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653 questions

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The practical nurse (PN) is collecting data on a client who is 4 hours postpartum following a vaginal delivery of a large-for-gestational-age newborn. Which assessment findings indicate a complication of physiological adaptation requiring immediate notification of the registered nurse (RN)? Select all that apply.

Select all that apply

A perineal pad completely saturated with blood within 20 minutes.

Resting heart rate increasing from 76 to 114 beats per minute.

Client report of severe, unremitting perineal pressure.

Intermittent, dull uterine cramping while breastfeeding.

An oral temperature of

100.1^\circ\text{F}

(

37.8^\circ\text{C}

A white blood cell (WBC) count of

18,000 / \text{mm}^3

Show answer & explanation

Answer: A perineal pad completely saturated with blood within 20 minutes.; Resting heart rate increasing from 76 to 114 beats per minute.; Client report of severe, unremitting perineal pressure.

Answer

The correct findings requiring immediate notification are rapid pad saturation, a progressively increasing resting heart rate, and severe, unremitting perineal pressure.

The correct selections represent acute, life-threatening complications of postpartum adaptation. A rapidly saturated pad indicates overt hemorrhage. Tachycardia is a subtle, early compensatory mechanism for hypovolemia. Unremitting perineal pressure strongly suggests a concealed hemorrhage (hematoma). All three require emergency intervention to prevent severe hemodynamic instability.

Step-by-Step Solution

Analyze the client's current status and risk factors.

The client is 4 hours postpartum after delivering a large-for-gestational-age infant, placing her at high risk for uterine atony, hemorrhage, and perineal trauma.

Identifying specific clinical risks guides the PN to anticipate potential life-threatening complications.

Evaluate each finding to differentiate between expected physiological adaptation and acute decompensation.

Heavy bleeding, tachycardia, and severe localized pressure indicate active or concealed blood loss. Uterine cramping during feeding, slight temperature elevation, and elevated WBCs are expected normal variants in the immediate postpartum period.

The PN must accurately interpret clinical data to avoid missing early signs of shock or escalating normal findings unnecessarily.

Determine the priority nursing action based on the identified data.

The abnormal findings threaten Airway, Breathing, and Circulation (ABCs) via hypovolemic shock and require immediate escalation to the RN for medical intervention.

Prompt recognition and reporting of clinical deterioration fall squarely within the PN scope of practice for maintaining physiological integrity.

Key Concept

Early recognition of postpartum hemorrhage and hematoma versus expected normal physiological adaptations (afterpains, transient hyperthermia, and leukocytosis).

Question 2Question →

A practical nurse (PN) is providing care for a client who is 12 hours postoperative following a total thyroidectomy. Which of the following actions by the PN demonstrate appropriate risk reduction and clinical prioritization? Select all that apply.

Select all that apply

Ensuring that emergency suction equipment and a tracheostomy tray are immediately accessible at the bedside.

Promptly escalating a reported morning serum calcium level of 7.4 mg/dL (1.85 mmol/L) to the registered nurse.

Assessing the client's voice quality for hoarseness by asking them to speak a few words during routine checks.

Documenting a resting heart rate of 112 beats per minute and a blood pressure of 100/60 mm Hg without immediate notification.

Accepting a directive from the registered nurse to independently administer an intravenous (IV) push dose of calcium gluconate.

Administering a prescribed oral analgesic by visually recognizing the client rather than verifying two distinct identifiers.

Show answer & explanation

Answer: Ensuring that emergency suction equipment and a tracheostomy tray are immediately accessible at the bedside.; Promptly escalating a reported morning serum calcium level of 7.4 mg/dL (1.85 mmol/L) to the registered nurse.; Assessing the client's voice quality for hoarseness by asking them to speak a few words during routine checks.

Answer

The correct actions include ensuring emergency airway equipment is at the bedside, escalating the critically low serum calcium level, and systematically assessing voice quality for laryngeal nerve damage.

Appropriate risk reduction following a thyroidectomy involves proactive preparation for airway emergencies, immediate escalation of abnormal physiological data (like a critical calcium level of 7.4 mg/dL), and targeted assessments for procedure-specific complications such as recurrent laryngeal nerve damage.

Step-by-Step Solution

Analyze the client's postoperative context and associated physiological risks.

The client is 12 hours post-total thyroidectomy. Primary risks include airway compromise (from edema/bleeding), hypocalcemia (from parathyroid gland damage), and laryngeal nerve injury.

Identifying procedure-specific complications dictates the appropriate nursing assessments and escalation priorities.

Evaluate each nursing action against the identified post-thyroidectomy risks.

Keeping airway equipment at the bedside prepares for respiratory emergencies. Escalating a calcium of 7.4 mg/dL addresses critical hypocalcemia. Checking voice quality actively monitors for nerve damage.

Appropriate clinical actions must directly mitigate the primary risks associated with the client's specific surgery.

Evaluate the remaining actions for general safety and scope of practice violations.

Failing to report borderline vitals (HR 112, BP 100/60) ignores early signs of shock. Accepting an IV push assignment violates the PN scope of practice. Skipping two-identifier checks violates medication administration safety protocols.

Comprehensive risk reduction requires adherence to basic safety standards and legal boundaries of practice, regardless of the specific procedure.

Key Concept

Post-thyroidectomy complication management and practical nurse scope of practice

Question 3Question →

The healthcare team is managing the recovery of a client who underwent a left total knee arthroplasty the previous day. The client is receiving continuous epidural analgesia and requires assistance with daily activities. Which interventions are appropriate for the practical nurse to incorporate into the client's basic care routine? Select all that apply.

Select all that apply

Place a rolled towel or small blanket under the client's left ankle to suspend the heel.

Position a supportive pillow directly beneath the left popliteal space to alleviate joint tension.

Instruct unlicensed assistive personnel (UAP) to perform the client's first out-of-bed transfer to the bedside recliner.

Apply intermittent cold therapy packs to the surgical joint for 20 minutes at a time.

Utilize a fracture pan rather than a standard bedpan when assisting the client with elimination in bed.

Continue routine hygiene care without reporting a borderline blood pressure of 96/58 mm Hg, assuming it is an expected effect of the epidural.

Show answer & explanation

Answer: Place a rolled towel or small blanket under the client's left ankle to suspend the heel.; Apply intermittent cold therapy packs to the surgical joint for 20 minutes at a time.; Utilize a fracture pan rather than a standard bedpan when assisting the client with elimination in bed.

Answer

The correct interventions include suspending the heel with a rolled towel, applying intermittent cold therapy, and utilizing a fracture pan for elimination.

The correct interventions focus on preventing joint contractures by maintaining knee extension through heel suspension, utilizing intermittent cold therapy to manage local edema, and using a fracture pan to minimize painful hip and knee flexion. These actions directly support comfort and physiological integrity without risking joint deformities or compromising safety.

