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Question 141Question →

A practical nurse (PN) is transporting a basin of contaminated fluids from a client's room and accidentally spills a significant amount on the hallway floor. Arrange the following actions in the chronological order the PN should perform them to safely manage the hazard and prevent injury.

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Answer

The correct sequence is to first secure the area, then obtain the spill kit, don personal protective equipment (PPE), apply the absorbent material, and finally dispose of the waste in a biohazard container.
When managing a biohazardous spill, the immediate nursing priority is to secure the environment to prevent secondary accidents, such as slips and falls, and to prevent exposure to bystanders. Once the area is restricted, the nurse must retrieve the facility's approved biohazard spill kit. Before making any contact with the hazardous material, the nurse must don appropriate personal protective equipment (PPE) to ensure occupational safety. After putting on PPE, the nurse applies absorbent materials to contain and solidify the liquid, which prevents splashing and spreading. Finally, the solidified material is safely collected and discarded in a regulated biohazard waste container according to facility policy.

Step-by-Step Solution

1
Secure the immediate area by warning others and restricting access to the spill.
The area is isolated.
Prevents slips, falls, and accidental exposure to biohazardous material by bystanders.
2
Obtain the facility's biohazard spill kit from the designated utility area.
Necessary supplies are available.
Provides the approved materials for safe handling and cleanup.
3
Put on the appropriate personal protective equipment (PPE), including gloves and a gown.
The nurse is protected.
Creates a barrier against potential pathogens before interacting with the spill.
4
Apply the absorbent powder or pads from the spill kit directly over the fluid.
The spill is solidified.
Prevents spreading and splashing while making the fluid safe to pick up.
5
Collect the absorbed material and dispose of it in a designated biohazard waste container.
The hazard is safely removed.
Ensures contaminated materials are handled according to infection control and environmental safety regulations.

Key Concept

Accident, Error, and Injury Prevention (Hazard Handling)
Question 142Question →

During a routine bed bath at a long-term care facility, a practical nurse discovers multiple unexplained bruises in various stages of healing and small, circular burns on an older adult client's back. The client becomes visibly anxious and withdrawn when asked about the injuries. Arrange the following actions the nurse should take in the correct priority order.

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Answer

The correct sequence of actions is to first ensure client safety, followed by collecting objective data, notifying the internal chain of command, making the external mandated report, and finally documenting the event.
The sequence follows standard nursing prioritization: immediate physiological safety is the absolute highest priority. This is followed by data collection to ascertain the facts. Once the objective data is gathered, the practical nurse must inform the internal chain of command, ensure the legal mandate to report to external authorities is met, and finally complete a thorough documentation of the objective findings and the sequence of actions taken.

Step-by-Step Solution

1
Ensure the client's immediate safety and well-being.
The client is protected from further immediate harm.
According to prioritization principles, ensuring physical safety is always the primary concern in suspected abuse situations.
2
Collect objective data regarding the characteristics of the bruises and burns.
Factual information is gathered to support the suspicion.
Data collection must occur immediately after securing safety to provide accurate information for the subsequent reports.
3
Notify the charge nurse or nursing supervisor of the suspected abuse.
The facility's nursing leadership is made aware of the situation.
Following the chain of command ensures that internal facility protocols for abuse reporting and client protection are activated.
4
Report the suspected abuse to Adult Protective Services or the designated state agency.
Legal obligations for mandatory reporting are fulfilled.
Nurses are legally mandated reporters and must ensure suspected abuse is reported to the appropriate external state authorities.
5
Document the objective physical findings, notifications, and actions taken in the client's health record.
A legal and comprehensive record of the event is created.
Accurate documentation should be completed after the immediate situation is managed and all required verbal reports are made.

Key Concept

Mandatory Reporting and Prioritization in Suspected Abuse
Question 143Question →

A client with partial weight-bearing capability needs to be moved from an armchair back to their bed. The nurse decides to use a mechanical sit-to-stand device. Arrange the steps of this procedure in the correct sequence for safe equipment use.

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Answer

The correct sequence is to first assess the client's ability, then position the device, wrap the sling around the client, connect the sling to the lift, and finally instruct the client to hold the grips.
Safe use of a sit-to-stand lift requires a systematic and ergonomic approach. Assessment of the client's physical capability is always the first step. Then, the equipment is brought into the correct position. Following this, the nurse applies the supportive sling to the client's torso. Next, the sling is securely attached to the lift's hooks. Finally, the client is instructed to hold the handles to maintain balance before the machine is activated.

