacteria, while soap and water physically wash away alcohol-resistant spores.

Key Concept

Contact Precautions and Hand Hygiene for C. difficile
Question 1465Question →

An older adult client is resting in the preoperative holding area awaiting an elective joint replacement. The primary surgeon has just finished explaining the procedure to the client and departed the unit. The charge nurse assigns the practical nurse to secure the client's signature on the preoperative consent document. As the practical nurse hands a pen to the client, the client states, 'I am willing to sign this, but I still have absolutely no idea what the recovery time will be or what the specific risks are.' Which of the following is the most appropriate action for the practical nurse to take?

Show answer & explanation

Answer: Pause the signing process and ensure the surgeon is notified to return and clarify the procedure for the client.

Answer

The practical nurse must halt the signing process and contact the surgeon to return and answer the client's questions, as nurses cannot provide the primary medical explanation for a procedure.
The correct answer emphasizes that informed consent is a legal right requiring the client to fully understand the procedure, risks, and alternatives. The practical nurse acts as a client advocate and a witness to the signature, not as the primary source of medical information. If a client expresses confusion or a lack of understanding, the nurse must immediately halt the signing process and notify the primary healthcare provider to return and clarify the details.

Step-by-Step Solution

1
Analyze the client's statement regarding the consent form.
The client indicates a clear lack of understanding regarding the procedure's risks and the expected recovery time.
Informed consent is only legally valid if the client fully comprehends the procedure, risks, benefits, and alternatives before signing.
2
Determine the practical nurse's scope of practice regarding informed consent.
The nurse's role is strictly to act as an advocate and to witness that the signature is given voluntarily by a competent, informed client.
Practical nurses and registered nurses cannot provide the primary medical explanation or answer specific medical questions about the surgery itself; this is the provider's duty.
3
Formulate the safest and most appropriate advocacy intervention.
The nurse must protect the client's rights by refusing to obtain the signature at this time and notifying the primary healthcare provider to return.
Only the provider performing the procedure can adequately explain the risks and recovery to establish true informed consent.

Key Concept

Informed Consent and the Practical Nurse's Role
Question 1466Question →

A risk management committee at a healthcare facility is reviewing recent staff interventions to evaluate adherence to legal and ethical regulations. Which documented action by a practical nurse (PN) demonstrates appropriate compliance with established standards of practice?

Show answer & explanation

Answer: Advocating for a competent adult client's right to refuse a prescribed blood transfusion by promptly notifying the healthcare provider.

Answer

Advocating for a competent adult client's right to refuse a prescribed blood transfusion by promptly notifying the healthcare provider.
A competent adult has the ethical and legal right to refuse any medical treatment, including life-saving interventions such as blood transfusions. The practical nurse acts ethically by respecting client autonomy, advocating for their wishes, and immediately notifying the provider so the refusal and its potential consequences can be formally addressed and documented.

Step-by-Step Solution

1
Analyze the practical nurse's role regarding a client's right to refuse treatment.
Recognize that a competent adult has the ethical and legal right to refuse any medical intervention, including life-saving ones.
The principle of autonomy dictates that clients make their own healthcare decisions.
2
Determine the appropriate nursing intervention when a client refuses treatment.
The nurse must respect the decision, advocate for the client, and immediately notify the primary healthcare provider.
To ensure the provider can discuss the consequences of refusal with the client and properly document the interaction in the medical record.

Key Concept

Client Rights, Advocacy, and Scope of Practice
Question 1467Question →

A client is placed on concurrent airborne and contact precautions due to active pulmonary tuberculosis and a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which action by the practical nurse demonstrates adherence to safe infection control and scope of practice standards?

Show answer & explanation

Answer: Completes the prescribed wound care, removes the gown and gloves inside the client's room, and removes the N95 respirator in the hallway.

Answer

The nurse should complete the wound care, remove the gown and gloves inside the client's room, and remove the N95 respirator after stepping into the hallway.
For a client on concurrent contact and airborne precautions, the gown and gloves must be removed inside the room to prevent environmental contamination with MRSA. The N95 respirator must remain in place until the nurse has exited the negative-pressure room and the door is closed to protect against airborne tuberculosis transmission.