Step-by-Step Solution

Analyze the surgical procedure (total knee arthroplasty) to determine specific positioning requirements.

The knee must be kept in full extension to prevent contractures. Placing anything behind the knee is contraindicated, but suspending the heel is appropriate.

Flexion contractures permanently impair mobility and surgical success.

Evaluate the impact of continuous epidural analgesia on basic care and mobility.

Epidural analgesia affects motor function, sensory perception, and sympathetic tone (blood pressure).

These physiological changes increase the risk for orthostatic hypotension and falls during initial transfers.

Differentiate between tasks appropriate for the LPN versus those requiring RN assessment or those that can be delegated to UAP.

Initial transfers for complex patients cannot be delegated to UAP. Reporting borderline vital signs is a required LPN action.

Operating strictly within the LPN scope of practice ensures client safety.

Select the basic care options that promote comfort, prevent complications, and adhere to safety standards.

Cold therapy, fracture pans, and heel suspension are selected as safe, effective basic care measures.

These interventions directly address the client's postoperative physiological needs.

Key Concept

Postoperative Basic Care and Positioning Precautions

Question 4Question →

A practical nurse is caring for a client who is 24 hours postoperative following a left-sided modified radical mastectomy with axillary lymph node dissection. Which of the following interventions should the nurse include in the client's care plan? Select all that apply.

Select all that apply

Elevate the client's left arm and hand on a pillow above the level of the heart.

Position the client in a left lateral position to splint the incision and reduce postoperative pain.

Assist the client with performing prescribed gentle hand and wrist range-of-motion exercises on the left side.

Document a heart rate of 118 beats per minute and blood pressure of 92/58 mm Hg as expected postoperative anxiety without reporting.

Elevate the head of the bed to a semi-Fowler's position to promote comfortable lung expansion.

Ensure that a limb alert bracelet is placed on the left arm to restrict venipunctures and blood pressure readings.

Show answer & explanation

Answer: Elevate the client's left arm and hand on a pillow above the level of the heart.; Assist the client with performing prescribed gentle hand and wrist range-of-motion exercises on the left side.; Elevate the head of the bed to a semi-Fowler's position to promote comfortable lung expansion.; Ensure that a limb alert bracelet is placed on the left arm to restrict venipunctures and blood pressure readings.

Answer

The correct interventions are elevating the left arm, assisting with left hand and wrist exercises, elevating the head of the bed to a semi-Fowler's position, and ensuring a limb alert bracelet is on the left arm.

For a client recovering from a modified radical mastectomy with axillary lymph node dissection, basic care and comfort must focus on preventing lymphedema, promoting lymphatic drainage, and ensuring adequate respiratory function. Elevating the affected arm above the level of the heart facilitates fluid return. Maintaining a semi-Fowler's position promotes comfortable lung expansion and drainage. Assisting with early, gentle hand and wrist exercises prevents contractures and promotes circulation. Placing a limb alert on the affected side is essential to prevent injury and lymphedema from venipunctures or blood pressure cuffs.

Step-by-Step Solution

Analyze the client's surgical procedure and associated risks.

The client had a left-sided modified radical mastectomy with axillary lymph node dissection, resulting in a high risk for lymphedema on the left side and a need for specific positioning.

Understanding the anatomical changes determines the correct basic care and comfort measures.

Evaluate the positioning and comfort measures provided in the options.

Elevating the affected arm, elevating the head of the bed, and avoiding the operative side promote fluid drainage and respiratory function. Positioning on the left side is contraindicated.

Correct positioning prevents complications like edema and compromised respiratory status.

Evaluate the safety and physiological stability measures.

The left arm must be protected from trauma (e.g., blood pressure cuffs, needles). Additionally, borderline vital signs like tachycardia and hypotension must be recognized as potential shock, not ignored.

Preventing limb injury and escalating critical vital signs are essential components of safe physiological care.

Key Concept

Postoperative basic care following a mastectomy with lymph node dissection includes preventing lymphedema, protecting the affected limb, promoting respiratory function, and maintaining vigilance for signs of hypovolemic shock.

Question 5Question →

A newly admitted client with a history of severe osteoporosis and bilateral cataracts is starting a prescribed loop diuretic regimen. The client has limited mobility and uses a rolling walker. Which actions are appropriate for the practical nurse (PN) to take regarding this client's safety and care? (Select all that apply.)

Select all that apply

Position a bedside commode directly adjacent to the bed on the client's strongest side.

Activate a weight-sensitive bed exit alarm to provide early warning if the client attempts to ambulate unassisted.

Place the client's eyeglasses, call light, and personal items within their immediate physical and visual reach.

Keep all four bed side rails in the raised and locked position while the client is sleeping to prevent falls.

Document any sudden onset of nighttime disorientation as an expected, age-related cognitive transition.

Accept the delegation to independently formulate and establish the client's initial comprehensive safety care plan.

Show answer & explanation

Answer: Position a bedside commode directly adjacent to the bed on the client's strongest side.; Activate a weight-sensitive bed exit alarm to provide early warning if the client attempts to ambulate unassisted.; Place the client's eyeglasses, call light, and personal items within their immediate physical and visual reach.

Answer

The appropriate actions are positioning a bedside commode nearby, activating a weight-sensitive bed exit alarm, and keeping the client's essential items within immediate physical and visual reach.

The correct actions focus on mitigating the client's specific risks while maintaining a safe, least-restrictive environment. Positioning a bedside commode addresses the urinary urgency caused by the loop diuretic, minimizing the distance the client must ambulate. Placing items within immediate reach accommodates the client's bilateral cataracts and prevents overreaching, which could lead to a fall. Activating a bed exit alarm provides a safe, non-restrictive alternative to physical restraints, alerting staff if the high-risk client attempts to get up unassisted.

Step-by-Step Solution

Analyze the client's clinical profile and identified risk factors.

The client has high fall and injury risks compounded by osteoporosis (fragile bones), cataracts (impaired vision), and a loop diuretic (which causes urinary urgency and frequency).

Identifying specific physiological and pharmacological risk factors is the first step in formulating targeted safety interventions.

Select interventions that safely address the identified risks without exceeding the PN scope of practice.

Safe interventions include placing a commode near the bed, keeping items within visual reach, and using a bed alarm.

These actions directly mitigate the risks of urinary urgency and visual impairment while providing safe monitoring.

Identify and eliminate actions that represent unsafe practices or scope violations.

Raising four side rails, dismissing sudden confusion as normal, and independently establishing the initial care plan are identified as inappropriate.

Four side rails act as a physical restraint, sudden confusion indicates acute delirium requiring investigation, and establishing the initial care plan requires RN-level clinical judgment.

Key Concept

Comprehensive injury prevention for high-risk clients requires non-restrictive safety measures, environmental modifications tailored to sensory deficits, and strict adherence to the PN scope of practice.