Step-by-Step Solution

1
Assess the client's weight-bearing status and cognition.
Client is confirmed to be appropriate for the sit-to-stand device.
Ensures baseline safety and prevents falls, as this specific device requires active client participation.
2
Position the sit-to-stand equipment.
Device is ready and stable in front of the client.
Prepares the environment and equipment for the transfer.
3
Apply the supportive sling.
Client's torso is safely supported.
Provides structural support for the upper body during the lift.
4
Attach the sling to the lift hooks.
Client is physically connected to the lifting mechanism.
Secures the lifting mechanism before any upward movement begins.
5
Instruct the client to hold the hand grips.
Client is properly positioned and ready to be lifted.
Promotes stability, proper body mechanics, and client participation in the transfer.

Key Concept

Safe use of mechanical transfer devices
Question 144Question →

A client recovering from viral encephalitis is exhibiting severe psychomotor agitation and repeatedly pulling at their intravenous (IV) line. Environmental modifications and one-to-one supervision have been ineffective. The healthcare provider has just evaluated the client and determined that physical restraints are necessary. Arrange the following practical nursing actions in the correct chronological sequence to safely implement this intervention.

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Answer

The correct sequence is to first verify the provider's prescription, explain the procedure to the client and family, apply the restraints with a two-finger gap, secure them to a movable part of the bed frame using a quick-release knot, assess the neurovascular status of the extremities, and finally, ensure the restraints are released one at a time every two hours for basic care.
The application of restraints follows a strict legal and safety protocol. The practical nurse must first ensure a valid provider prescription is in place. Next, communication with the client and family is essential to provide reassurance. During application, correct technique (padding and leaving a two-finger gap) prevents immediate injury. Securing the straps to the movable bed frame with a quick-release knot ensures patient safety during bed adjustments and emergencies. Once applied, frequent neurovascular monitoring is the highest priority, followed by scheduled release every two hours for skin care and range of motion.

Step-by-Step Solution

1
Verify the provider's written prescription detailing the clinical justification, type of device, and time limit.
Legal authorization is confirmed.
A physical restraint cannot be applied without a valid, current face-to-face provider order, except in an extreme emergency where the order must be obtained immediately after.
2
Explain the temporary nature and safety purpose of the intervention to the client and their family.
The client and family understand the intervention.
Providing a clear rationale helps reduce anxiety, promotes cooperation, and fulfills ethical obligations.
3
Wrap the padded devices around the wrists, ensuring sufficient space to accommodate two fingers.
The restraints are placed safely without causing constriction.
Leaving a two-finger gap prevents impaired circulation and nerve damage.
4
Secure the attachment straps to the movable section of the bed frame utilizing a quick-release knot.
The restraints are anchored securely but can be released instantly if needed.
Attaching to a movable part of the frame prevents injury if the bed position is adjusted, and a quick-release knot ensures rapid removal during emergencies.
5
Assess the peripheral pulses, capillary refill, and skin temperature of the restrained extremities.
Neurovascular status is monitored.
Frequent neurovascular checks (e.g., every 15 to 30 minutes) are critical to detect and prevent circulatory or neurological impairment.
6
Remove one device at a time at least every two hours to provide hygiene and range-of-motion exercises.
Basic physical needs and skin integrity are maintained.
Periodic removal allows for essential nursing care, skin assessment, and joint mobility while maintaining safety.

Key Concept

The safe and legal application of physical restraints requires a chronological protocol prioritizing legal authorization, proper mechanics, and ongoing assessment.
Question 145Question →

A practical nurse (PN) is monitoring a client who is receiving a packed red blood cell (PRBC) transfusion. The client suddenly reports severe lower back pain and begins to experience chills. In what order should the PN perform the following actions? Arrange the actions in the correct sequence from first to last.

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Answer

The correct sequence is to first stop the blood transfusion, then maintain the IV line with normal saline, notify the supervising RN, and finally obtain the client's vital signs.
In any suspected blood transfusion reaction, the absolute highest priority is to stop the source of the reaction to prevent further harm. After stopping the blood, the IV site must be maintained with a normal saline infusion using new tubing to keep the vein open for emergency interventions. The RN must then be notified immediately to further assess the client and contact the healthcare provider. Finally, the PN obtains vital signs to establish the client's current status and monitor for impending shock.

Step-by-Step Solution

1
Stop the blood transfusion immediately.
Further infusion of the potentially incompatible blood is halted.
Severe lower back pain and chills are classic signs of an acute hemolytic transfusion reaction; stopping the source is the absolute first priority to prevent further harm.
2
Maintain the intravenous (IV) line open with normal saline.
Venous access is preserved and kept patent.
An open IV line is critical for administering emergency medications and fluids to manage the severe reaction.
3
Notify the supervising registered nurse (RN).
The RN is informed of the critical situation.
The RN needs to evaluate the client, contact the healthcare provider, and initiate emergency protocols as per facility policy.
4
Obtain the client's vital signs.
Current hemodynamic status is documented.
Vital signs provide essential data regarding the severity of the reaction and help guide further medical interventions.

