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Soru 181Soru →

A competent adult client informs the practical nurse (PN) that they wish to designate their oldest child as their healthcare proxy and create a living will. Arrange the actions the PN should take in the correct chronological order.

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Cevap

The correct sequence is: First, determine the client's current understanding. Second, provide the facility's standardized written information. Third, notify the registered nurse and request a social services consultation. Finally, document the actions in the medical record.
Clinical prioritization requires following the nursing process. Data collection (determining understanding) comes first. Next, the PN implements care within their scope by providing standardized information. The PN then advocates for the client by communicating the need for advanced assistance to the RN and social worker. Finally, all actions must be accurately documented in the client's medical record.

Adım Adım Çözüm

1
Determine the client's current understanding of advance directives.
The PN establishes a baseline for the client's knowledge and needs.
Data collection must always precede nursing interventions to ensure that care is individualized and appropriate.
2
Provide the client with the facility's standardized written information about advance directives.
The client receives factual, approved information to help them make an informed decision.
The Patient Self-Determination Act requires healthcare facilities to provide written information regarding advance directives, which is within the PN's scope to distribute and reinforce.
3
Notify the registered nurse (RN) and request a social services consultation.
The appropriate interdisciplinary team members are mobilized to assist the client.
While the PN can provide standard information, completing and witnessing complex legal forms such as a healthcare proxy typically requires collaboration with a social worker or the RN.
4
Document the client's request, the materials provided, and the referrals made in the medical record.
A permanent legal record of the advocacy actions is created.
Documentation should accurately reflect all nursing actions and client interactions immediately after they occur.

Anahtar Kavram

The practical nurse's role in client advocacy regarding advance directives involves initial data collection, providing standardized information, collaborating with the interdisciplinary team for legal execution, and comprehensive documentation.
Soru 182Soru →

A client with advanced dementia is at high risk for severe falls and has a new prescription for a belt restraint while sitting in a wheelchair. The practical nurse (PN) is preparing to initiate the use of the restraint. Arrange the following actions the PN should take in the correct chronological order from first to last.

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The correct sequence is to first verify the prescription, explain the procedure to the client, place the restraint over clothing, check the fit with two fingers, and finally secure the ties to the structural wheelchair frame.
The proper sequence for restraint application begins with verifying the provider's prescription to ensure authorization. The nurse then communicates with the client to explain the procedure and reduce anxiety. Next, the restraint is positioned over clothing to protect the skin from breakdown. The nurse subsequently evaluates the fit by sliding two fingers underneath the restraint to prevent constriction of breathing or circulation. Lastly, the restraint is anchored to a stable, structural component of the wheelchair with a quick-release knot, ensuring it can be removed immediately if a safety emergency occurs.

Adım Adım Çözüm

1
Verify the healthcare provider's current prescription for the restraint.
Ensures legal and clinical appropriateness.
Restraints cannot be applied without a valid medical order, except in extreme emergencies where an order must be obtained immediately after application.
2
Explain the purpose of the restraint to the client in a calm and reassuring manner.
Promotes cooperation and respects client rights.
Communication is essential to decrease fear and agitation, even when caring for clients with advanced dementia.
3
Place the belt restraint around the client's waist, over their clothing or gown.
Protects the client's skin from direct contact.
Applying restraints directly to bare skin increases the risk of friction and skin breakdown over time.
4
Slide two fingers between the restraint and the client's body to ensure adequate fit.
Prevents injury and respiratory restriction.
A properly fitted belt restraint allows two fingers to fit between the device and the client, ensuring it is secure but not overly constrictive.
5
Attach the restraint ties to the structural frame of the wheelchair using a quick-release knot.
Secures the device safely while allowing emergency access.
Ties must be attached to a non-removable part of the chair (not armrests or footrests) using a knot that allows for rapid release.

Anahtar Kavram

The correct procedural steps for applying a restraint prioritize legal verification, client communication, safe physical application, fit assessment, and secure attachment for emergency accessibility.
Soru 183Soru →

A client admitted with a severe novel respiratory virus is placed on airborne, contact, and eye precautions requiring full personal protective equipment (PPE). A practical nurse is at the dedicated donning station outside the client's room. Place the following steps for donning PPE in the correct chronological sequence.