Step-by-Step Solution

1
Analyze the transmission-based precautions required for the client's diagnoses.
Tuberculosis requires airborne precautions (N95 respirator), and MRSA requires contact precautions (gown and gloves).
Identifying the specific precautions dictates the necessary personal protective equipment (PPE) and the correct sequence for removal.
2
Determine the appropriate location for removing each piece of PPE.
Contact PPE (gown and gloves) must be removed inside the room. Airborne PPE (N95 respirator) must be removed outside the room.
Removing contact PPE inside prevents the spread of pathogens to the hallway. Keeping the N95 on until outside the room protects the nurse from inhaling aerosolized droplet nuclei.
3
Evaluate the appropriateness of delegating the wound care task.
The nurse must perform the dressing change rather than delegating it.
An infected MRSA wound requires sterile or modified-sterile technique and ongoing assessment of the wound bed, which cannot be delegated to unlicensed assistive personnel (UAP).

Key Concept

Personal Protective Equipment (PPE) Doffing Sequence and Delegation Scope
Question 1468Question →

A client with dementia is pacing the unit hallway and repeatedly attempting to enter other clients' rooms. Which intervention should the practical nurse implement first to promote safety?

Show answer & explanation

Answer: Redirect the client to a quiet area and provide a simple, familiar activity.

Answer

Redirect the client to a quiet area and provide a simple, familiar activity.
The standard of nursing care dictates that the least restrictive measures must be attempted before any physical or chemical restraints are utilized. Redirecting a pacing client and providing a simple, familiar diversionary activity (such as folding towels) promotes safety, reduces agitation, and preserves the client's freedom and dignity.

Step-by-Step Solution

1
Identify the client's immediate safety risk and behavioral presentation.
The client is pacing and entering other rooms due to dementia, creating a potential safety and privacy concern.
Understanding the behavior guides the selection of the most appropriate and least restrictive intervention.
2
Recall the nursing guidelines regarding the use of restraints and safety devices.
Guidelines require implementing and documenting least restrictive alternatives before using any physical or chemical restraints.
Restraints pose significant physical and psychological risks and are legally restricted to be a measure of last resort.
3
Evaluate the given options to identify the least restrictive alternative.
Redirecting the client and providing a diversionary activity is the only option that does not act as a physical or chemical restraint.
Raising four side rails, administering sedatives, and applying a belt are all forms of restraint and violate the principle of least restrictive care when used as an initial step.

Key Concept

Implementing least restrictive alternatives before utilizing physical or chemical restraints.
Question 1469Question →

While managing care for assigned individuals on a telemetry step-down unit, a practical nurse encounters several situations requiring clinical decision-making. Which action by the practical nurse demonstrates appropriate scope of practice and interprofessional collaboration?

Show answer & explanation

Answer: Deferring the comprehensive admission assessment of a client newly transferred from critical care to the supervising registered nurse.

Answer

Deferring the comprehensive admission assessment of a client newly transferred from critical care to the supervising registered nurse.
The scope of practice dictates that comprehensive initial assessments, particularly for clients transitioning from a critical care environment, require the advanced clinical judgment of a registered nurse. Deferring this task ensures the client receives appropriate, safe care and demonstrates excellent interprofessional collaboration.

Step-by-Step Solution

1
Analyze the role of the practical nurse regarding patient assessments.
The practical nurse is legally permitted to gather data and perform focused assessments on stable clients with predictable outcomes.
Recognizing foundational scope boundaries is essential for safe practice and legal compliance.
2
Evaluate the acuity and needs of a client transferring from critical care.
A newly transferred client from an intensive care environment requires a comprehensive admission assessment to establish a new clinical baseline.
Comprehensive assessments for complex or potentially unstable clients fall strictly within the registered nurse's scope of practice.
3
Determine the appropriate collaborative action for the practical nurse.
The practical nurse must hand off or defer this admission assessment to the registered nurse.
Delegation up the chain of command ensures the client receives the required level of care and maintains patient safety.