Key Concept

Prioritization during a suspected blood transfusion reaction
Question 146Question →

A practical nurse is reinforcing teaching with a client who has a right short-leg cast about how to ascend stairs using axillary crutches. In which order should the nurse instruct the client to perform the following actions? Arrange the steps from first to last.

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Answer

The correct sequence is: Assume the tripod position, transfer weight to the crutches, step up with the unaffected leg, shift weight to the unaffected leg, and finally bring the crutches and affected leg up.
When ascending stairs with crutches, the client must follow the safety principle of 'up with the good'. The client begins in a stable tripod position and transfers weight to the crutch handles. The unaffected (strong) leg is then placed on the step above. Once the strong leg is firmly planted, the client shifts their weight onto it. Finally, the client uses the strong leg to elevate the body, bringing the crutches and the affected (weak) leg up to the same step. This sequence ensures that the strong leg does the work of lifting the body against gravity.

Step-by-Step Solution

1
Assume the tripod position at the base of the stairs.
The client has a stable, three-point base of support.
Ensures balance before attempting to move.
2
Transfer body weight entirely onto the crutch handles.
The client's legs are freed from bearing weight.
Allows the unaffected leg to be lifted without destabilizing the client.
3
Step up onto the first stair with the unaffected left leg.
The unaffected leg is placed on the higher step.
The strong leg must go first ('up with the good') to lift the rest of the body.
4
Shift body weight from the crutches to the unaffected left leg.
The body weight is now supported by the strong leg.
Provides the upward force needed to lift the affected leg and crutches.
5
Bring the crutches and the affected right leg up to the stair.
The client completes the ascent of one step.
The weak leg and crutches follow the strong leg to maintain safety.

Key Concept

Assistive Device Ambulation: Ascending Stairs
Question 147Question →

During a shift in a neurological rehabilitation unit, a client with a traumatic brain injury becomes intensely agitated after a sudden schedule change. The client begins pacing the hallway rapidly, clenching their fists, and shouting at staff. Arrange the following nursing interventions in the correct sequence, prioritizing from least restrictive to most restrictive.

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Answer

The correct sequence from least to most restrictive is: verbal de-escalation, voluntary environmental modification, oral PRN medication, IM chemical restraint, and finally mechanical restraints.
Behavioral management follows a strict hierarchy designed to protect client rights, dignity, and safety. The nurse must always begin with the least restrictive intervention (verbal de-escalation), progress to environmental changes (quiet room), step up to voluntary chemical interventions (oral medication), move to rapid-acting chemical restraints (IM medication), and only use physical interventions (mechanical restraints) as a final, emergency option to prevent imminent harm.

Step-by-Step Solution

1
Identify the least restrictive and least invasive intervention.
Select verbal de-escalation techniques.
Standard behavioral guidelines require starting with non-physical, non-chemical communication to help the client regain control independently.
2
Determine the next level of intervention involving the milieu.
Select offering a voluntary transition to a quiet room.
Environmental modification is slightly more restrictive than simple conversation but still relies on voluntary client cooperation.
3
Identify the least invasive pharmacological intervention.
Select administering a prescribed PRN oral sedative.
Voluntarily taking an oral medication is less invasive and less restrictive than receiving an involuntary or rapid-acting injection.
4
Determine the next pharmacological step if severe agitation persists.
Select administering a prescribed IM medication.
IM injections are considered a chemical restraint when used to rapidly manage severe agitation, making them highly restrictive.
5
Identify the most restrictive safety intervention.
Select applying mechanical restraints.
Physical or mechanical restraints completely eliminate the client's mobility and are only legally and ethically permissible as a final alternative to prevent imminent injury.

Key Concept

Hierarchy of Restrictive Interventions
Question 148Question →

An assigned client has left-sided hemiplegia resulting from a recent cerebrovascular accident. The healthcare provider prescribes out-of-bed activity to a chair for all meals. Arrange the following nursing actions for a safe bed-to-wheelchair transfer in the correct chronological order. (Place the initial action at the top and the final action at the bottom.)

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Answer

The correct chronological sequence prioritizes environmental safety first, followed by physiological adaptation (dangling), equipment application (gait belt), biomechanical stabilization (bracing the weak leg), standing utilizing the strong side, and finally pivoting to safely complete the transfer.
Executing a safe transfer for a client with hemiplegia requires a highly systematic approach based on biomechanical principles. The sequence must begin with securing the environment by placing the chair on the client's strong (right) side. Next, physiological safety is ensured by having the client dangle to prevent orthostatic hypotension. Once seated safely, the gait belt is applied to provide the nurse with a safe handling point. Before standing, the nurse must physically brace the weak (left) leg to prevent it from buckling under the client's weight. The client then actively participates by pushing up with their strong (right) arm. Finally, a controlled pivot leads the client to the chair, where they reach for the armrest to guide a safe descent.