Question 6Question →

A practical nurse (PN) is employed at an outpatient specialty clinic that heavily utilizes electronic health records (EHR) and digital communication. Which actions by the PN demonstrate correct adherence to client confidentiality and information security standards? Select all that apply.

Select all that apply

Placing a printed daily schedule containing client names and appointment times into a locked destruction bin at the end of the shift.

Minimizing the active EHR screen on a mobile workstation before stepping into the hallway to retrieve a sterile dressing.

Using a facility-approved, encrypted smartphone application to transmit a photograph of a client's surgical incision to the attending provider.

Confirming a client's appointment time to a caller who identifies themselves as the client's employer and states they need to arrange shift coverage.

Accessing the laboratory results of a client assigned to another nurse in order to provide an update to the client's anxious spouse in the waiting area.

Refusing to provide a client's toxicology report to a uniformed police officer who lacks a valid subpoena or the client's written consent.

Show answer & explanation

Answer: Placing a printed daily schedule containing client names and appointment times into a locked destruction bin at the end of the shift.; Using a facility-approved, encrypted smartphone application to transmit a photograph of a client's surgical incision to the attending provider.; Refusing to provide a client's toxicology report to a uniformed police officer who lacks a valid subpoena or the client's written consent.

Answer

The correct actions are placing the printed schedule in a locked destruction bin, using a facility-approved encrypted application to transmit a clinical photograph, and refusing to release records to law enforcement without a subpoena or consent.

Adhering to confidentiality standards requires multiple layers of security. Placing printed schedules in a locked destruction bin ensures safe disposal of physical PHI. Utilizing facility-approved, encrypted applications guarantees that electronic transmissions of clinical data remain secure. Denying law enforcement access to records without a subpoena or consent upholds the client's legal right to privacy under HIPAA regulations.

Step-by-Step Solution

Evaluate the disposal method for physical documents containing protected health information.

Placing documents in a locked destruction bin secures them from unauthorized viewing.

HIPAA requires physical safeguards for printed records to ensure they cannot be intercepted before shredding.

Assess the security of digital devices and communication methods.

Using encrypted, facility-approved applications for clinical photos is secure and compliant, whereas merely minimizing an active screen is insecure.

Data must be encrypted in transit, and workstations must be fully locked or logged out when unattended to prevent unauthorized access.

Determine the legal boundaries for verbal and electronic disclosure to third parties.

Disclosing information to employers or unassigned clients' spouses, and releasing records to police without a subpoena, are violations of privacy.

PHI can only be shared with authorized individuals on a need-to-know basis or with explicit legal authorization.

Key Concept

HIPAA compliance requires securing physical documents, utilizing encrypted digital platforms, maintaining role-based EHR access, and requiring strict legal authorization prior to third-party disclosures.

Estimated Time:1m 30s

Question 7Question →

A practical nurse (PN) is providing basic care and comfort for an older adult client who returned to the unit 4 hours ago following a right femoral cardiac catheterization. The client has a history of mild dementia and requires assistance with activities of daily living (ADLs). Which actions should the PN include in the plan of care? (Select all that apply.)

Select all that apply

Assist with feeding while keeping the head of the bed elevated no more than 30 degrees.

Place the client on a fracture bedpan for elimination to minimize movement of the right leg.

Support the right leg with a trochanter roll to maintain proper alignment and promote comfort.

Assist the client to sit on the side of the bed to facilitate a comfortable position for a bed bath.

Delegate the evaluation of the client's right pedal pulse to the unlicensed assistive personnel (UAP) during hygiene care.

Attribute the client's sudden onset of extreme restlessness to their dementia and dim the room lights.

Show answer & explanation

Answer: Assist with feeding while keeping the head of the bed elevated no more than 30 degrees.; Place the client on a fracture bedpan for elimination to minimize movement of the right leg.; Support the right leg with a trochanter roll to maintain proper alignment and promote comfort.

Answer

The correct actions are to assist with feeding while keeping the head of the bed elevated no more than 30 degrees, use a fracture bedpan to minimize leg movement, and support the right leg with a trochanter roll.

Following a femoral cardiac catheterization, the client must remain on bed rest with the affected leg completely straight and the head of the bed elevated no more than 30 degrees to prevent dislodging the clot at the arterial puncture site. Using a fracture bedpan allows for elimination without excessive lifting or bending of the hips. A trochanter roll maintains alignment and prevents external rotation, promoting comfort. Assisting with feeding at a safe, low elevation ensures basic nutritional needs are met without compromising the surgical site.

Step-by-Step Solution

Identify the physiological constraints based on the recent procedure.

The client had a right femoral cardiac catheterization, which requires strict bed rest, the right leg to be kept completely straight, and the head of the bed to be elevated no more than 30 degrees.

Bending the hip increases pressure on the femoral artery puncture site, risking severe hemorrhage.

Evaluate the proposed basic care interventions against the procedural constraints.

Feeding at a 30-degree angle, using a fracture bedpan, and applying a trochanter roll all allow for necessary ADLs while maintaining the required straight-leg and low-elevation position.

Basic care must be adapted to prioritize client safety and prevent procedural complications.

Analyze the clinical presentation and delegation tasks for safety.

Evaluating a pedal pulse is an assessment that cannot be delegated, and sudden restlessness is a critical sign of potential shock, not a baseline dementia symptom.

The PN must practice within their legal scope and prioritize physiological life-threatening changes over routine comfort measures.

Key Concept

Adapting Basic Care to Post-Procedural Positioning Restrictions

Question 8Question →

While administering medications on a busy progressive care unit, a practical nurse (PN) encounters several situations involving the handling of protected health information (PHI). Which of the following actions demonstrate appropriate adherence to information security and confidentiality protocols? Select all that apply.

Select all that apply

Logging out of the electronic health record (EHR) system before stepping away from the mobile workstation to respond to a nearby bed alarm.

Providing the client's spouse with printed laboratory results after the spouse expresses severe anxiety about the client's current condition.

Providing a client's current vital signs to the respiratory therapist who is preparing to administer a scheduled nebulizer treatment to the client.

Confirming the time of a client's scheduled surgery to a telephone caller who successfully verifies the client's full name and date of birth.

Positioning the mobile workstation screen to face the wall while verifying a complex medication order with the pharmacy over the telephone.

Placing empty intravenous fluid bags containing intact client prescription labels into the regular waste receptacle inside the client's room.

Show answer & explanation

Answer: Logging out of the electronic health record (EHR) system before stepping away from the mobile workstation to respond to a nearby bed alarm.; Providing a client's current vital signs to the respiratory therapist who is preparing to administer a scheduled nebulizer treatment to the client.; Positioning the mobile workstation screen to face the wall while verifying a complex medication order with the pharmacy over the telephone.

