Examkin

All practice questions

2933 questions

All types2,933Multiple choice1,506Multiple select653Numeric68Matching70Ordering636
Question 141Question →

A practical nurse (PN) is evaluating a client who is 6 hours postoperative following a total thyroidectomy. The client's current vital signs are: heart rate 114 beats/min, blood pressure 104/58 mm Hg, respiratory rate 18 breaths/min, and temperature 99.2°F (37.3°C). The morning laboratory results reveal a serum calcium level of 7.4 mg/dL (1.85 mmol/L). Which of the following actions should the PN take? (Select all that apply.)

Select all that apply

Show answer & explanation

Answer: Notify the registered nurse (RN) immediately regarding the client's vital signs and laboratory results.; Assess the client for the presence of Chvostek's sign or perioral numbness.; Ensure that emergency suction equipment and a tracheostomy tray are at the bedside.

Answer

The correct actions include notifying the RN immediately, assessing the client for signs of hypocalcemia (such as Chvostek's sign or numbness), and ensuring emergency airway equipment is kept at the bedside.
Following a total thyroidectomy, clients face immediate risks of hemorrhage, airway compromise, and hypocalcemia. The client's tachycardia and borderline hypotension may indicate early shock. The calcium level of 7.4 mg/dL is critically low. To reduce risk potential safely, the PN must escalate these findings to the RN immediately, assess for symptoms of tetany (such as Chvostek's sign), and ensure emergency airway equipment is physically present at the bedside.

Step-by-Step Solution

1
Analyze the client's postoperative status and identify surgical risks.
The client is 6 hours post-thyroidectomy, placing them at high risk for hemorrhage, airway obstruction, and hypocalcemia (due to potential parathyroid gland removal).
Understanding the specific risks of the procedure guides focused data collection and safety preparation.
2
Evaluate the current assessment data against normal parameters.
The heart rate of 114 beats/min and blood pressure of 104/58 mm Hg suggest compensatory mechanisms for hypovolemia. The serum calcium level of 7.4 mg/dL is critically below the normal range (9.0-10.5 mg/dL).
Recognizing subtle signs of shock and identifying critical lab values are essential components of risk potential reduction.
3
Determine appropriate interventions within the PN scope of practice.
The PN must secure the bedside with emergency equipment, assess for tetany, and escalate the findings to the RN. The PN must avoid RN-level tasks, such as administering IV push medications.
Operating strictly within legal and professional scope ensures safe, effective, and coordinated client care.

Key Concept

Following a thyroidectomy, reduction of risk potential requires vigilant monitoring for hypovolemic shock, airway compromise, and hypocalcemia, combined with immediate escalation of critical findings and adherence to the PN scope of practice.
Question 142Question →

During the morning shift on a surgical unit, a nurse is assisting a postoperative client with daily hygiene and comfort needs. Which actions represent appropriate care for this client? (Select all that apply)

Select all that apply

Show answer & explanation

Answer: Offer a back massage using lotion to promote relaxation.; Place the call light and personal items within easy reach of the client's unaffected side.; Assist the client with oral hygiene using a soft-bristled toothbrush after breakfast.

Answer

The appropriate actions are offering a back massage, keeping the call light within reach, and assisting with oral hygiene.
Appropriate basic care and comfort measures focus on promoting hygiene, ensuring a safe environment, and providing nonpharmacological relief. Assisting with oral care, offering a relaxing massage, and keeping essential items within reach directly fulfill these fundamental nursing responsibilities safely.

Step-by-Step Solution

1
Identify the primary goal of the clinical scenario.
The goal is to provide safe and effective basic hygiene and comfort care to a postoperative client.
Understanding the goal helps filter out actions that are unsafe, outside the scope of practice, or non-therapeutic.
2
Evaluate each intervention for safety, efficacy, and scope of practice.
Massages, oral care, and environmental safety (keeping the call light near) are safe basic care actions. Flat positioning, false reassurance, and delegating evaluation are incorrect.
Each nursing action must align with evidence-based comfort measures and legal delegation rules.

Key Concept

Basic comfort measures include hygiene, environmental safety, and nonpharmacological relaxation, while avoiding improper positioning or inappropriate delegation.
Question 143Question →

During morning rounds, a practical nurse evaluates a client admitted with a severe urinary tract infection. The client was fully oriented yesterday but is now highly agitated, picking at their clothing, and unable to recognize family members. Which action should the nurse take first?

Show answer & explanation

Answer: Measure the client's current vital signs and oxygen saturation

Answer

Measure the client's current vital signs and oxygen saturation
The correct answer addresses the immediate need to evaluate physiological stability. An acute change in mental status, such as sudden agitation and disorientation, is a primary indicator of a severe physiological complication like hypoxia, hypoglycemia, or sepsis. The practical nurse must immediately gather objective data (vital signs and oxygen saturation) to identify the underlying physiological cause before notifying the registered nurse or provider.