Step-by-Step Solution

1
Prepare the wheelchair on the client's right side and lock brakes.
The environment is secure and oriented for a strong-side transfer.
Clients with hemiplegia must always transfer toward their unaffected side to utilize their intact muscle strength and coordination.
2
Assist the client to dangle and assess for dizziness.
The client adapts to the upright posture safely.
Moving a client from supine to standing too quickly risks orthostatic hypotension, which could cause a sudden fall during the transfer.
3
Apply a gait belt securely around the waist.
A safe handling interface is established.
A gait belt provides a center-of-gravity hold, preventing the nurse from lifting the client by their flaccid or weak arms.
4
Brace the client's left knee.
The hemiplegic leg is externally stabilized.
The affected leg lacks the motor control to support body weight independently and will collapse unless physically blocked by the nurse's knee.
5
Have the client push off the bed with their right hand to stand.
The client reaches a standing position.
Pushing off a solid surface (the mattress) with the unaffected arm maximizes the client's functional ability and reduces the physical load on the nurse.
6
Pivot toward the chair and have the client reach for the armrest.
The transfer is completed safely.
Pivoting as a single unit maintains alignment, and grasping the armrest provides necessary support to control the sitting motion.

Key Concept

Safe mobility and transfer techniques for clients with hemiplegia require utilizing the unaffected side for weight-bearing and spatial orientation, while physically supporting the affected side.
Question 149Question →

A client with major depressive disorder is admitted to the inpatient psychiatric unit with active suicidal ideation. The registered nurse has initiated suicide precautions. In which order should the practical nurse (PN) implement the following actions? (Arrange from first action to last.)

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Answer

The correct sequence prioritizes immediate life-safety (continuous observation), followed by the removal of environmental hazards (searching belongings), assessment for hidden hazards/injuries (changing into a gown), therapeutic communication (explaining the rationale), and finally, administrative duties (documentation).
In psychiatric emergencies involving active suicidal ideation, nursing prioritization follows the hierarchy of immediate physical safety. Continuous one-to-one observation ensures the client is never left alone, making it the most critical initial intervention. Next, removing environmental hazards and changing the client into a gown prevents access to contraband that could be used for self-harm. Once the physical environment and the client's person are secured, the nurse addresses psychosocial needs by explaining the rationale for the precautions. Finally, after all direct care is completed, the nurse documents the events and findings in the medical record.

Step-by-Step Solution

1
Establish continuous visual observation.
The client is immediately protected from attempting self-harm.
Immediate life-safety is the highest priority. A suicidal client must never be left unobserved while other tasks are completed.
2
Search belongings and remove hazards.
Means of self-harm are removed from the client's immediate environment.
Once the client is actively observed, environmental risks must be systematically mitigated.
3
Assist into a gown and observe the skin.
Hidden contraband is discovered, and existing injuries are noted.
This further secures physical safety on the client's person and contributes to the admission data collection.
4
Explain the rationale for the precautions.
The client understands the purpose of the restrictive measures.
Psychosocial interventions follow physical safety. Explaining the rules helps de-escalate fear and builds rapport.
5
Document the interventions and findings.
The medical record accurately reflects the care provided.
Charting must be completed only after all direct client care and life-safety measures are securely in place.

Key Concept

Prioritization of physical safety and least-restrictive environment in clients with active suicidal ideation.
Question 150Question →

A client with a history of chronic stable angina is scheduled to receive a new transdermal nitroglycerin patch. What is the correct sequence of steps the practical nurse should follow to safely administer this medication? Arrange the actions in the correct chronological order.

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Answer

The correct sequence ensures safety and proper absorption: perform hand hygiene and don gloves, remove the old patch, cleanse the old site, label the new patch, and apply the new patch to a rotated site.
The correct sequence minimizes the risk of medication errors and protects the nurse. Gloves must be worn first to prevent self-medication. The old patch must be removed and the site cleaned to prevent a dangerous overdose. The new patch must be labeled before application to prevent skin trauma or a sudden bolus dose, and then applied to a new, rotated site to prevent skin irritation.

Step-by-Step Solution

1
Perform hand hygiene and don clean gloves.
Nurse and client are protected from exposure.
Gloves prevent the nurse from accidentally absorbing nitroglycerin through the skin, which could cause a severe headache or dangerous hypotension.
2
Remove the old transdermal patch and fold it in half.
Old medication source is safely contained and removed.
Leaving an old patch on while applying a new one can lead to medication toxicity and adverse cardiovascular events.
3
Cleanse the skin of the old site.
Skin is completely free of residual medication.
Nitroglycerin residue left on the skin continues to absorb and may cause unintended dosing if not washed away.
4
Label the new patch.
Patch is identified with date, time, and initials prior to application.
Writing on the patch before applying it prevents pressing down on the client's tissue and inadvertently squeezing out a bolus of medication.
5
Apply the new patch to a new site.
Medication is administered correctly to a fresh area.
Rotating sites prevents contact dermatitis and ensures consistent, reliable systemic absorption of the drug.