Answer

The correct actions are logging out of the EHR system before leaving the workstation, providing vital signs to the respiratory therapist for treatment purposes, and positioning the screen away from public view during phone calls.

Appropriate information security requires safeguarding protected health information (PHI) across all formats. PNs must secure unattended workstations by logging off to prevent unauthorized access, even during emergencies. Sharing PHI with interdisciplinary team members, such as respiratory therapists, is legally permitted because it directly facilitates client treatment. Finally, positioning screens away from public view effectively prevents incidental visual disclosures in busy clinical areas.

Step-by-Step Solution

Analyze each scenario to determine if the disclosure or security practice aligns with HIPAA regulations and the need-to-know principle.

Identified that logging out of the EHR, sharing information with direct care providers, and physically shielding screens are acceptable and required practices.

Information security involves securing electronic devices, ensuring appropriate interdisciplinary communication for treatment, and preventing incidental disclosures.

Evaluate the scenarios involving unauthorized parties or improper disposal.

Identified that sharing PHI with a spouse without consent, confirming medical details over the phone using only basic demographics, and throwing intact prescription labels in regular trash are violations.

Good intentions do not override the legal requirement for explicit client consent, strict telephone verification protocols, and secure destruction of physical PHI.

Key Concept

Under HIPAA, nurses must secure physical, electronic, and verbal PHI. Disclosures are permitted for treatment, payment, and healthcare operations (e.g., to interdisciplinary team members), but require explicit authorization or passcodes for family members and telephone callers.

Question 9Question →

A practical nurse (PN) is reviewing the care requirements for a group of assigned clients at the beginning of a shift. Which of the following planned actions demonstrate appropriate application of risk reduction principles within the PN scope of practice? Select all that apply.

Select all that apply

Pausing a continuous enteral tube feeding before placing a client in a supine position for a linen change.

Accepting primary care responsibility for a newly admitted client who requires initiation and titration of a continuous intravenous heparin infusion.

Administering a scheduled oral dose of potassium chloride to a client whose morning serum potassium level is reported as 6.1 mEq/L.

Checking a client's most recent capillary blood glucose level prior to administering a scheduled dose of rapid-acting insulin.

Verifying a client's identity solely by checking the room number and bed assignment before administering a routine daily medication.

Documenting a subtle decrease in urine output and a heart rate increase from 82 to 108 beats/min as expected findings in a client with an active gastrointestinal bleed.

Show answer & explanation

Answer: Pausing a continuous enteral tube feeding before placing a client in a supine position for a linen change.; Checking a client's most recent capillary blood glucose level prior to administering a scheduled dose of rapid-acting insulin.

Answer

The appropriate actions that demonstrate risk reduction within the PN scope are pausing a continuous enteral tube feeding before placing a client supine, and checking a client's capillary blood glucose level prior to administering rapid-acting insulin.

Risk reduction is successfully achieved when the practical nurse adheres to safety protocols and practices within their defined scope. Pausing enteral feedings before laying a client flat prevents regurgitation and aspiration pneumonia. Checking a blood glucose level before administering rapid-acting insulin is a critical safeguard required to prevent iatrogenic hypoglycemia.

Step-by-Step Solution

Evaluate the risk of aspiration associated with continuous enteral feedings.

Pausing the feeding before laying the client flat is identified as a necessary action to prevent aspiration.

Maintaining the head of the bed elevated during and immediately after feedings uses gravity to keep stomach contents from refluxing.

Assess the PN scope of practice regarding intravenous therapy and patient assignments.

Accepting an assignment for a client requiring titration of continuous IV heparin is identified as an action outside the PN scope.

Titrating high-risk IV medications based on laboratory values requires the comprehensive assessment skills of a registered nurse.

Analyze laboratory values in relation to scheduled medications.

Administering additional potassium to a client with a serum level of 6.1 mEq/L is identified as unsafe.

A potassium level above 5.0 mEq/L is elevated; administering more potassium could cause fatal cardiac dysrhythmias.

Review the protocol for safe administration of high-alert medications like insulin.

Checking the blood glucose level prior to insulin administration is identified as a safe, required practice.

Insulin lowers blood sugar; administering it without knowing the current level risks inducing severe hypoglycemia.

Identify the standard requirements for safe client identification.

Using a room and bed number is identified as an unsafe client identification method.

Two unique, client-specific identifiers (such as name and date of birth) must be used to prevent medication errors.

Evaluate the clinical significance of vital sign trends in a client at risk for hemorrhage.

Dismissing tachycardia and decreased urine output in a bleeding client is identified as a dangerous failure to rescue.

These findings represent early compensatory mechanisms for hypovolemic shock and require immediate escalation rather than routine documentation.

Key Concept

Risk reduction involves practicing strictly within the established scope of practice, properly identifying clients using two unique identifiers, escalating critical laboratory and vital sign abnormalities, and performing procedural safeguards such as verifying blood glucose before insulin and preventing aspiration during enteral feeding.

Question 10Question →

An older adult client is admitted to the medical-surgical unit with a sacral pressure injury infected with Vancomycin-resistant *Enterococcus* (VRE). The healthcare provider has prescribed contact precautions. Which actions should the practical nurse implement? Select all that apply.

Select all that apply

Don a clean gown and gloves upon entering the client's room.

Discard the contaminated gown and gloves in a hallway receptacle after exiting the room.

Delegate the evaluation of the wound's drainage to the unlicensed assistive personnel (UAP).

Ensure that a dedicated stethoscope and thermometer remain inside the client's room for exclusive use.

Request a transfer to a private negative-pressure isolation room for this client.

Place the client in a room with another client who has an active VRE infection if a private room is unavailable.

Show answer & explanation

Answer: Don a clean gown and gloves upon entering the client's room.; Ensure that a dedicated stethoscope and thermometer remain inside the client's room for exclusive use.; Place the client in a room with another client who has an active VRE infection if a private room is unavailable.

Answer

The nurse should don a clean gown and gloves upon entering the room, ensure dedicated medical equipment remains inside the room, and cohort the client with another VRE-positive client if a private room is unavailable.

Contact precautions require the use of a gown and gloves upon entering the room to prevent transmission of epidemiologically important microorganisms like VRE. Medical equipment must be dedicated to a single client and left in the room to avoid cross-contamination. Furthermore, if a private room is unavailable, cohorting the client with another individual who has the identical active infection is an accepted infection control standard.

Step-by-Step Solution

Identify the mode of transmission for the organism specified in the scenario.

Vancomycin-resistant Enterococcus (VRE) is transmitted via direct or indirect contact.

Determining the transmission route dictates the specific isolation precautions required.

Select interventions that align with contact precautions.

Appropriate interventions include using a gown and gloves upon room entry, dedicating reusable equipment, and cohorting clients with the same infection.