Step-by-Step Solution

1
Analyze the clinical scenario
The client has experienced a sudden, acute change in mental status (agitation and disorientation) compared to their baseline.
Recognizing a sudden change in condition is the first step in clinical judgment.
2
Determine the potential underlying cause
Acute confusion (delirium) in a client with an infection often indicates systemic compromise, such as hypoxia, sepsis, or fluid imbalance.
Linking the symptom to potential physiological complications guides prioritization.
3
Select the highest priority nursing action
Obtaining vital signs and oxygen saturation must be done immediately.
According to the nursing process and ABC prioritization, objective physiological data must be collected first to ensure airway, breathing, and circulation are stable before implementing other interventions.

Key Concept

Early recognition of acute physiological deterioration requires immediate data collection (vital signs and oxygenation) before implementing secondary interventions.
Estimated Time:45s
Question 144Question →

A practical nurse (PN) is planning care and medication administration for a group of assigned clients. Which of the following actions by the PN demonstrate safe pharmacological practice within the practical nursing scope of practice? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Identifying a client by asking them to state their name and date of birth while verifying it against the medication administration record.; Withholding a scheduled dose of oral digoxin for an adult client with an apical pulse of 54 beats/minute and notifying the supervising registered nurse.; Reinforcing the registered nurse's teaching about the importance of reporting dark, tarry stools to a client prescribed warfarin.

Answer

The correct actions are identifying the client using two identifiers, withholding digoxin for bradycardia and notifying the registered nurse, and reinforcing teaching about bleeding precautions for a client on warfarin.
The practical nurse demonstrates safe practice by always using two client identifiers before medication administration, which is a fundamental safety right. Withholding digoxin for an adult with an apical pulse below 60 beats/minute and notifying the registered nurse is the correct clinical protocol to prevent cardiac toxicity. Additionally, reinforcing previous teaching provided by the registered nurse regarding medication side effects, such as signs of internal bleeding with warfarin, is directly within the practical nursing scope of practice.

Step-by-Step Solution

1
Analyze each action to determine if it falls within the practical nurse (PN) scope of practice.
The PN scope of practice includes administering oral medications, reinforcing teaching, and reporting abnormal findings, but generally excludes administering high-risk IV push medications.
Ensuring actions are within scope prevents legal violations and protects client safety.
2
Evaluate the medication safety principles and clinical judgment for each scenario.
Identifying clients with two identifiers, checking an apical pulse before digoxin, and recognizing bleeding risks with warfarin are standard safe practices.
These actions adhere to the rights of medication administration and prevent severe adverse outcomes.
3
Identify contraindicated or unsafe pharmacological actions.
Giving live vaccines to immunosuppressed clients and estimating pediatric weight-based doses are highly unsafe practices.
These actions ignore critical contraindications and mathematical safety standards, potentially causing fatal harm.

Key Concept

Safe Medication Administration and Practical Nurse Scope of Practice
Question 145Question →

A client is 48 hours postpartum following a primary cesarean birth. The practical nurse is assisting with data collection prior to the client's planned discharge. Which finding is the highest priority to report to the registered nurse?

Show answer & explanation

Answer: Unilateral calf swelling accompanied by localized redness and warmth

Answer

Unilateral calf swelling accompanied by localized redness and warmth
Pregnancy and the postpartum period are hypercoagulable states, and a cesarean birth further increases the risk for deep vein thrombosis (DVT). Unilateral calf swelling, redness, and warmth are classic clinical indicators of a DVT. Because a DVT can dislodge and cause a life-threatening pulmonary embolism (a circulatory emergency), this finding is the highest priority and must be reported to the registered nurse immediately.

Step-by-Step Solution

1
Analyze the client's timeframe and surgical history.
The client is 48 hours postpartum after a cesarean birth, placing her at an increased physiological risk for hypercoagulability and thromboembolic events.
Pregnancy and surgery both increase the risk of deep vein thrombosis (DVT).
2
Evaluate the clinical data in each option to distinguish normal adaptations from complications.
Pinkish lochia, mild cramping during breastfeeding, and a low-grade temperature are all expected physiological findings at this stage.
Recognizing normal postpartum healing prevents unnecessary alarm and allows the nurse to focus on true abnormalities.
3
Identify the finding that represents a threat to life or safety (ABC prioritization).
Unilateral calf swelling with redness and warmth is a sign of a circulatory complication (DVT) that could lead to a pulmonary embolism.
Circulatory emergencies take priority over expected normal findings and expected procedural pain.