Key Concept

Safe administration of transdermal medications
Question 151Question →

A practical nurse (PN) is working on a subacute rehabilitation unit when a client unexpectedly dies. The client's adult child arrives on the unit, learns of the death, and begins to hyperventilate and pace erratically in the busy main corridor. In which order should the PN implement the following interventions? (Arrange from first action to last.)

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Answer

The correct sequence is to first guide the individual to a private room, then coach them in deep breathing, followed by remaining with them to provide therapeutic presence, then asking about notifying support persons, and finally preparing the body for viewing.
Nursing prioritization follows a framework of safety, physiological needs, psychosocial needs, and finally procedural tasks. Guiding the individual to privacy ensures environmental safety. Coaching breathing addresses the acute physiological threat of hyperventilation. Remaining present provides immediate psychosocial support during shock. Mobilizing external support follows stabilization. Preparing the body is a procedural task that is safely deferred until the living family member's crisis is managed.

Step-by-Step Solution

1
Guide the adult child into a private, quiet consultation room.
The individual is removed from the busy corridor.
According to Maslow's hierarchy of needs, ensuring a safe and secure environment is a top priority. This protects the grieving individual's privacy and prevents distress among other clients.
2
Coach the adult child to take slow, deep breaths.
The hyperventilation is addressed and managed.
Physiological needs take precedence over psychosocial ones. Hyperventilation is an acute physical response that requires immediate intervention to prevent further medical complications.
3
Remain in the room to provide continuous, silent therapeutic presence.
The individual receives immediate emotional grounding.
Therapeutic presence is the most effective initial psychosocial intervention during acute shock, providing safety and support without demanding verbal interaction.
4
Ask if there are specific relatives or a chaplain who should be notified.
External support systems are identified.
Once the acute physical and emotional reactions are stabilized, mobilizing broader support systems helps the individual begin to process the loss.
5
Arrange the deceased client's room and prepare the body for family viewing.
The environment is prepared for the family to say goodbye.
Task-oriented post-mortem care is essential but represents a lower priority than managing an acute physiological or psychological crisis in a living client or family member.

Key Concept

Prioritization in Acute Grief Crisis
Question 152Question →

A practical nurse (PN) is a member of the emergency department's hazardous materials team. A local factory worker is brought to the facility after being covered in radioactive dust. Arrange the following decontamination actions in the correct chronological order.

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Answer

The correct sequence requires the nurse to first protect themselves, then perform initial bulk decontamination by removing clothing, contain the hazard, wash the skin, and finally evaluate the client for remaining radiation.
In any hazardous materials response, the nurse must first prioritize their own safety by donning appropriate PPE and a dosimeter. Once protected, the most effective immediate decontamination method is removing the client's outer clothing, which can eliminate up to 90% of radioactive material. This clothing must be immediately secured in a sealed container to prevent cross-contamination within the facility. After securing the primary hazard, the nurse washes the client's skin with mild soap and water to remove any residual particles. Finally, the nurse evaluates the overall effectiveness of the decontamination using a radiation survey meter before transferring the client to a clean area.

Step-by-Step Solution

1
Put on a water-resistant gown, double gloves, a mask, and a dosimeter badge.
The nurse is protected from radioactive exposure.
Protecting the healthcare worker is always the first priority in any hazardous materials incident.
2
Instruct the client to carefully take off all outer garments.
The majority of the radioactive dust is separated from the client.
Clothing removal acts as the primary decontamination step, quickly eliminating 70% to 90% of external contaminants.
3
Secure the removed garments inside a designated hazardous waste container.
The radioactive source is safely isolated.
Immediate containment ensures the dust does not become airborne and contaminate the treatment facility.
4
Cleanse the client's skin thoroughly utilizing mild soap and warm water.
Any residual radioactive particles are removed from the body surface.
Washing the skin is necessary to remove the remaining localized contamination without causing abrasion.
5
Scan the client's body utilizing a radiation survey meter.
The client is confirmed safe for standard medical treatment.
Evaluating the effectiveness of the decontamination process is the final necessary step before releasing the client from isolation.