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The correct sequence for donning full PPE is: hand hygiene, gown, N95 respirator, face shield/goggles, and finally gloves.
According to the Centers for Disease Control and Prevention (CDC) guidelines, the safest chronological sequence for donning full PPE begins with hand hygiene to prevent contamination. Next, the gown is applied to cover the torso and arms. The mask or respirator is then placed and sealed to protect the airway, followed by eye protection to prevent mucous membrane exposure. Finally, gloves are donned last so they can be securely pulled over the gown's cuffs, creating a continuous barrier.

Adım Adım Çözüm

1
Perform hand hygiene.
Hands are clean and ready to handle uncontaminated PPE.
Prevents the transfer of pathogens from the nurse's hands onto the clean protective equipment.
2
Don the isolation gown.
The torso and arms are protected.
The gown requires tying at the neck and waist, which is easiest to do without gloves or face gear in the way.
3
Apply the N95 respirator.
The respiratory tract is protected.
The respirator must sit directly against the skin to form a tight seal; applying it before eye protection ensures the straps are correctly positioned.
4
Apply the face shield or goggles.
The eyes and mucous membranes are protected from splashes.
Eye protection sits over the bridge of the nose and the respirator straps, completing facial protection.
5
Don gloves.
Hands are protected and the wrist gap is sealed.
Gloves are placed last so they can be pulled up and over the cuffs of the isolation gown, leaving no skin exposed.

Anahtar Kavram

Standard Sequence for Donning Personal Protective Equipment (PPE)
Soru 184Soru →

A practical nurse (PN) is preparing to transfer a client from the bed to a bedside chair for the first time following abdominal surgery. To ensure client safety and comfort, in what order should the PN perform the following actions? (Arrange the steps in the correct chronological sequence.)

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The nurse must first raise the head of the bed, assist the client to sit on the edge, allow them to dangle while assessing for dizziness, apply a transfer belt, and finally assist them to stand and pivot into the chair.
Safe mobility for a post-operative client requires a deliberate, step-by-step approach to prevent orthostatic hypotension and protect the surgical site. The head of the bed is elevated first to initiate cardiovascular adjustment and ease movement. After pivoting to the edge of the bed, the client must dangle to ensure they are not experiencing dizziness. Only after stability is confirmed is a transfer belt applied to provide physical support. Finally, the nurse assists the client to stand and pivot into the chair.

Adım Adım Çözüm

1
Raise the head of the bed to a high-Fowler's position.
The client is transitioned from a supine to an upright seated position in bed.
This gradually introduces orthostatic changes and minimizes physical strain on the abdominal surgical site when moving.
2
Assist the client to pivot and sit on the edge of the bed.
The client is positioned at the edge of the mattress with their feet toward the floor.
This is a prerequisite physical maneuver before weight-bearing and standing.
3
Allow the client to dangle their legs while assessing for dizziness.
The client rests in a seated position while the nurse evaluates their physiological tolerance.
Post-operative clients are at high risk for orthostatic hypotension. Dangling prevents syncope and potential falls.
4
Apply a transfer belt securely around the client's waist.
The nurse establishes a safe, mechanical gripping point on the client.
Applying the belt while the client is sitting ensures it is snug and ready for the standing transfer without compromising the client's balance.
5
Assist the client to stand, pivot, and sit in the bedside chair.
The client is safely relocated from the bed to the chair.
This finalizes the transfer using safe body mechanics and physical support.

Anahtar Kavram

Safe Post-Operative Client Transfer and Positioning
Soru 185Soru →

A practical nurse (PN) is preparing to administer prescribed ophthalmic drops to a client with glaucoma. In what order should the PN perform the following actions? Arrange the steps from first to last.

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The correct sequence is: Verify identity and medication, position the client's head, expose the conjunctival sac, instill the drops, and apply pressure to the nasolacrimal duct.
Safe and effective administration of eye drops follows a specific anatomical and safety sequence. First, baseline safety checks must be completed. Second, the client is positioned to comfortably receive the medication. Third, the conjunctival sac is exposed to create a safe pouch. Fourth, the medication is instilled into this pouch to avoid direct corneal trauma. Finally, pressure is applied to the nasolacrimal duct (inner canthus) to prevent the medication from draining into the nasal mucosa and causing unintended systemic effects.