Key Concept

Postpartum Complications: Recognizing Deep Vein Thrombosis (DVT)
Estimated Time:1m 0s
Question 146Question →

While working in a skilled nursing facility, a practical nurse receives a report from an assistive personnel regarding an older adult resident with a healing stage 3 sacral pressure injury. The resident is described as unusually difficult to awaken and suddenly disoriented to place. Current vital signs reveal a blood pressure of 94/58 mmHg, a heart rate of 114 beats/min, a respiratory rate of 24 breaths/min, and a tympanic temperature of 96.2°F (35.7°C). Based on these assessment data, what is the most appropriate initial action for the practical nurse to take?

Show answer & explanation

Answer: Communicate the clinical changes to the supervising registered nurse for urgent evaluation.

Answer

Communicate the clinical changes to the supervising registered nurse for urgent evaluation.
The client's presentation of sudden confusion, hypothermia, tachycardia, and borderline hypotension strongly suggests the onset of sepsis, likely originating from the sacral pressure injury. In older adults, infection often presents atypically with hypothermia and altered mental status rather than a fever. Because these vital signs indicate impending hemodynamic instability and distributive shock, the practical nurse must prioritize communicating these changes to the supervising registered nurse immediately to initiate life-saving interventions.

Step-by-Step Solution

1
Analyze the client's current clinical presentation and vital signs.
The resident exhibits sudden confusion, hypothermia (96.2°F), tachycardia (114 beats/min), tachypnea (24 breaths/min), and borderline hypotension (94/58 mmHg).
Identifying abnormal data is the first step in recognizing a change in client condition.
2
Correlate the physical findings with the client's medical history.
The presence of a stage 3 sacral pressure injury provides a high-risk source for systemic infection. The combined signs strongly suggest systemic inflammatory response syndrome (SIRS) or septic shock.
Older adults frequently present with atypical signs of infection, such as hypothermia and acute delirium, rather than classic high fevers.
3
Determine the priority nursing intervention within the practical nurse scope of practice.
The client is experiencing a life-threatening acute decompensation that requires advanced hemodynamic support and medical orders.
The practical nurse must recognize the instability and immediately escalate the findings to the supervising registered nurse or provider for urgent intervention.

Key Concept

Recognition of Sepsis and Shock in Older Adults
Estimated Time:1m 15s
Question 147Question →

A newly licensed practical nurse (PN) is reviewing safety protocols and scope of practice during clinical orientation on a progressive care unit. Which of the following actions indicate that the PN is correctly applying risk reduction principles? (Select all that apply)

Select all that apply

Show answer & explanation

Answer: Verifying a client's identity by checking the name and date of birth on the wristband before administering treatments.; Immediately escalating a newly reported serum potassium level of 2.8 mEq/L to the supervising registered nurse (RN).; Withholding a scheduled dose of oral digoxin and notifying the RN when the client's apical pulse is 52 beats/minute.

Answer

The correct actions include verifying client identity using two identifiers, immediately escalating critical potassium levels, and withholding digoxin for bradycardia while notifying the RN.
Verifying two client identifiers directly reduces the risk of medication errors. Escalating a critical potassium level of 2.8 mEq/L ensures prompt treatment of hypokalemia, preventing cardiac arrhythmias. Withholding digoxin when the apical pulse is less than 60 beats/minute is a standard risk reduction action to prevent medication toxicity.

Step-by-Step Solution

1
Evaluate each nursing action against the established practical nurse (PN) scope of practice and basic safety protocols.
Identify safe versus unsafe actions in clinical scenarios.
Risk reduction requires acting within scope and prioritizing immediate client safety over routine tasks.
2
Identify the correct applications of risk reduction.
Verifying identity, escalating a critical hypokalemia lab (2.8 mEq/L), and holding digoxin for a heart rate below 60 beats/minute are identified as correct safety measures.
These actions directly prevent medication errors and address physiological deterioration.
3
Identify and exclude unsafe actions.
Ignoring hypotensive tachycardia, giving IV push medications, and delaying critical lab reporting are excluded.
These represent severe breaches of safety principles and fall outside the appropriate LPN scope.

Key Concept

Reduction of Risk Potential through adherence to safety protocols, timely escalation of critical findings, and operating within the LPN scope of practice.
Question 148Question →

During bedside handoff, a practical nurse assumes care for a client who underwent an open bowel resection 4 hours ago. The client is receiving continuous intravenous fluids. Upon initial assessment, the client reports incisional pain of 7 on a 0 to 10 scale. The electronic health record displays the following recent vital signs: blood pressure 98/62 mm Hg, heart rate 118/min, respirations 20/min, and oxygen saturation 95% on room air.