These measures create a physical barrier and limit the spread of the pathogen to the hospital environment and other vulnerable clients.

Eliminate inappropriate actions related to doffing sequence, delegation, and incorrect precaution types.

Discarding PPE in the hallway, delegating assessment to a UAP, and using negative-pressure rooms are incorrect.

PPE must be doffed before exiting the room, UAPs cannot assess, and negative-pressure rooms are strictly for airborne pathogens.

Key Concept

Contact precautions require a private room or cohorting, dedicated equipment, and the use of a gown and gloves upon entry and removed before exiting.

Question 11Question →

A practical nurse (PN) is collecting data on a 78-year-old client who is receiving intravenous antibiotics for a severe urinary tract infection. Which of the following assessment findings should the PN identify as early indicators of systemic decompensation and report to the registered nurse (RN) immediately? Select all that apply.

Select all that apply

A resting heart rate of 114 beats/min and a blood pressure of 96/58 mm Hg

New-onset restlessness and the client stating they are waiting for a train

A respiratory rate of 26 breaths/min with shallow chest expansion

The client reports a pain level of 4 on a 0 to 10 scale localized to the suprapubic area

The client's most recent void yielded 150 mL of cloudy, foul-smelling urine

The client's spouse reports the client has experienced gradual forgetfulness over the past two years

Show answer & explanation

Answer: A resting heart rate of 114 beats/min and a blood pressure of 96/58 mm Hg; New-onset restlessness and the client stating they are waiting for a train; A respiratory rate of 26 breaths/min with shallow chest expansion

Answer

The correct findings are a resting heart rate of 114 beats/min with a blood pressure of 96/58 mm Hg, new-onset restlessness with confusion, and a respiratory rate of 26 breaths/min.

The correct options indicate acute systemic deterioration (sepsis), prioritizing Airway, Breathing, and Circulation (ABC) issues. Tachycardia with borderline hypotension suggests early shock. Tachypnea is a primary respiratory compensatory mechanism during systemic stress. Furthermore, older adults frequently exhibit acute confusion (delirium) as a primary sign of hypoxia or worsening infection.

Step-by-Step Solution

Analyze the client's current diagnosis and primary risk factors.

The older adult client has a severe urinary tract infection, placing them at high risk for the infection spreading systemically (sepsis).

Identifying the primary risk helps distinguish expected localized symptoms from emergent systemic complications.

Evaluate vital signs for Airway, Breathing, and Circulation (ABC) compromise.

A heart rate of 114 beats/min with borderline hypotension (96/58 mm Hg) and a respiratory rate of 26 breaths/min indicate physiological stress.

ABCs are the highest priority in acute care, and these borderline vital signs are classic early indicators of shock and respiratory decompensation.

Assess for acute neurological changes compared to baseline.

New-onset restlessness and confusion (delirium) are critical acute findings, distinguishing them from the chronic gradual forgetfulness reported by the spouse.

In older adults, acute mental status changes are often the first sign of hypoxia or systemic infection.

Compare emergent findings with expected localized symptoms.

Mild suprapubic pain and cloudy urine are localized, expected findings that do not require immediate emergency escalation.

Prioritization requires the nurse to address systemic physiological instability before expected, chronic, or local symptoms.

Key Concept

Physiological Adaptation: Recognizing Early Signs of Systemic Decompensation and Sepsis

Estimated Time:1m 30s

Question 12Question →

A client with a continuous intravenous (IV) infusion is scheduled for transport to the radiology department. The client appears restless and repeatedly grasps at the IV tubing. Which actions should the practical nurse implement to prevent accidental dislodgement and maintain a safe environment? (Select all that apply.)

Select all that apply

Obscure the IV insertion site by wrapping it loosely with a conforming bandage or stockinette.

Apply bilateral soft wrist restraints to secure the client's hands during the transport process.

Provide a textured item, such as a folded washcloth, for the client to hold in the unaffected hand.

Instruct the transport personnel to silence and adjust the IV pump infusion rate if an occlusion alarm sounds.

Arrange for an unlicensed assistive personnel (UAP) to ride along and sit directly beside the client.

Show answer & explanation

Answer: Obscure the IV insertion site by wrapping it loosely with a conforming bandage or stockinette.; Provide a textured item, such as a folded washcloth, for the client to hold in the unaffected hand.; Arrange for an unlicensed assistive personnel (UAP) to ride along and sit directly beside the client.

Answer

The correct interventions are obscuring the IV site, providing a sensory diversion item, and assigning a UAP to accompany the client.

The correct actions focus on prioritizing client safety using least-restrictive methods and appropriate delegation. Obscuring the IV site removes the visual trigger, providing a washcloth offers a safe sensory distraction for restless hands, and having a UAP accompany the client ensures immediate supervision and redirection.

Step-by-Step Solution

Analyze the client's behavior and the risk presented.

The client is restless and grasping at the IV tubing, creating a high risk for accidental dislodgement and subsequent injury or bleeding.

Identifying the specific safety hazard dictates the necessary interventions.

Evaluate the proposed interventions against the principle of least restrictive restraints.

Applying wrist restraints is a restrictive measure and a last resort. Hiding the site, providing a distraction, and using a sitter are least-restrictive alternatives.

Nursing standards require attempting and documenting least-restrictive alternatives before utilizing physical restraints.

Evaluate the delegation and assignment aspects of the interventions.

Assigning a UAP to sit with the client is an appropriate delegation of a routine safety task. However, delegating the adjustment of an IV pump to transport personnel is outside their scope of practice.

The practical nurse must only delegate tasks that fall within the receiver's scope of practice and training to ensure client safety.

Key Concept

Implementing least restrictive alternatives and appropriate delegation to maintain client safety.

Question 13Question →

A practical nurse (PN) is reviewing the medication administration record (MAR) and morning laboratory results for assigned clients. Identify the actions that represent safe and appropriate practice for the PN. Select all that apply.

Select all that apply

Withhold scheduled subcutaneous enoxaparin for a client with a morning platelet count of

75,000\text{/mm}^3

and notify the registered nurse.

Accept a delegated task from the registered nurse to administer an initial intravenous (IV) push dose of hydromorphone for a client experiencing severe pain.

Reinforce teaching for a client starting oral rifampin that their urine, sweat, and tears may turn a harmless red-orange color.

Administer a scheduled dose of oral metoprolol to a client who has an asymptomatic resting heart rate of

54\text{ beats/min}

Administer a prescribed oral potassium chloride supplement to a client with a morning serum potassium level of

3.2\text{ mEq/L}

Bypass the barcode medication administration scanner during a temporary system outage and identify the client using only their room number.

Show answer & explanation

Answer: Withhold scheduled subcutaneous enoxaparin for a client with a morning platelet count of $75,000\text{/mm}^3$ and notify the registered nurse.; Reinforce teaching for a client starting oral rifampin that their urine, sweat, and tears may turn a harmless red-orange color.; Administer a prescribed oral potassium chloride supplement to a client with a morning serum potassium level of $3.2\text{ mEq/L}$ .