Key Concept

During a radiological incident, the standard decontamination sequence is: protect the responder, remove the client's clothing, contain the hazard, wash the client, and survey for residual radiation.
Question 153Question →

A practical nurse (PN) is preparing to apply prescribed soft bilateral wrist restraints to a client who is severely agitated and at risk of disrupting life-sustaining medical equipment. Arrange the following nursing actions in the correct chronological order from first to last.

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Answer

The correct sequence is: Explain the rationale, pad the wrists, secure the straps to the movable bed frame, check the fit and neurovascular status, and finally release periodically for ongoing care.
Applying restraints requires a systematic approach to ensure patient safety and comfort. First, the nurse must communicate the purpose of the intervention. Next, the site must be prepared with padding to protect skin integrity. Then, the restraints are applied and secured to an appropriate structure (the movable bed frame, not the side rails) using a quick-release knot. Immediately following application, the nurse must verify the fit and ensure neurovascular compromise has not occurred. Finally, ongoing care protocols require regular release for basic needs and reassessment.

Step-by-Step Solution

1
Explain the rationale for the restraints.
The client and family receive information about the safety intervention.
Even if the client is agitated, providing information is a fundamental right and can help de-escalate anxiety.
2
Place protective padding around the client's wrists.
Bony prominences are cushioned.
Padding reduces friction and minimizes the risk of skin breakdown caused by the restraints rubbing against the skin.
3
Secure the straps to the movable portion of the bed frame with a quick-release tie.
The client is safely restrained.
Attaching to a movable part of the frame prevents injury if the bed head or foot is raised or lowered. A quick-release knot ensures rapid removal in an emergency.
4
Insert two fingers under the restraints and evaluate neurovascular status.
The nurse confirms adequate circulation and appropriate fit.
Restraints applied too tightly can cause nerve damage, ischemia, or compartment syndrome. Checking immediately prevents injury.
5
Release the restraints periodically (e.g., every 2 hours) for care.
The client receives range-of-motion exercises and skin care.
Ongoing maintenance prevents joint contractures, muscle atrophy, and pressure injuries while ensuring basic physiological needs are met.

Key Concept

Proper application, safety verification, and ongoing maintenance of physical restraints.
Question 154Question →

A client with persistent asthma is scheduled to receive a dose of inhaled fluticasone propionate using a metered-dose inhaler (MDI) and a spacer device. How should the practical nurse sequence the actions to administer this medication? Arrange the following steps in the correct chronological order.

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Answer

The correct sequence is: Shake the canister, attach it to the spacer, have the client exhale completely, depress the canister while the client inhales, hold the breath for 10 seconds, and finally rinse the mouth with water.
Safe administration of a corticosteroid MDI requires meticulous preparation of the device (shaking and attaching the spacer), optimizing the client's respiratory mechanics (exhaling before inhaling), ensuring medication deposition (holding the breath), and preventing drug-specific adverse effects (rinsing the mouth to prevent thrush).

Step-by-Step Solution

1
Shake the inhaler canister.
The medication and propellant are evenly mixed.
Ensures the prescribed dosage of the active medication is delivered rather than just the propellant.
2
Attach the inhaler to the spacer.
The MDI is secured to the delivery chamber.
Spacers eliminate the need for perfect hand-breath coordination and increase the amount of medication reaching the lungs.
3
Instruct the client to exhale completely.
The client's lungs are emptied of functional reserve air.
Prepares the respiratory tract to take in the maximum volume of medicated air.
4
Depress the canister and have the client inhale.
The medication is drawn deeply into the lower respiratory tract.
A slow, deep inhalation pulls the aerosolized particles past the upper airway and into the bronchioles.
5
Instruct the client to hold their breath for 10 seconds.
The air remains trapped in the lungs momentarily.
Provides time for the medication particles to precipitate out of the air and coat the lung tissue.
6
Have the client rinse their mouth and spit.
Steroid residue is cleared from the oral mucosa.
Prevents localized immunosuppression in the mouth, which can lead to fungal infections such as thrush.

Key Concept

Pharmacological Therapies: Safe Administration of Inhaled Corticosteroids via MDI
Estimated Time:1m 30s
Question 155Question →

A practical nurse (PN) in a long-term care facility observes a client with moderate dementia becoming increasingly agitated, pacing the hallway, and shouting at other residents. In what order should the PN perform the following interventions? (Arrange from first action to last action)

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Answer

The correct sequence of actions prioritizes immediate milieu safety, followed by personal safety and verbal de-escalation, emotional validation, behavioral redirection, and finally, documentation.
The correct order follows the nursing process and safety priorities for behavioral emergencies. Immediate safety of the milieu is paramount, so moving bystanders is always the first action. Next, the nurse must establish a safe connection using a calm voice and safe physical distance. Once contact is made, validating feelings helps to de-escalate the emotional state. After the client is calmer, redirection to a constructive activity provides an outlet for their energy. Finally, documentation is completed once the situation is fully resolved.