Which of the following actions should the practical nurse take? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Alert the supervising registered nurse about the current heart rate and blood pressure values.; Examine the client's surgical dressing and the dependent linens for evidence of active hemorrhage.; Utilize the electronic barcode scanner to match the client's wristband with the medication packaging before giving oral antibiotics.

Answer

The correct actions are to alert the registered nurse about the vital signs, examine the dressing and linens for hemorrhage, and utilize the barcode scanner for medication administration.
The correct actions prioritize client safety by recognizing and responding to early signs of hypovolemic shock. A heart rate of 118/min with a blood pressure of 98/62 mm Hg warrants immediate escalation to the registered nurse and targeted data collection for bleeding (inspecting the dressing and dependent linens). Additionally, using barcode scanning for all medication administration is a fundamental risk-reduction strategy.

Step-by-Step Solution

1
Analyze the client's postoperative vital signs.
The heart rate of 118/min and blood pressure of 98/62 mm Hg indicate tachycardia and borderline hypotension.
These findings are early compensatory mechanisms for hypovolemia or active hemorrhage, which require immediate clinical attention rather than routine monitoring.
2
Determine the appropriate practical nursing interventions for the identified risk.
The practical nurse must escalate the findings to the registered nurse and gather focused data by checking the surgical site and dependent linens for bleeding.
Timely communication and targeted data collection reduce the risk of severe complications from delayed treatment.
3
Evaluate other standard care actions against the practical nurse scope of practice and safety protocols.
Intravenous push medications must be avoided, knee flexion must be minimized to prevent deep vein thrombosis, and barcode scanning must be used for oral medications.
Adhering strictly to the legal scope of practice and evidence-based safety guidelines minimizes the potential for adverse events.

Key Concept

Early recognition of postoperative complications and adherence to the practical nurse scope of practice are essential to risk reduction.
Question 149Question →

A newly admitted client on a dual-diagnosis unit is experiencing acute sensory alterations following recent illicit substance ingestion. The client abruptly backs into a corner, tightly clenches both fists, and shouts, "The snakes are coming out of the air vents to bite me!" Which action should the practical nurse take first?

Show answer & explanation

Answer: Maintain a safe physical distance and call for the facility's designated crisis response personnel.

Answer

Maintain a safe physical distance and call for the facility's designated crisis response personnel.
The primary nursing priority during an active behavioral crisis with escalating agitation is to ensure the safety of the client, staff, and others. Maintaining a safe physical distance prevents sudden injury from an unpredictable client, while activating the crisis response team ensures adequate personnel are present to manage the situation safely.

Step-by-Step Solution

1
Analyze the client's behavior and physiological cues.
The client is experiencing a substance-induced hallucination, clenching fists, and backing into a corner.
Identifying signs of escalating agitation and potential violence is essential for determining the appropriate intervention.
2
Determine the priority need based on the nursing process.
The immediate priority is the physical safety of the client and the nursing staff.
When a client is in an active behavioral crisis, environmental and personal safety supersedes therapeutic communication or routine assessment.
3
Select the most appropriate, least restrictive safety intervention.
Maintaining distance and calling for help is chosen over logical reasoning or immediate restraints.
Distance protects the nurse from sudden physical outbursts, and additional trained staff can help safely manage the situation without prematurely resorting to physical restraints.

Key Concept

De-escalation and safety management for substance-induced acute agitation.
Question 150Question →

A practical nurse is participating in the care of a client admitted with a suspected upper gastrointestinal bleed. Which action by the nurse demonstrates the appropriate application of risk reduction principles?

Show answer & explanation

Answer: Promptly notifying the registered nurse about a client blood pressure of 100/64 mm Hg and a heart rate of 108 beats/min

Answer

Promptly notifying the registered nurse about a client blood pressure of 100/64 mm Hg and a heart rate of 108 beats/min.
The client is at high risk for hypovolemic shock due to a gastrointestinal bleed. A slight drop in blood pressure paired with a rising heart rate (tachycardia) are early, subtle indicators that the body is attempting to compensate for blood loss. Prompt escalation to the registered nurse allows for early intervention, directly reducing the risk of severe cardiovascular collapse.

Step-by-Step Solution

1
Analyze the clinical scenario and the client's primary risk factor.
The client has a suspected upper gastrointestinal bleed, placing them at high risk for hypovolemia and hemorrhagic shock.
Understanding the client's diagnosis highlights the need to monitor for signs of active bleeding and impaired perfusion.
2
Evaluate each nursing action against safety guidelines and the practical nurse scope of practice.
Delaying critical lab reports, bypassing proper medication identifiers, and accepting IV push delegations are unsafe practices. Escalating borderline vital signs is a safe and required practice.
Risk reduction requires identifying early signs of deterioration and adhering strictly to safety protocols and scope of practice.
3
Select the action that best mitigates risk for the client.
Reporting the borderline low blood pressure and elevated heart rate directly addresses the immediate risk of shock.
Tachycardia and borderline hypotension are often the first physiological signs of significant blood loss.