Key Concept

Practical Nurse Scope of Practice in Assessment and Delegation
Question 1470Question →

While completing client rounds in a long-term care facility, a practical nurse (PN) observes an assistive personnel (AP) attempting to increase the flow rate on a client's continuous enteral feeding pump. Arrange the following actions the PN should take in the correct chronological order of priority.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence prioritizes immediate client safety, physiological assessment, equipment correction, staff education, and administrative escalation.
In any clinical situation where an unauthorized or unsafe action is observed, the nursing process dictates a specific priority hierarchy. The nurse must first intervene directly to stop the action and prevent harm. Immediately following, the nurse must perform data collection on the client to identify if any injury has already occurred. Once the client is deemed safe, the therapeutic environment is restored (verifying and resetting the pump). Only after client safety is fully secured does the nurse address the interpersonal and administrative tasks of educating the personnel and reporting the breach to the supervising registered nurse.

Step-by-Step Solution

1
Stop the unsafe action.
The AP ceases altering the enteral feeding pump.
Halting the action immediately prevents further potential harm to the client.
2
Collect client data.
The client's physiological status is determined.
Assessing the client identifies if any adverse effects, such as fluid overload, nausea, or aspiration, have already occurred.
3
Restore prescribed settings.
The enteral feeding continues at the correct rate.
Correcting the equipment ensures the client receives the precise nutritional therapy ordered by the healthcare provider.
4
Educate the assistive personnel.
The AP understands their scope limitations.
Immediate feedback prevents future occurrences and clarifies that regulating tube feedings requires nursing judgment and cannot be delegated.
5
Report the incident.
The supervising RN is informed.
Escalating the issue ensures appropriate facility protocols, documentation, and further disciplinary or educational actions are managed by administration.

Key Concept

Prioritization of Care and Delegation Boundaries
Question 1471Question →

An oriented, competent adult client with end-stage renal disease informs the clinical team of their decision to permanently discontinue hemodialysis. Later, the client's adult child confronts the practical nurse (PN) in a busy unit hallway, stating, "My parent is not thinking clearly! You must go in there, explain what will happen without dialysis, and make them sign the consent for tomorrow's treatment." Which action by the PN represents the most appropriate response?

Show answer & explanation

Answer: Guide the family member to a private area, affirm the competent client's right to decline medical interventions, and notify the registered nurse.

Answer

The most appropriate response is to guide the family member to a private area, affirm the competent client's right to decline medical interventions, and notify the registered nurse.
The correct response prioritizes client advocacy by upholding the competent client's right to autonomy and self-determination. By moving the conversation to a private area, the practical nurse protects the client's confidentiality. Notifying the registered nurse ensures the interdisciplinary team is appropriately engaged to handle the ethical conflict and family distress.

Step-by-Step Solution

1
Analyze the client's legal rights regarding the refusal of care.
The client is documented as competent and therefore has the legal right to refuse hemodialysis.
Competent adults possess the legal right of self-determination and autonomy in all medical decisions, regardless of family wishes.
2
Evaluate the environmental and confidentiality factors of the interaction.
The conversation is occurring in a busy hallway, which poses a risk to patient privacy.
Under HIPAA regulations, discussing patient care or family conflicts in a public space risks an unintentional confidentiality breach; the conversation must be relocated.
3
Determine the practical nurse's scope of practice in resolving the family's demand.
The PN must advocate for the client's decision and report the conflict to the RN, but cannot formally obtain consent or perform comprehensive cognitive assessments.
Scope of practice limits the PN to reinforcing education and performing focused assessments. Complex ethical conflicts and primary procedural education must be escalated to the RN and provider.

Key Concept

Client Autonomy, Confidentiality, and PN Scope of Practice
Estimated Time:1m 30s
Question 1472Question →

After providing care for a client diagnosed with active pulmonary tuberculosis in a negative-pressure isolation room, a nurse prepares to remove personal protective equipment (PPE). The nurse is currently wearing clean gloves, an isolation gown, a face shield, and a particulate respirator. Which action demonstrates the correct procedure for removing the respirator?