Answer

The correct actions are withholding enoxaparin for thrombocytopenia, reinforcing teaching about expected side effects of rifampin, and administering potassium chloride for hypokalemia.

Safe pharmacological practice for the practical nurse involves withholding enoxaparin when the platelet count is critically low to prevent hemorrhage, educating clients on harmless but startling medication side effects (like rifampin causing red-orange secretions), and appropriately treating documented electrolyte deficits (such as administering potassium for hypokalemia).

Step-by-Step Solution

Evaluate the clinical data and prescribed medication for each client scenario.

Identify therapeutic indications, potential contraindications, and required monitoring for the specific drug classes (anticoagulants, antimicrobials, electrolytes, beta-blockers, opioids).

To ensure clinical safety and prevent adverse pharmacological events.

Analyze each proposed nursing action against the established LPN/PN scope of practice.

Differentiate between tasks that are safe to perform (administering oral/subcutaneous medications, reinforcing teaching) and tasks that must be refused or escalated (IV push medications, ignoring critical safety parameters).

To maintain legal practice boundaries and ensure the highest level of client safety.

Key Concept

The practical nurse must integrate pharmacological knowledge with strict adherence to scope of practice, ensuring safe medication administration, accurate monitoring of laboratory values, and appropriate client teaching reinforcement.

Question 14Question →

A practical nurse (PN) is preparing to administer the measles, mumps, and rubella (MMR) live vaccine to an adult female client in a community health clinic. Which of the following actions should the PN take to ensure safe practice? Select all that apply.

Select all that apply

Inquire if the client is currently pregnant or plans to become pregnant within the next four weeks.

Withhold the vaccine and notify the registered nurse if the client is currently receiving immunosuppressive therapy.

Proceed with the immunization without assessing for gelatin or neomycin allergies if the client has received previous vaccines.

Bypass the barcode scanning process because the vaccine is administered as a standard, prepackaged dose.

Calculate the required medication volume to administer by converting the client's current weight from pounds to kilograms.

Accept a delegated task to administer a newly prescribed intravenous (IV) push antibiotic to the client during the same visit.

Show answer & explanation

Answer: Inquire if the client is currently pregnant or plans to become pregnant within the next four weeks.; Withhold the vaccine and notify the registered nurse if the client is currently receiving immunosuppressive therapy.

Answer

The correct actions are to inquire if the client is pregnant or plans to become pregnant, and to withhold the vaccine if the client is receiving immunosuppressive therapy.

The MMR vaccine is a live attenuated virus. It is strictly contraindicated during pregnancy due to the risk of fetal harm, and clients should be advised to avoid pregnancy for at least four weeks after vaccination. Additionally, live vaccines are contraindicated in clients who are severely immunocompromised (such as those receiving immunosuppressive therapy), as they can cause severe or fatal infections. Therefore, the practical nurse must actively screen for these conditions before administration.

Step-by-Step Solution

Identify the medication classification and properties.

The MMR vaccine is a live attenuated viral vaccine.

Understanding that the vaccine contains live viruses helps identify absolute contraindications related to immune function and fetal safety.

Evaluate the client's current health status against known contraindications.

Pregnancy and severe immunosuppression are absolute contraindications for live vaccines.

Live vaccines can cross the placenta or cause severe systemic infection in clients lacking an adequate immune response.

Review the practical nurse (PN) scope of practice and medication safety standards.

The PN must perform all medication rights verification, recognize that adult MMR doses are standardized rather than weight-based, and refuse tasks outside their scope, such as IV push administration.

Adhering to strict safety standards and scope of practice prevents patient harm and professional liability.

Key Concept

Safe administration of live attenuated vaccines and adherence to the practical nurse scope of practice.

Question 15Question →

The practical nurse (PN) is reviewing the morning assessment data and medication administration record (MAR) for a $65$ -year-old client admitted with chronic kidney disease and hypertension.

Assessment Data	Current Finding
Blood pressure	$142/88$ mmHg
Heart rate	$64$ beats/minute
Respiratory rate	$18$ breaths/minute
Oxygen saturation	$96\%$ on room air
Serum potassium	$5.9$ mEq/L ( $5.9$ mmol/L)

Scheduled Medications:
* Lisinopril $20$ mg PO daily
* Sodium polystyrene sulfonate $15$ g PO stat
* Metoprolol $5$ mg IV push stat
* Influenza virus vaccine (inactivated) $0.5$ mL IM once

Based on this data, which actions by the PN are appropriate? Select all that apply.

Select all that apply

Withhold the scheduled oral lisinopril and immediately report the hyperkalemia to the registered nurse (RN).

Administer the oral sodium polystyrene sulfonate after verifying the client's full name and date of birth.

Notify the charge nurse that the stat IV push metoprolol requires administration by an RN.

Administer the stat IV push metoprolol slowly over

2

minutes while observing the client for hypotension.

Verify the client's identity using their room number and physical location before administering the influenza vaccine.

Withhold the influenza vaccine because the client reports experiencing a mild, localized rash at the injection site after last year's dose.

Show answer & explanation

Answer: Withhold the scheduled oral lisinopril and immediately report the hyperkalemia to the registered nurse (RN).; Administer the oral sodium polystyrene sulfonate after verifying the client's full name and date of birth.; Notify the charge nurse that the stat IV push metoprolol requires administration by an RN.

Answer

The practical nurse should withhold the oral lisinopril and notify the RN, safely administer the oral sodium polystyrene sulfonate using proper client identifiers, and notify the charge nurse that the IV push metoprolol requires RN administration.

The client's serum potassium level of

5.9

mEq/L indicates hyperkalemia. Because ACE inhibitors like lisinopril cause potassium retention, the scheduled dose must be withheld and the registered nurse (RN) notified to prevent cardiac complications. Administering oral sodium polystyrene sulfonate is an appropriate action to treat hyperkalemia, provided the PN verifies the client's identity using two client-specific identifiers (such as full name and date of birth). Furthermore, because administering medications via direct intravenous (IV) push typically exceeds the PN scope of practice, the PN must advocate for client safety by notifying the charge nurse that an RN is required to administer the IV metoprolol.

Step-by-Step Solution

Analyze the client's laboratory results in relation to the prescribed medications.

The serum potassium level is

5.9

mEq/L, indicating hyperkalemia. Lisinopril is an ACE inhibitor that can cause further potassium retention, whereas sodium polystyrene sulfonate is prescribed to lower potassium levels.

Identifying contraindications based on current laboratory data prevents potentially life-threatening adverse events.

Determine the legal boundaries of the practical nurse (PN) scope of practice.