Key Concept

Early recognition and escalation of subtle signs of shock (borderline vital signs) in clients with active bleeding risk.
Question 151Question →

During an afternoon shift at an inpatient care facility, a 68-year-old client with a documented history of severe alcohol use disorder begins experiencing visual hallucinations, coarse hand tremors, and profound diaphoresis. The client is pacing the room and shouting about insects crawling on the walls. Which actions should the practical nurse (PN) take? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Remain with the client to provide continuous observation and maintain a safe environment.; Notify the registered nurse (RN) immediately regarding the client's acute physiological and behavioral changes.; Ensure the room is well-lit to minimize shadows and reduce the risk of sensory misinterpretation.

Answer

The correct actions are to remain with the client, notify the registered nurse (RN) immediately, and ensure the room is well-lit.
The correct actions prioritize immediate client safety and the appropriate escalation of care. Remaining with the client provides a safe presence and allows for continuous monitoring during a medical emergency. Notifying the RN is essential because alcohol withdrawal delirium is life-threatening and requires urgent pharmacological intervention that the RN or provider must initiate. Finally, keeping the room well-lit reduces shadows, which helps decrease visual misinterpretations and terrifying hallucinations.

Step-by-Step Solution

1
Identify the client's clinical presentation and underlying risk factors.
The client has a history of severe alcohol use disorder and is exhibiting hallucinations, tremors, and diaphoresis, which are classic signs of alcohol withdrawal delirium (delirium tremens).
Recognizing acute alcohol withdrawal is critical because it is a life-threatening medical emergency requiring immediate intervention.
2
Determine the priority nursing interventions for a client in acute withdrawal.
The PN must prioritize client safety, physiological stability, and prompt communication with the supervising healthcare team.
The client requires immediate medical management and a safe, modified environment to prevent self-harm or accidental injury during hallucinations.
3
Evaluate the proposed actions against safe PN practice and therapeutic communication standards.
Staying with the client, notifying the RN, and optimizing room lighting are appropriate and safe. Asking "why", using premature restraints, or dismissing the acute confusion as age-related are unsafe and non-therapeutic.
Interventions must fall within the PN scope of practice, prioritize the least restrictive safety measures, and avoid communication blocks.

Key Concept

Nursing management and safety priorities for acute alcohol withdrawal (delirium tremens).
Question 152Question →

An adult client on a medical-surgical unit is due for a scheduled dose of oral amlodipine. When the practical nurse attempts to scan the client's identification wristband, the barcode is unreadable due to water damage. Which action is the most appropriate method for the practical nurse to verify the client's identity?

Show answer & explanation

Answer: Ask the client to state their full name and date of birth while comparing the response to the medication administration record.

Answer

The practical nurse should ask the client to explicitly state their full name and date of birth, comparing these details to the medication administration record.
When automated safety systems like barcode scanners fail, the nurse must manually verify the client's identity using two approved identifiers (typically full name and date of birth). Asking the client to state this information requires active participation, ensuring accurate identification and fulfilling the 'right client' parameter of safe medication administration.

Step-by-Step Solution

1
Recognize that barcode scanning is a primary safety tool, but manual verification is required when technology fails.
The nurse must actively identify the client using alternative, approved methods.
Bypassing identification protocols due to equipment failure is a leading cause of medication errors.
2
Identify the most reliable manual method for patient verification according to standard safety guidelines.
Asking the client to state two acceptable identifiers (such as name and date of birth) provides active confirmation.
Active confirmation prevents false identification that can occur if a client simply nods or answers 'yes' to a closed-ended question.

Key Concept

Medication Safety and Patient Identification
Question 153Question →

While working on a medical-surgical unit, a practical nurse evaluates an older adult client who is two days postoperative following percutaneous endoscopic gastrostomy (PEG) tube placement. The client is receiving continuous enteral nutrition. Suddenly, the individual becomes restless, complains of severe nausea, and demonstrates tachypnea. Which interventions should the practical nurse implement? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Stop the enteral feeding infusion pump immediately.; Raise the head of the bed to an angle of 45 degrees or higher.; Obtain a current set of vital signs and oxygen saturation levels.