Show answer & explanation

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

Answer

Remove the respirator outside the client's room after exiting and closing the door.
For clients on airborne precautions, such as those with active pulmonary tuberculosis, the particulate respirator must remain in place until the nurse has completely exited the negative-pressure room and securely closed the door. This sequence ensures continuous respiratory protection against infectious airborne particles that remain suspended in the room's air environment.

Step-by-Step Solution

1
Identify the type of transmission-based precautions required for the client's diagnosis.
Active pulmonary tuberculosis requires airborne precautions.
Tuberculosis is transmitted via small airborne droplet nuclei that can remain suspended in the air for extended periods.
2
Recall the required personal protective equipment (PPE) and environmental controls for airborne precautions.
Care requires a negative-pressure isolation room and a particulate respirator, along with standard precautions (gown, gloves, face shield as needed).
These specific controls prevent the inhalation and spread of suspended infectious particles.
3
Determine the correct sequence and location for doffing the particulate respirator.
The respirator must be removed last, completely outside the client's room, after the door has been closed.
Removing the respirator inside the room or before the door is shut would instantly expose the nurse to the airborne pathogens still circulating in the client's room.

Key Concept

Personal protective equipment (PPE) doffing sequence for airborne precautions
Question 1473Question →

An acute care unit is managing the discharge preparation for a client newly diagnosed with type 1 diabetes mellitus. Various healthcare professionals are collaborating to ensure the client is ready for a safe transition home. Based on legal scopes of practice and delegation guidelines, match each clinical task with the most appropriate healthcare team member.

Click a left item, then click its matching right item

Items

Providing in-depth medical nutrition counseling on advanced carbohydrate counting.
Recording the percentage of the dietary tray consumed and assisting with menu completion.
Developing the initial educational plan regarding insulin action and recognizing signs of hypoglycemia.
Reinforcing the established teaching plan on proper subcutaneous injection site rotation.

Matches

Show answer & explanation

Answer

Developing the initial educational plan maps to the Registered Nurse (RN). Reinforcing the established teaching plan maps to the Practical Nurse (PN). Providing in-depth medical nutrition counseling maps to the Registered Dietitian (RD). Recording the percentage of the dietary tray consumed maps to Assistive Personnel (AP).
Safe and effective care delegation relies on understanding the legal scopes of practice for each team member. The Registered Nurse (RN) is responsible for all initial assessments, care plan formulation, and primary client education. The Practical Nurse (PN) may safely reinforce teaching that the RN has already established and perform standard nursing interventions. The Registered Dietitian (RD) is the appropriate interprofessional collaborator for specialized, complex nutritional counseling. Finally, Assistive Personnel (AP) are assigned routine, standard tasks with predictable outcomes, such as assisting with basic daily activities and recording intake.

Step-by-Step Solution

1
Analyze the task requiring initial education and care plan development.
This task must be assigned to the Registered Nurse (RN).
The RN is legally responsible for initial comprehensive assessments and formulating the primary teaching plan.
2
Analyze the task involving the reinforcement of an established teaching plan.
This task should be assigned to the Practical Nurse (PN).
The PN scope of practice permits reinforcing education that has already been initiated by the RN.
3
Analyze the task requiring in-depth medical nutrition counseling.
This task is referred to the Registered Dietitian (RD).
The RD is the interprofessional team member with specialized training to provide advanced medical nutrition therapy.
4
Analyze the task involving recording intake and assisting with menu completion.
This task is delegated to Assistive Personnel (AP).
APs are safely assigned routine, standard tasks with predictable outcomes that do not require nursing judgment.

Key Concept

Interprofessional collaboration and delegation based on legal scopes of practice.
Question 1474Question →

A newly admitted client has a draining leg wound that recently cultured positive for methicillin-resistant Staphylococcus aureus (MRSA). Which personal protective equipment (PPE) must the practical nurse don before entering the client's room?

Show answer & explanation

Answer: A clean gown and gloves

Answer

A clean gown and gloves
Methicillin-resistant Staphylococcus aureus (MRSA) is an organism transmitted via direct physical contact with the client or indirect contact with contaminated environmental surfaces. To prevent cross-contamination and healthcare-associated infections, contact precautions are strictly required. The CDC guidelines for contact precautions mandate that healthcare workers don a clean isolation gown and gloves before entering the client's room.