Adım Adım Çözüm

1
Verify identity and medication.
The correct client is identified for the correct medication.
This is the fundamental first step of all medication administration procedures to prevent medication errors.
2
Instruct the client to tilt their head backward and look upward.
The eye is properly positioned for administration.
This position uses gravity to help keep the medication in the eye and moves the cornea away from the lower lid.
3
Pull down gently on the lower eyelid.
The conjunctival sac is exposed.
Creating a small pouch allows the medication to be held in the eye safely without striking the sensitive cornea.
4
Instill the drops into the lower conjunctival sac.
Medication is delivered to the eye.
Placing it in the sac ensures proper distribution across the eye surface when the client blinks.
5
Apply gentle pressure to the nasolacrimal duct.
The tear duct is temporarily blocked.
This prevents the medication from draining into the nasal mucosa and causing unintended systemic absorption.

Anahtar Kavram

Safe administration of ophthalmic medications requires verifying safety checks, correct client positioning, instillation into the conjunctival sac, and prevention of systemic absorption.
Soru 186Soru →

An older adult client with generalized weakness is prescribed to sit in a wheelchair for meals. The nurse is preparing to perform a stand-and-pivot transfer using a gait belt. Place the following steps in the correct chronological order.

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The correct sequence ensures environmental safety first, prepares the client physically, secures the safety equipment, utilizes proper body mechanics, and then executes the movement.
Safe transfer protocols require a systematic approach that prioritizes environmental safety (locking wheels), patient readiness (dangling, feet flat), application of safety devices (gait belt), nurse ergonomics (wide base, bent knees), and finally the execution of the physical movement.

Adım Adım Çözüm

1
Position and lock the wheelchair on the client's stronger side.
The receiving equipment is secure and properly angled.
Prevents the chair from rolling away during the transfer, minimizing fall risk.
2
Assist the client to sit at the bedside with feet flat.
The client is in a stable starting position.
Allows for equalization of blood pressure and establishes a base of support for the client.
3
Apply the gait belt around the waist.
The safety device is properly fitted.
Provides a secure handle for the nurse to guide the client without pulling on their arms or shoulders.
4
Grasp the belt and brace the client's knees and feet.
The nurse is in an ergonomic lifting posture.
Maintains the nurse's center of gravity and prevents the client's knees from buckling.
5
Execute the stand and pivot motion.
The client safely transitions from the bed to the wheelchair.
Completes the transfer using coordinated momentum and proper alignment.

Anahtar Kavram

Safe patient handling and proper body mechanics during a stand-and-pivot transfer
Soru 187Soru →

A practical nurse (PN) is admitting a young adult client to an ambulatory surgery center for an elective upper endoscopy. The client has already signed the informed consent document. While the PN is taking the client's vital signs, the client suddenly becomes tearful and states, "I cannot go through with this. I want to cancel the test right now." In what order should the PN perform the following actions? Arrange the steps from first to last.

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The correct sequence is to first immediately cease all physical preparations to respect the client's autonomy. Next, the practical nurse should ask open-ended questions to explore the client's concerns. Following this data collection, the nurse must notify the healthcare provider and supervising registered nurse. The practical nurse then observes while the healthcare provider discusses the implications of refusal. Finally, the nurse documents the entire event in the health record.
The nursing process and client advocacy dictate the sequence of actions when a client revokes informed consent. The most immediate priority is to ensure the client's autonomy and physical safety by halting any further preparation. Once the procedure is paused, the practical nurse (PN) must collect data by exploring the client's concerns to understand the situation fully. After gathering this information, the PN must promptly communicate the client's decision to the supervising RN and the healthcare provider, as it is the provider's legal responsibility to address the refusal. The PN then remains to support the client while the provider explains the risks and consequences of canceling the procedure. Finally, the PN must provide a comprehensive legal record of the entire event, including the client's exact words and the actions taken, in the medical chart.

Adım Adım Çözüm

1
Cease all preoperative physical preparations immediately.
The client's right to refuse is respected and physical preparation is halted.
Continuing with preparations after a client withdraws consent constitutes battery; immediate cessation is required.
2
Ask open-ended questions to determine the reason for the client's change of mind.
The PN gathers crucial information about the client's sudden anxiety or concern.
Data collection follows immediate safety interventions in the nursing process, helping to clarify the root cause of the refusal.
3
Notify the healthcare provider and the supervising registered nurse.
The care team and the acting physician are alerted to the client's decision.
The provider must be notified immediately as it is their legal responsibility to address procedure cancellations and informed consent issues.
4
Observe as the healthcare provider discusses the implications of refusal with the client.
The client receives the necessary medical information regarding their refusal.
Explaining the risks and alternatives of refusing a procedure falls strictly under the provider's scope of practice, not the PN's.
5
Document the client's verbal refusal and the provider's intervention in the health record.
A legal and accurate account of the incident is created.
Documentation should occur only after the client's immediate needs and safety have been fully addressed.