Answer

The correct actions are to stop the enteral feeding infusion pump, raise the head of the bed to 45 degrees or higher, and obtain a current set of vital signs.
The client's presentation of restlessness, nausea, and tachypnea strongly suggests aspiration, hypoxia, or feeding intolerance. The immediate nursing priorities are to protect the airway by halting the continuous enteral feeding and elevating the head of the bed to maximize chest expansion. Collecting vital signs is a safe, within-scope action that provides critical objective data for the RN or provider.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client is showing sudden signs of respiratory distress (tachypnea), gastrointestinal distress (severe nausea), and hypoxia (restlessness) while receiving continuous enteral feeding.
Recognizing the combination of these symptoms indicates a high risk for aspiration or acute feeding intolerance.
2
Identify the immediate priority interventions.
The most urgent actions are related to airway protection and breathing (ABCs).
Stopping the source of potential aspiration (the feeding pump) and using gravity to protect the airway and expand the lungs (elevating the head of the bed) address the most life-threatening risks.
3
Determine appropriate data collection and scope of practice constraints.
Gathering vital signs is within the practical nurse scope and provides necessary data; administering IVP medications is out of scope.
The practical nurse must collect objective data to report to the RN while safely avoiding delegated tasks that exceed licensure bounds.

Key Concept

Prioritizing airway protection, recognizing acute status changes, and adhering to the legal scope of practice during basic care and enteral feeding management.
Estimated Time:2m 0s
Question 154Question →

A practical nurse is caring for a client who had a cardiac catheterization through the right femoral artery 6 hours ago. The client reports a new, continuous lower backache. During data collection, the nurse notes the right pedal pulse is palpable but weaker than the left, a heart rate of 104 beats per minute, and a blood pressure of 102/60 mm Hg. What is the priority action for the practical nurse?

Show answer & explanation

Answer: Alert the registered nurse immediately about the client's changing condition.

Answer

The correct action is to alert the registered nurse immediately about the client's changing condition.
The client is exhibiting classic signs of retroperitoneal bleeding, a severe complication of a femoral artery cardiac catheterization. The new onset of continuous backache occurs because blood is accumulating in the retroperitoneal space, causing pressure. The diminished distal pulse and borderline vital signs (tachycardia and mild hypotension) indicate early hemorrhagic shock. The practical nurse must immediately escalate this critical circulatory emergency to the registered nurse for rapid medical intervention.

Step-by-Step Solution

1
Analyze the client's procedure and current symptoms.
The client had a right femoral cardiac catheterization and now presents with new back pain, a weaker distal pulse, and borderline tachycardia and hypotension.
Identifying the combination of symptoms following this specific invasive procedure is crucial for recognizing early complications.
2
Correlate the clinical findings with potential postoperative complications.
These findings strongly indicate retroperitoneal bleeding.
Blood pooling in the retroperitoneal space causes referred back pain, while active volume loss leads to a compensatory increase in heart rate and a drop in blood pressure.
3
Determine the priority nursing action based on the practical nurse scope of practice.
The nurse must immediately escalate the findings to the registered nurse or provider.
A retroperitoneal hemorrhage is a critical circulatory emergency that requires immediate medical intervention and fluid resuscitation beyond the independent scope of a practical nurse.

Key Concept

Recognition of retroperitoneal bleeding following femoral artery procedures
Question 155Question →

A practical nurse is reviewing morning laboratory results for an adult client with a history of heart failure who is receiving a daily loop diuretic. The client's serum potassium level is 2.8 mEq/L (2.8 mmol/L). Which action should the nurse take first?

Show answer & explanation

Answer: Promptly notify the registered nurse and the healthcare provider about the laboratory result.

Answer

Promptly notify the registered nurse and the healthcare provider about the laboratory result.
The correct answer addresses the urgent need to report a critically low serum potassium level. Normal serum potassium ranges from 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Severe hypokalemia can lead to life-threatening cardiac dysrhythmias. Immediate escalation ensures that the client receives prompt medical intervention, such as intravenous potassium replacement and the temporary discontinuation of the potassium-wasting diuretic.

Step-by-Step Solution

1
Identify the normal reference range for serum potassium.
The expected normal range is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L).
This establishes a baseline to evaluate the significance of the client's laboratory results.
2
Evaluate the client's specific laboratory value.
A value of 2.8 mEq/L (2.8 mmol/L) indicates severe hypokalemia.
Loop diuretics commonly cause potassium wasting, leading to this expected but dangerous imbalance.
3
Determine the priority nursing intervention based on the practical nurse's scope of practice.
The nurse must immediately escalate this critical finding to the registered nurse or healthcare provider.
Severe hypokalemia can cause fatal cardiac dysrhythmias, making this a time-sensitive physiological emergency that requires immediate medical intervention.

Key Concept

Electrolyte Imbalances (Hypokalemia) and Critical Value Escalation
Question 156Question →

A client with a history of type 2 diabetes mellitus activates the call light at 07:15. Upon entering the room, the practical nurse observes that the client is fully conscious but visibly diaphoretic and experiencing hand tremors. A point-of-care capillary blood glucose test reveals a level of 5858 mg/dL (3.23.2 mmol/L). A scheduled dose of oral glipizide is due at 07:30. Which action should the practical nurse take next?