Step-by-Step Solution

1
Identify the pathogen and its specific mode of transmission.
Methicillin-resistant Staphylococcus aureus (MRSA) is a multidrug-resistant organism that is transmitted primarily through direct and indirect physical contact.
Understanding the transmission route is necessary to select the appropriate category of isolation precautions.
2
Determine the CDC-recommended precautions for the identified transmission route.
Contact precautions must be implemented for this client.
Standard protocols require contact precautions for all clients with known or suspected infections from epidemiologically important microorganisms spread by direct or indirect contact.
3
Select the required Personal Protective Equipment (PPE) for contact precautions.
The nurse must don a clean gown and gloves before entering the client's room.
The gown protects the uniform from contamination, and the gloves protect the hands when touching the client or potentially contaminated environmental surfaces.

Key Concept

Personal Protective Equipment Selection for Contact Precautions
Question 1475Question →

During the night shift, a 75-year-old client who is two days postoperative following a hip arthroplasty suddenly becomes highly agitated and attempts to climb over the side rails. The unlicensed assistive personnel (UAP) recommends applying a vest restraint to prevent a fall. Which action should the practical nurse (PN) take first?

Show answer & explanation

Answer: Assign a staff member to remain in the room with the client while gathering data on potential reversible causes of the agitation.

Answer

The practical nurse should first implement a less restrictive alternative, such as assigning a staff member for one-to-one observation, while collecting data to identify potential reversible causes of the sudden agitation.
The correct approach requires the implementation of least restrictive alternatives, such as one-to-one observation (a sitter), before considering physical restraints. Additionally, gathering focused data on potential underlying physiological causes (e.g., hypoxia, pain, infection) is within the PN scope of practice and is essential for addressing the root cause of acute delirium.

Step-by-Step Solution

1
Evaluate the clinical scenario and the UAP's recommendation.
The client is experiencing sudden, severe agitation and is at high risk for a fall, prompting a suggestion for physical restraints.
Immediate safety must be prioritized, but interventions must comply with strict legal and ethical restraint guidelines.
2
Apply the principles of least restrictive interventions.
Physical restraints cannot be applied simply because a client is agitated. Less restrictive alternatives must be attempted and documented first.
Restraints pose significant risks to client safety and dignity, and are legally mandated to be a measure of last resort.
3
Determine the appropriate nursing intervention within the PN scope of practice.
The PN can delegate a sitter for continuous observation and gather data (e.g., checking oxygen saturation, vital signs, or pain levels) to identify the cause of delirium.
Providing a sitter ensures immediate safety without a restraint. Gathering focused data is within the PN scope, whereas performing a comprehensive initial diagnostic assessment is not.

Key Concept

Least Restrictive Restraint Alternatives and PN Scope of Practice
Question 1476Question →

A practical nurse is assisting with the admission of a client who has just arrived on the surgical unit following a right total hip arthroplasty. Which actions should the nurse take to prevent client injury and clinical errors? (Select all that apply.)

Select all that apply

Show answer & explanation

Answer: Place an abduction pillow between the client's lower extremities.; Verify the client's identity using two distinct identifiers before administering intravenous fluids.; Keep the client's bed in the lowest locked position with the call light within reach.

Answer

The correct actions are placing an abduction pillow between the legs, verifying identity with two identifiers, and keeping the bed in the lowest locked position with the call light in reach.
The correct actions demonstrate comprehensive injury and error prevention for a postoperative client. Maintaining the bed in the lowest locked position with the call bell in reach minimizes fall risk. Using an abduction pillow maintains proper hip alignment and prevents joint dislocation. Utilizing two distinct identifiers prior to initiating treatments or medications is a standard protocol to prevent clinical errors.