Step-by-Step Solution

1
Secure the environment.
Other residents are safely moved out of harm's way.
Client and bystander safety is always the highest priority in a behavioral crisis.
2
Initiate safe verbal contact.
The nurse approaches safely and uses a calm, non-confrontational tone.
A non-threatening posture and a calm voice prevent further escalation while establishing a therapeutic presence.
3
Validate the client's emotions.
The client feels heard and understood.
Acknowledging distress reduces the client's need to act out to communicate their frustration.
4
Redirect the behavior.
The client engages in a safe, familiar task.
Distraction channels the client's excess energy into a positive, low-stress activity.
5
Record the event.
The incident is accurately charted.
Documentation must occur after the crisis has been managed and the client is stabilized.

Key Concept

Crisis De-escalation and Milieu Safety Prioritization
Question 156Question →

A practical nurse has completed care for a client on contact and droplet precautions and is preparing to exit the room. The nurse is wearing a gown, gloves, a surgical mask, and goggles. Arrange the following steps for removing (doffing) the personal protective equipment (PPE) in the correct sequence to minimize the risk of cross-contamination.

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Answer

The correct sequence for doffing PPE is to first remove the gloves, followed by the goggles, then the gown, then the surgical mask, and finally perform hand hygiene.
The standard sequence for removing PPE ensures that the most contaminated items (gloves) are removed first. Items protecting the respiratory tract and mucous membranes (mask and goggles) are removed subsequently by handling only their 'clean' straps or earpieces. Hand hygiene must always conclude the process to eliminate any residual contamination.

Step-by-Step Solution

1
Remove and discard the gloves.
The most contaminated PPE is safely disposed of.
Gloves are the most likely items to carry pathogens and must be removed first to prevent transferring pathogens to the face or other clean areas.
2
Remove the goggles by handling only the earpieces.
Eye protection is safely removed without touching the contaminated front.
The outside of the goggles is contaminated; they must be removed by the clean earpieces to protect the nurse's bare hands and face.
3
Untie and remove the gown, rolling it inside out.
The gown is safely bundled and discarded.
Rolling the gown inside out traps any pathogens on the outside of the gown, preventing environmental cross-contamination.
4
Remove the surgical mask by grasping the ties or ear loops.
The mask is safely removed without touching the contaminated front surface.
The front of the mask is highly contaminated from droplet exposure and must be handled only by the straps to protect the respiratory tract.
5
Perform thorough hand hygiene.
Any remaining pathogens on the nurse's hands are eliminated.
Hand hygiene is the essential final step to ensure absolute safety before interacting with the environment or other clients.

Key Concept

Personal Protective Equipment (PPE) Doffing Sequence
Question 157Question →

During rounds, a client receiving continuous enteral tube feeding suddenly begins to cough vigorously, displays audible wheezing, and appears acutely dyspneic. In which order should the practical nurse (PN) perform the following actions? Arrange the interventions from highest priority (first) to lowest priority (last).

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Answer

The correct sequence prioritizes immediate airway protection: stop the feeding, position the client, suction the airway, obtain vital signs, and finally notify the registered nurse.
When managing an acute aspiration event, the nurse must immediately apply the airway, breathing, and circulation (ABC) prioritization framework. The absolute first priority is to stop the source of the aspiration. Next, physically positioning the client and clearing the airway take precedence over diagnostic assessment (vital signs) and communication (notifying the RN).

Step-by-Step Solution

1
Stop the continuous enteral tube feeding pump.
Further aspiration of formula is prevented.
Removing the source of harm is always the first action in an aspiration emergency.
2
Place the client in a high Fowler's or side-lying position.
The airway is physically protected using gravity.
Elevating the head of the bed or turning the client to the side prevents further aspiration of stomach contents and maximizes chest expansion.
3
Suction the client's oropharyngeal airway.
Aspirated formula and mucus are cleared from the upper airway.
Clearing the airway resolves the immediate physical obstruction to breathing.
4
Obtain the client's vital signs and oxygen saturation.
Objective data regarding the client's respiratory compromise is collected.
Assessment data is necessary to determine the severity of the hypoxia and need for further interventions like supplemental oxygen.
5
Notify the supervising registered nurse (RN) of the event.
The healthcare team is alerted to the critical change in condition.
Medical evaluation is required to assess for complications such as aspiration pneumonia and to order subsequent treatments.

Key Concept

Prioritization of Airway, Breathing, and Circulation (ABC) during aspiration emergencies
Question 158Question →

A practical nurse is preparing to administer a prescribed liquid medication via a percutaneous endoscopic gastrostomy (PEG) tube to a client receiving continuous enteral feedings. The continuous feeding has been paused. Arrange the following steps for medication administration in the correct chronological order.