Show answer & explanation

Answer: Withhold the glipizide, provide 1515 grams of a fast-acting oral carbohydrate, and alert the registered nurse.

Answer

Withhold the glipizide, provide 15 grams of a fast-acting oral carbohydrate, and alert the registered nurse.
The client is experiencing symptomatic hypoglycemia (blood glucose less than 70 mg/dL). Because the client is fully conscious and able to swallow, the safest and most appropriate immediate action is to provide 15 grams of a fast-acting oral carbohydrate (such as 4 ounces of fruit juice). The practical nurse must withhold the glipizide, as its mechanism of action is to stimulate insulin release, which would further lower the blood glucose level. After initiating treatment, the practical nurse must promptly report the client's condition to the registered nurse for further evaluation.

Step-by-Step Solution

1
Analyze the client's assessment data.
The client has a blood glucose level of 58 mg/dL and is exhibiting diaphoresis and tremors.
Identifying the clinical signs and laboratory confirmation of hypoglycemia is required to determine the appropriate intervention.
2
Evaluate the scheduled medication.
Glipizide is a sulfonylurea that stimulates insulin secretion and lowers blood glucose.
Understanding the medication's mechanism reveals that administering it would dangerously exacerbate the hypoglycemia.
3
Determine the practical nurse's scope of practice and prioritize actions.
The nurse must provide an oral carbohydrate (since the client is conscious), withhold the contraindicated medication, and escalate the critical findings to the RN.
This sequence ensures immediate patient safety, adheres to the LPN/LVN scope of practice, and maintains effective interdisciplinary communication.

Key Concept

Management of hypoglycemia and practical nurse scope of practice in medication administration
Estimated Time:1m 30s
Question 157Question →

A practical nurse (PN) at an urgent care clinic is collecting data from a young adult client who reports severe, continuous vomiting and abdominal pain for the past two days. The client states, 'I smoke cannabis every day, and the only thing that temporarily stops the nausea is taking a really hot shower.' The PN obtains the following vital signs: heart rate 118/min, blood pressure 92/58 mm Hg, and respiratory rate 20/min. Which action should the PN take first?

Show answer & explanation

Answer: Report the vital signs to the supervising registered nurse or healthcare provider immediately.

Answer

The correct action is to immediately report the vital signs to the supervising registered nurse or healthcare provider, as the client is showing early signs of hypovolemic shock due to severe dehydration.
The client's history of daily cannabis use, severe vomiting, and relief from hot showers strongly indicates cannabinoid hyperemesis syndrome. The vital signs reveal tachycardia and hypotension, which are early physiological signs of hypovolemic shock secondary to severe dehydration. Within the practical nurse scope of practice, recognizing and immediately reporting critical physiological deterioration to the registered nurse or healthcare provider is the highest priority.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client exhibits frequent vomiting, a history of daily cannabis use, and relief from hot showers, which are hallmark signs of cannabinoid hyperemesis syndrome.
Recognizing the underlying substance-related syndrome helps anticipate associated physiological complications.
2
Evaluate the vital signs.
The client has tachycardia (heart rate 118/min) and mild hypotension (blood pressure 92/58 mm Hg).
These are early compensatory mechanisms for fluid volume deficit (hypovolemia) caused by 48 hours of continuous vomiting.
3
Determine the priority action within the PN scope of practice.
The PN must immediately escalate these borderline shock findings to the RN or healthcare provider for emergent fluid resuscitation.
The immediate physiological threat to life takes precedence over psychosocial assessments or documentation.

Key Concept

Cannabinoid hyperemesis syndrome can lead to severe dehydration and hypovolemic shock, requiring prompt recognition of abnormal vital signs and immediate escalation within the practical nurse scope of practice.
Question 158Question →

A practical nurse (PN) is performing focused assessments on a group of assigned clients. Which of the following client situations are considered expected or stable, allowing the nurse to safely document the data and continue routine care WITHOUT immediately notifying the registered nurse (RN)? Select all that apply.

Select all that apply

Show answer & explanation

Answer: A client with a new left forearm arteriovenous (AV) fistula who has a continuous palpable thrill and an audible bruit at the access site.; A client 12 hours post-laparoscopic cholecystectomy who reports mild right shoulder pain and has hypoactive bowel sounds.; A client with an indwelling urinary catheter whose total urine output over the previous 4 hours is 160 mL.