The PN can safely administer oral (PO) and intramuscular (IM) medications, but administering intravenous (IV) push medications must be deferred to the RN.

Nurses must practice strictly within their legal scope to ensure safe, competent client care.

Evaluate the safety principles for medication identification and vaccine contraindications.

Safe administration requires two client-specific identifiers (excluding room numbers). Additionally, a mild localized reaction to a previous vaccine is not a valid contraindication for current administration.

Adhering strictly to medication safety rights and evidence-based immunization guidelines minimizes the risk of clinical errors.

Key Concept

Safe pharmacological therapy requires integrating client laboratory data to withhold contraindicated medications, adhering strictly to the PN scope of practice, and applying evidence-based medication safety standards.

Question 16Question →

Following the morning handoff report, a practical nurse (PN) begins data collection for a group of assigned clients. Which client findings represent acute physiological deterioration and require immediate intervention? Select all that apply.

Select all that apply

A client with a deep vein thrombosis who suddenly develops a cough and rapid breathing.

A client who is 2 hours post-appendectomy and exhibits a steady heart rate increase from 80 to 115 beats per minute.

A client receiving intravenous insulin whose skin becomes pale, cold, and clammy while becoming highly agitated.

A client with a closed tibia fracture who is crying and urgently requesting pain medication.

An older adult client with advanced dementia who is completely unable to state their current location.

A client who is 24 hours postpartum and has saturated one perineal pad over the past 4 hours.

Show answer & explanation

Answer: A client with a deep vein thrombosis who suddenly develops a cough and rapid breathing.; A client who is 2 hours post-appendectomy and exhibits a steady heart rate increase from 80 to 115 beats per minute.; A client receiving intravenous insulin whose skin becomes pale, cold, and clammy while becoming highly agitated.

Answer

The correct findings indicating acute physiological deterioration are the client with a deep vein thrombosis developing a cough and rapid breathing, the post-appendectomy client with a rising heart rate, and the client on insulin exhibiting pale, clammy skin with agitation.

The correct findings all represent acute, life-threatening physiological changes. Sudden respiratory distress in a DVT client suggests a pulmonary embolism. A rising heart rate post-surgery is a classic early sign of internal bleeding and shock. Agitation with cold, clammy skin during insulin therapy indicates profound hypoglycemia. All three require immediate nursing intervention.

Step-by-Step Solution

Evaluate the client with deep vein thrombosis (DVT) for airway and breathing compromise.

The sudden onset of a cough and rapid breathing indicates a potential pulmonary embolism.

DVT clots can dislodge and travel to the lungs, creating a severe, life-threatening respiratory emergency.

Evaluate the post-appendectomy client and the client receiving insulin for systemic instability.

The rising heart rate indicates early hypovolemic shock, and pale, clammy skin with agitation indicates severe hypoglycemia.

Both represent acute, life-threatening circulatory and metabolic changes that demand urgent medical treatment.

Evaluate the remaining clients to differentiate acute deterioration from expected or non-emergent findings.

The clients with the tibia fracture, advanced dementia, and postpartum status have expected or non-life-threatening findings.

Expected pain, baseline cognitive disorientation, and normal lochia flow do not take precedence over ABC emergencies.

Key Concept

Prioritization of Acute Physiological Deterioration

Question 17Question →

An adult client is recovering on the surgical unit 12 hours after a total thyroidectomy. The practical nurse is planning care to prevent and identify potential postoperative emergencies. Which of the following actions should the nurse include? Select all that apply.

Select all that apply

Verify that an emergency tracheostomy kit and functioning suction equipment are present at the bedside.

Monitor the client for reports of numbness or tingling around the mouth and fingertips.

Check the surgical dressing and the back of the client's neck for unexpected pooling of blood.

Maintain the client in a flat, supine position to prevent flexion of the neck.

Administer prescribed intravenous push calcium gluconate immediately if tetany develops.

Document a new resting heart rate of 105 beats per minute without immediately notifying the registered nurse.

Show answer & explanation

Answer: Verify that an emergency tracheostomy kit and functioning suction equipment are present at the bedside.; Monitor the client for reports of numbness or tingling around the mouth and fingertips.; Check the surgical dressing and the back of the client's neck for unexpected pooling of blood.

Answer

The appropriate actions are verifying emergency airway equipment is at the bedside, monitoring for perioral and extremity numbness, and checking the back of the neck for blood pooling.

Appropriate risk reduction following a thyroidectomy includes preparing for potential airway emergencies, assessing for hidden bleeding behind the neck, and closely monitoring for signs of parathyroid gland damage (hypocalcemia), such as perioral tingling.

Step-by-Step Solution

Identify the client's specific surgical risks based on the procedure.

Primary risks include airway obstruction, hidden hemorrhage, and hypocalcemia.

A thyroidectomy involves the anterior neck, placing the airway, major blood vessels, and parathyroid glands at risk.

Evaluate the proposed monitoring actions against these specific risks.

Actions targeting airway preparation, detecting subtle hemorrhage, and recognizing calcium deficit signs are appropriate.

These actions actively reduce the potential for severe complications and align with established protocols.

Identify actions that are outside the scope of practice or clinically contraindicated.

Supine positioning, administering IV push medications, and delaying reports of tachycardia are unsafe.

These actions violate the practical nurse's scope of practice, post-procedure positioning standards, and early escalation requirements.

Key Concept

Reduction of postoperative risks following a thyroidectomy requires anticipating airway compromise, assessing for hidden hemorrhage, monitoring for hypocalcemia, and operating strictly within the practical nursing scope of practice.

Question 18Question →

A licensed practical nurse (LPN) is assisting with the care of a client who is 12 hours postoperative following an open cholecystectomy and has a nasogastric tube connected to low wall suction. Which of the following independent or collaborative actions by the LPN demonstrate appropriate risk reduction strategies? Select all that apply.

Select all that apply

Reporting a morning serum potassium level of 3.1 mEq/L (3.1 mmol/L) to the registered nurse immediately upon viewing the laboratory results.

Attributing a new heart rate of 112 beats per minute and a blood pressure of 98/62 mm Hg to postoperative pain and administering prescribed oral analgesics without further escalation.

Silencing an intravenous infusion pump alarm and hanging a replacement bag of normal saline without rechecking the client's identification band, since the client was verified earlier in the shift.

Verifying the placement of the nasogastric tube by assessing the pH of aspirated gastric contents prior to administering any prescribed enteral medications.

Accepting a delegated task from the charge nurse to perform the initial admission assessment and develop the care plan for a new client transferred from the intensive care unit.

Applying prescribed sequential compression devices (SCDs) to the client's lower extremities while the client is resting in bed.

Show answer & explanation

Answer: Reporting a morning serum potassium level of 3.1 mEq/L (3.1 mmol/L) to the registered nurse immediately upon viewing the laboratory results.; Verifying the placement of the nasogastric tube by assessing the pH of aspirated gastric contents prior to administering any prescribed enteral medications.; Applying prescribed sequential compression devices (SCDs) to the client's lower extremities while the client is resting in bed.