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Answer

The correct sequence is: 1) Elevate the head of the bed, 2) Aspirate to check residual, 3) Flush with water, 4) Administer the medication, and 5) Flush again with water.
To safely administer a medication via a PEG tube, the practical nurse must prioritize airway protection by first elevating the head of the bed. Next, verifying the residual volume ensures the stomach is not dangerously full. Flushing with water then clears the tube and confirms patency before pouring the medication into the syringe barrel for gravity administration. Finally, a concluding flush ensures all the medication reaches the stomach and keeps the tube clear of residue.

Step-by-Step Solution

1
Elevate the head of the bed.
The client is positioned safely.
Maintaining an upright position of at least 30 degrees minimizes the risk of aspiration during and after administration.
2
Aspirate stomach contents.
Gastric residual volume is measured.
Checking residual volume ensures the stomach is not overly distended, which could lead to vomiting or regurgitation.
3
Flush the tube with 30 mL of sterile water.
The tube is cleared of feeding formula.
Flushing establishes patency and prevents chemical interactions between the feeding formula and the medication.
4
Administer the liquid medication.
The medication enters the stomach via gravity.
Gravity administration prevents excessive pressure that could damage the tube or cause discomfort.
5
Flush the tube again with 15 to 30 mL of sterile water.
The tube is completely cleared of the medication.
The final flush delivers the remaining medication in the tube into the stomach and prevents future occlusions.

Key Concept

Safe enteral medication administration requires verifying placement, ensuring patency, preventing formula-drug interactions, and minimizing aspiration risk.
Question 159Question →

A practical nurse is preparing to administer a prescribed bolus enteral feeding via a gastrostomy tube to an adult client. Arrange the following actions in the correct chronological sequence.

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Answer

The correct sequence is to first elevate the head of the bed, then check the gastric residual, flush the tube, administer the feeding formula, and finally flush the tube again.
Safe administration of enteral feedings requires a strict sequence to prevent complications, primarily aspiration. The client must first be positioned upright. Next, the nurse must assess gastrointestinal tolerance by checking residual volume. Once tolerance is established, the tube is flushed to ensure patency. The feeding is then administered, followed immediately by a final flush to maintain tube patency and hygiene.

Step-by-Step Solution

1
Elevate the head of the bed.
The client is placed in a semi-Fowler's or Fowler's position.
This utilizes gravity to keep gastric contents in the stomach, minimizing the risk of reflux and aspiration during the procedure.
2
Check gastric residual volume.
The nurse determines how much formula remains in the stomach from prior feedings.
This assesses gastrointestinal tolerance; a high residual indicates delayed emptying and a high risk for aspiration if more feeding is added.
3
Perform the initial flush.
The tube is cleared with water.
This verifies that the tube is patent and functioning properly before administering a thicker substance.
4
Administer the feeding formula.
The client receives the prescribed nutrition.
Gravity feeding allows for a controlled rate, reducing the risk of nausea, cramping, and diarrhea.
5
Perform the final flush.
The tube is cleared of formula residue.
Formula left in the tube can solidify, causing blockages, and provides a medium for bacterial proliferation.

Key Concept

Enteral Nutrition Administration and Aspiration Precautions
Question 160Question →

A practical nurse is preparing to initiate prescribed phototherapy for a 2-day-old newborn who has hyperbilirubinemia. In what order should the nurse perform the following actions? Arrange the steps from first to last.

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Answer

The correct sequence is to first remove the newborn's clothing except the diaper, then apply opaque eye shields, place the newborn under the unit, and finally turn on the phototherapy lights.
The priority when initiating phototherapy is to ensure treatment efficacy while maintaining strict safety standards. The newborn must first be undressed down to the diaper to maximize skin exposure. Next, opaque eye shields are applied to protect the retinas before the infant is exposed to the light source. The infant is then safely positioned under the unit. Finally, the lights are turned on, and the start time is documented to initiate the prescribed therapy.

Step-by-Step Solution

1
Remove the newborn's clothing except for the diaper.
The newborn's skin is maximally exposed.
Maximum skin exposure is required for the phototherapy lights to effectively convert bilirubin into a water-soluble form.
2
Apply opaque eye shields over the newborn's closed eyes.
The newborn's eyes are securely protected.
The intense lights can cause retinal damage, so eye protection must be secured before exposure to the light source.
3
Place the newborn in the bassinet or incubator under the phototherapy unit.
The newborn is positioned in the treatment area.
The infant must be safely placed in the appropriate environment designed for the therapy.
4
Turn on the phototherapy lights and document the therapy start time.
Phototherapy is initiated and recorded.
Activating the lights begins the treatment, and documentation ensures accurate tracking of therapy duration.

Key Concept

Phototherapy setup and newborn safety
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