Step-by-Step Solution

1
Identify the client's postoperative risks.
The client is at risk for falls, hip dislocation, and clinical errors during the admission transition.
Understanding the specific risks dictates the appropriate preventive measures.
2
Select interventions that mitigate specific risks without causing harm.
Placing an abduction pillow, keeping the bed low, and verifying identifiers directly address these risks.
These actions align with evidence-based safety protocols for postoperative orthopedic clients.
3
Eliminate unsafe or out-of-scope actions.
Elevating the head of the bed 90 degrees, delegating the initial assessment, and applying unjustified restraints are identified as unsafe.
Avoiding contraindicated positioning, improper delegation, and unnecessary restraints protects the client from harm.

Key Concept

Postoperative Injury and Error Prevention
Question 1477Question →

A practical nurse (PN) is providing care for a group of clients on a busy medical-surgical unit. Which actions by the PN correctly uphold client rights, advocacy, and safety principles? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Ensuring the room door is closed and the privacy curtain is drawn before assisting a client with personal hygiene.; Verifying that the client has signed the informed consent document prior to administering preoperative sedation.; Providing a newly admitted client with a copy of the facility's Patient Bill of Rights and answering basic questions about its contents.

Answer

The correct actions are ensuring physical privacy during hygiene care, verifying signed consent before administering sedation, and providing the Patient Bill of Rights upon admission.
The practical nurse advocates for client rights by ensuring physical privacy during vulnerable moments, verifying that legal consent is documented before giving mind-altering medications, and informing clients of their rights upon admission. These actions demonstrate adherence to confidentiality, legal standards, and respect for client dignity.

Step-by-Step Solution

1
Evaluate each option against the Practical Nurse (PN) scope of practice and legal guidelines regarding client rights.
Actions protecting privacy, verifying informed consent, and educating on basic rights are within the PN scope and support client advocacy.
The PN must act as a client advocate while remaining strictly within their legal and professional scope of practice.
2
Identify actions that violate confidentiality, exceed scope of practice, or bypass safety protocols.
Explaining surgical risks, discussing care in public areas, and bypassing restraint alternatives are incorrect and unsafe actions.
These actions represent common clinical errors that compromise patient safety, privacy, and legal consent standards.

Key Concept

Client Rights and Advocacy
Question 1478Question →

Following an open reduction and internal fixation of the right femur, a 74-year-old client suddenly exhibits new-onset severe agitation. The client, who was previously oriented and cooperative, begins attempting to climb over the raised side rails and forcefully pulls off the continuous pulse oximeter. Which action should the practical nurse (PN) take first to prevent client injury?

Show answer & explanation

Answer: Remain at the bedside, activate the bed alarm system, and instruct an assistive personnel to notify the registered nurse (RN)

Answer

The priority action is to remain at the bedside, activate the bed alarm system, and instruct an assistive personnel to notify the registered nurse (RN).
Staying at the bedside and using a bed alarm provides immediate client safety through the least restrictive means. By delegating the task of notifying the RN to another staff member, the PN ensures that the acute change in condition is appropriately escalated for advanced assessment without leaving the client alone in a dangerous situation.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client is exhibiting sudden, new-onset agitation and attempting to get out of bed, indicating a high fall risk and a potential acute physiological complication (e.g., hypoxia, delirium).
Recognizing the difference between expected postoperative behavior and acute clinical deterioration is required to implement appropriate safety measures.
2
Identify the immediate safety needs.
The client requires continuous supervision to prevent a fall, meaning the PN must not leave the room.
Leaving an agitated, high-fall-risk client alone to seek help significantly increases the likelihood of a major injury.
3
Determine the least restrictive, within-scope intervention.
Activating a bed alarm and staying with the client provides immediate safety without using unauthorized restraints, while delegating the notification task to assistive personnel ensures the RN is alerted.
Client safety protocols dictate that less restrictive alternatives must be utilized before physical or chemical restraints, and acute changes must be assessed by the RN.