Answer

The correct selections are the client with the functioning AV fistula, the client with expected post-laparoscopic cholecystectomy findings, and the client with adequate urinary output.
The practical nurse must apply risk reduction principles by filtering benign, expected data from clinical emergencies. A palpable thrill and audible bruit prove that an AV fistula is patent and functioning properly. Right shoulder pain after a laparoscopic procedure is a common, non-emergent consequence of the carbon dioxide gas used to inflate the abdomen, and bowel sounds naturally remain sluggish after anesthesia. A urine output averaging 40 mL/hour comfortably exceeds the minimum safety threshold of 30 mL/hour. All of these situations reflect stable clients progressing as expected, allowing the PN to document the findings and proceed with routine care.

Step-by-Step Solution

1
Evaluate the assessment data for the client with the AV fistula.
A thrill and bruit are identified at the site.
These findings confirm normal, healthy blood flow through a newly created fistula and do not require escalation.
2
Analyze the post-operative findings for the client who underwent a laparoscopic cholecystectomy.
Right shoulder pain and hypoactive bowel sounds are present 12 hours post-surgery.
Both findings are expected physiological responses to abdominal insufflation and general anesthesia, respectively.
3
Calculate the hourly urine output for the client with the catheter.
160 mL divided by 4 hours equals 40 mL/hour.
This is above the critical minimum threshold of 30 mL/hour, demonstrating adequate organ perfusion and stability.
4
Identify the complications and scope-of-practice issues in the remaining scenarios.
The platelet count is critically low, the thoracentesis client is showing early shock/hypoxia signs, and the diltiazem titration is beyond PN scope.
These three situations carry high risk potential and mandate immediate notification of the RN to ensure client safety.

Key Concept

Distinguishing between expected clinical progression and subtle indicators of complications to determine when RN escalation is required.
Question 159Question →

A provider prescribes transmission-based precautions for a client newly diagnosed with *Neisseria meningitidis*. As the practical nurse coordinates care for the shift, which action should be implemented?

Show answer & explanation

Answer: Assigning the unlicensed assistive personnel (UAP) to deliver the client's meal tray while wearing a standard surgical mask

Answer

Assigning the unlicensed assistive personnel (UAP) to deliver the client's meal tray while wearing a standard surgical mask is the correct action.
Neisseria meningitidis is transmitted via large respiratory droplets, necessitating droplet precautions. This protocol requires healthcare workers to wear a standard surgical mask when entering the room or coming within 3 feet of the client. Delivering a meal tray is a safe, routine task that falls appropriately within the UAP's scope of practice as long as the correct personal protective equipment is utilized.

Step-by-Step Solution

1
Identify the mode of transmission for Neisseria meningitidis.
The pathogen is transmitted via large respiratory droplets, which requires Droplet Precautions.
Identifying the correct precaution type dictates the required personal protective equipment (PPE).
2
Determine the appropriate PPE for Droplet Precautions.
A standard surgical mask is required when entering the room or interacting within 3 feet of the client.
Surgical masks effectively block large respiratory droplets from reaching the healthcare worker's mucous membranes.
3
Evaluate the proposed nursing actions for safety and scope of practice.
Delivering a meal tray while wearing a surgical mask is within the UAP's scope of practice and adheres to infection control standards.
Other actions present critical errors involving incorrect PPE doffing sequences, out-of-scope delegation of nursing assessments, and breaches of client confidentiality.

Key Concept

Droplet precautions require a standard surgical mask, and any tasks delegated to UAPs must fall strictly within their non-clinical scope of practice.
Estimated Time:1m 0s
Question 160Question →

A client on a medical-surgical unit becomes acutely restless and persistently attempts to leave the facility. Before considering the use of any restraints, which action should the practical nurse (PN) implement FIRST?

Show answer & explanation

Answer: Provide a safe, repetitive diversionary activity such as folding towels to redirect the client's attention.

Answer

The PN should first provide a safe, repetitive diversionary activity to redirect the client's attention.
Providing a safe, repetitive diversionary activity, such as folding towels, is a non-pharmacological, least-restrictive alternative. It can safely redirect a restless client's attention and energy, thereby avoiding the immediate need for physical or chemical restraints while maintaining patient safety.

Step-by-Step Solution

1
Identify the client's immediate safety risk and behavioral change.
The client is acutely restless and attempting to leave the unit.
Recognizing the behavior dictates the need for a prompt, safe intervention.
2
Recall the principles of the least restrictive environment regarding restraint usage.
Physical or chemical restraints must be a last resort.
Nursing standards and laws require trying alternative, non-restrictive measures before applying any form of restraint.
3
Select the appropriate non-restrictive nursing intervention from the available choices.
Providing a diversionary activity is chosen as the first action.
Distraction techniques are a safe, within-scope, and effective first-line alternative to keep the client engaged and secure.

Key Concept

Least Restrictive Alternatives
PreviousPage 8 / 147Next
All practice questions — NCLEX-PN | Examkin