Answer

The correct risk reduction strategies are reporting the low potassium level, verifying nasogastric tube placement via pH aspirate, and applying sequential compression devices for venous thromboembolism prophylaxis.

Appropriate risk reduction requires the practical nurse to proactively identify and mitigate potential client harm. This includes recognizing abnormal laboratory values, such as a hypokalemic potassium level of 3.1 mEq/L caused by gastric suctioning, and immediately reporting them. Furthermore, implementing evidence-based practices like verifying nasogastric tube placement via aspirate pH and applying sequential compression devices directly prevents life-threatening complications such as pulmonary aspiration and deep vein thrombosis.

Step-by-Step Solution

Analyze the client's risk factors based on the clinical presentation.

The client is postoperative and undergoing continuous nasogastric suction, which introduces risks for hypovolemia, electrolyte imbalances (specifically hypokalemia), deep vein thrombosis, and aspiration.

Identifying specific risks based on the surgical procedure and active treatments guides the selection of appropriate preventative interventions.

Evaluate the laboratory finding and vital signs for necessary escalation.

The potassium level of 3.1 mEq/L is below the normal range (3.5-5.0 mEq/L) and must be reported. The vital signs (HR 112, BP 98/62) are borderline and suggest early shock, making it unsafe to attribute them solely to pain.

Risk reduction requires the timely recognition and communication of physiological deterioration.

Review the nursing actions for adherence to safety protocols and scope of practice.

Checking aspirate pH and applying SCDs are correct, safe practices. However, skipping patient identifiers for IV fluids and accepting an initial admission assessment violate core safety standards and the practical nursing scope of practice.

Bypassing established safety protocols or operating outside defined licensure limits directly increases the risk of client harm.

Key Concept

Reduction of Risk Potential requires the practical nurse to proactively identify early signs of complications (like abnormal labs or vital signs), verify the safe functioning of therapeutic devices, and adhere strictly to safety protocols and scope of practice boundaries.

Question 19Question →

A practical nurse (PN) is reviewing the legal and ethical guidelines of nursing practice on a medical-surgical unit. Which of the following actions by the PN are legally and ethically appropriate? Select all that apply.

Select all that apply

Witnessing a client's signature on a surgical consent form after the provider has completed the explanation.

Declining a delegated task from the charge nurse to administer an intravenous push (IVP) cardiac medication.

Explaining the potential complications of an upcoming procedure to a client who has questions before signing the consent form.

Discussing a client's complex medical history with an unassigned colleague while riding in the public hospital elevator.

Accepting an assignment to perform the comprehensive admission assessment and formulate the initial care plan for a new client.

Waiting to report suspected physical abuse of a vulnerable adult until concrete proof can be obtained from the family.

Show answer & explanation

Answer: Witnessing a client's signature on a surgical consent form after the provider has completed the explanation.; Declining a delegated task from the charge nurse to administer an intravenous push (IVP) cardiac medication.

Answer

The legally and ethically appropriate actions are witnessing a client's signature on a surgical consent form after the provider's explanation, and declining to administer an intravenous push (IVP) cardiac medication.

The practical nurse acts within their legal and ethical scope by witnessing informed consent only after the provider has explained the procedure, and by refusing delegated tasks that require advanced assessment, such as administering intravenous push medications.

Step-by-Step Solution

Identify the scope of practice and ethical obligations for a practical nurse (PN).

The practical nurse role involves assisting with care, observing, and performing stable tasks, but excludes initial assessments, intravenous push medications, and explaining surgical risks.

Establishing the baseline legal boundaries is required to evaluate which actions in the options are legally and ethically appropriate.

Evaluate the first two actions for appropriateness.

Witnessing a consent signature after the provider's explanation and declining an out-of-scope intravenous push medication are both correct and legally sound actions.

These actions adhere to the nurse practice act, protect the client, and ensure the practical nurse operates safely within their designated scope.

Analyze the remaining actions to identify legal or ethical violations.

Explaining surgical complications, discussing client cases in public, performing initial care plans, and delaying abuse reporting all violate legal or ethical standards.

These actions breach confidentiality, exceed the practical nurse scope of practice, or violate mandated reporting laws.

Key Concept

Practical Nurse Scope of Practice, Confidentiality, and Mandated Reporting

Question 20Question →

A practical nurse (PN) is caring for a client with mild dementia who is receiving continuous intravenous (IV) fluids and has a high risk for falls. Which interventions should the PN implement to maintain a safe environment and prevent injuries? Select all that apply.

Select all that apply

Maintain the bed in the lowest possible position with the wheels locked when the client is resting.

Secure the IV tubing to the client's hospital gown using a clip while they are out of bed.

Ensure the client's call light, eyeglasses, and frequently used items are placed within easy reach.

Raise all four side rails on the bed while the client is sleeping to prevent an accidental fall.

Complete the initial comprehensive fall risk assessment to establish the client's baseline safety needs.

Leave prescribed oral medications on the bedside table to avoid waking the sleeping client.

Show answer & explanation

Answer: Maintain the bed in the lowest possible position with the wheels locked when the client is resting.; Secure the IV tubing to the client's hospital gown using a clip while they are out of bed.; Ensure the client's call light, eyeglasses, and frequently used items are placed within easy reach.

Answer

The correct interventions are maintaining the bed in the lowest locked position, securing the IV tubing to the gown, and keeping essential items within easy reach.

Maintaining the bed in its lowest, locked position minimizes injury risk if a fall occurs and provides stability during transfers. Securing IV lines prevents accidental dislodgement and reduces tripping hazards when the client moves. Keeping essential items like the call light and eyeglasses within reach prevents the client from stretching or leaving the bed unassisted, directly mitigating fall triggers.

Step-by-Step Solution

Identify the client's specific risk factors based on the clinical scenario.

The client has mild dementia, is receiving continuous IV fluids, and is at high risk for falls.

Understanding the client's vulnerabilities helps prioritize the most appropriate safety interventions.

Evaluate each potential intervention for safety, effectiveness, and adherence to the PN scope of practice.

Keeping the bed low, securing lines, and placing items within reach are safe, standard practices. Using four side rails is an inappropriate restraint. Leaving medications is unsafe. Initial assessments are out of the PN scope.

Interventions must directly mitigate fall risks without violating safety protocols, legal scopes of practice, or evidence-based guidelines.

Select the appropriate interventions that safely prevent accidents and injuries.

The correct actions are maintaining a low bed, securing the IV tubing, and keeping items within reach.

These actions address the environmental hazards directly related to the client's condition and medical equipment.

Key Concept

Accident and Injury Prevention in Fall-Risk Clients

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