Key Concept

Accident, Error, and Injury Prevention: Least Restrictive Interventions and Scope of Practice
Question 1479Question →

A practical nurse (PN) accidentally drops a glass collection bottle containing a client's pleural fluid, which shatters and creates a biohazardous spill in a high-traffic unit hallway. Arrange the following actions in the correct priority order to safely manage this hazard.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first isolate the area, then don personal protective equipment (PPE), use a mechanical device to collect the broken glass, deposit the glass into a sharps container, and finally cover the remaining fluid with absorbent pads and disinfectant.
Managing a complex biohazardous spill involving broken glass requires a systematic, prioritized approach to safety. The immediate action is always to isolate the area to prevent injury or cross-contamination by others. Next, the nurse must protect themselves by donning appropriate PPE. Once protected, the physical sharps hazard (glass) must be removed using mechanical means (never by hand) to prevent percutaneous injury. The glass is immediately placed in a sharps container. Finally, once the sharps are cleared, the remaining liquid is absorbed and the area is chemically decontaminated.

Step-by-Step Solution

1
Isolate the immediate area and instruct clients and staff to avoid the spill location.
The spill perimeter is secured.
The absolute first priority in any acute hazard management scenario is securing the environment. This prevents other individuals from walking through the spill, which could result in falls, percutaneous injuries from unseen glass, or the tracking of bloodborne pathogens throughout the facility.
2
Don appropriate personal protective equipment (PPE), including gloves, a fluid-resistant gown, and a face shield.
The nurse is fully protected from biohazardous exposure.
Before physically interacting with the spill, the nurse must ensure their own safety by applying PPE to prevent mucosal or contact exposure to pleural fluid, which is a potentially infectious body fluid.
3
Use a mechanical device such as tongs or a disposable scoop to safely collect the shattered glass pieces.
The physical sharps hazard is safely collected without direct hand contact.
Occupational Safety and Health Administration (OSHA) standards explicitly dictate that contaminated broken glass must never be picked up by hand, even when wearing heavy-duty gloves. Mechanical devices are mandatory to prevent percutaneous exposure.
4
Deposit the collected glass fragments directly into a rigid, puncture-resistant sharps container.
The sharps hazard is permanently contained.
Broken glass must be placed immediately into a rigid, puncture-proof container to prevent downstream injuries to the nurse, other clients, or environmental services personnel.
5
Cover the remaining fluid with absorbent pads and saturate the area with an EPA-registered disinfectant.
The biohazardous fluid is absorbed and the floor is successfully decontaminated.
Only after the physical sharps hazard is fully removed should the nurse address the remaining biological liquid hazard by neutralizing it with absorbent materials and appropriate chemical disinfectants.

Key Concept

Biohazardous Spill and Sharps Management
Question 1480Question →

A practical nurse (PN) at a community pediatric clinic is collecting data on a toddler who presents with multiple bruises in various stages of healing. The caregiver's explanation of the injuries is inconsistent with the physical findings. Arrange the following actions in the order the PN should perform them to comply with legal and ethical standards.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence prioritizes immediate client safety, followed by objective data collection, utilization of the chain of command, fulfilling mandated reporting laws, and finally, comprehensive legal documentation.
In any scenario involving suspected abuse, the PN must first apply the nursing process and safety principles. Ensuring client safety is paramount (Step 1). Once safe, the PN collects objective data (Step 2) to have factual information. The PN then follows the chain of command (Step 3) before fulfilling the legal obligation of being a mandated reporter to the state (Step 4). Finally, documentation of all findings and actions completes the legal and ethical requirements (Step 5).

Step-by-Step Solution

1
Prioritize immediate client safety.
The child is placed in a secure environment within the clinic.
Client safety is the foundational step in any suspected abuse or emergency scenario.
2
Gather objective clinical data.
The PN accurately measures and describes the bruises.
Accurate physical details are required for an effective report and must be collected while the client is present.
3
Utilize the chain of command.
The supervising healthcare provider is informed of the situation.
Facility protocols require informing supervisors of critical safety or legal concerns immediately.
4
Fulfill legal mandated reporting obligations.
A report is filed with state child protective services.
Practical nurses are mandated by law to report suspected child abuse to authorities; this duty cannot be ignored.
5
Complete legal documentation in the electronic health record.
All physical findings and the agency report reference number are documented.
The medical record must legally reflect the objective evidence and the steps taken to protect the client.

Key Concept

Mandatory Reporting and Prioritization in Suspected Abuse
PreviousPage 74 / 147Next
All practice questions — NCLEX-PN | Examkin