Anahtar Kavram

Client's Right to Revoke Consent and the Nursing Process
Soru 188Soru →

While administering a prescribed intramuscular injection to a client, a practical nurse sustains an accidental needlestick injury to the index finger. Arrange the following actions the nurse must take in the correct chronological order to comply with standard precautions and occupational safety guidelines.

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The correct sequence for managing an occupational needlestick exposure is: first aid (washing the site), notifying the supervisor, seeking immediate medical evaluation, obtaining baseline testing, and completing long-term follow-up.
According to the Centers for Disease Control and Prevention (CDC) guidelines for occupational exposure to bloodborne pathogens, the immediate priority is first aid: washing the site with soap and water. Squeezing the wound or using harsh chemicals like bleach should be avoided. Once first aid is complete, the nurse must notify the supervisor to activate the exposure protocol. The nurse is then directed to occupational health or the emergency department for a time-sensitive risk assessment, as post-exposure prophylaxis (PEP) should be started within hours if indicated. Baseline serology is drawn during this initial visit, followed by scheduled serial testing in the months following the exposure to monitor for delayed seroconversion.

Adım Adım Çözüm

1
Cleanse the needlestick site immediately with soap and running water.
Physical removal of potential pathogens from the wound site.
Immediate first aid is the highest priority to minimize the viral load and reduce the risk of systemic infection.
2
Notify the unit charge nurse or nursing supervisor about the exposure.
Activation of the facility's exposure control plan.
Leadership must be informed to ensure the nurse is relieved of clinical duties to seek immediate care and to begin the process of evaluating the source client.
3
Proceed to the employee health department for an exposure risk assessment.
Clinical evaluation by an occupational health provider.
Immediate medical assessment is required to determine if post-exposure prophylaxis (PEP) is indicated. PEP for HIV is most effective when initiated within 1 to 2 hours of exposure.
4
Provide a blood sample for baseline serologic testing.
Establishment of the nurse's baseline serostatus.
Baseline testing is necessary for workers' compensation and to determine if any subsequent infection was a direct result of this specific occupational exposure.
5
Return for follow-up serologic testing at scheduled intervals.
Long-term monitoring for seroconversion.
Because bloodborne pathogens have an incubation period, follow-up testing is required to ensure no infection occurred over time.

Anahtar Kavram

Occupational Exposure Protocol for Bloodborne Pathogens
Soru 189Soru →

A practical nurse is providing care for a hospice client who suddenly begins experiencing severe air hunger, tachypnea, and restlessness. The client has standing PRN orders for end-of-life symptom management. In what order should the nurse perform the following actions? (Arrange from first to last)

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The correct sequence is to first elevate the head of the bed, followed by administering the sublingual morphine, directing a fan toward the client's face, supporting and educating the family, and finally documenting the event.
When a hospice client experiences severe terminal dyspnea (air hunger), the nurse must prioritize interventions using the ABCs (Airway, Breathing, Circulation) and Maslow's hierarchy of needs. The most immediate, non-pharmacological action is elevating the head of the bed to facilitate lung expansion. Next, administering the prescribed sublingual morphine is critical, as it is the primary pharmacological treatment for air hunger. Applying a fan provides additional, evidence-based symptom relief by stimulating the trigeminal nerve. Only after the client's acute physical symptoms are managed should the nurse transition to providing psychosocial support and explanation to the family. Finally, nursing documentation is completed after all direct care is safely rendered.

Adım Adım Çözüm

1
Elevate the head of the client's bed to maximize lung expansion.
The diaphragm lowers and chest expansion improves.
According to the ABCs (Airway, Breathing, Circulation) of prioritization, opening and optimizing the airway through physical positioning is always the first, fastest response to respiratory distress.
2
Administer the prescribed PRN sublingual morphine.
The client receives medication to decrease the respiratory drive and reduce anxiety.
Morphine is the primary pharmacological intervention for air hunger at the end of life; administering it immediately after positioning allows it time to absorb and take effect.
3
Turn on a bedside fan to direct cool air toward the client's face.
The client's trigeminal nerve is stimulated by the cool airflow.
Using a fan is a proven non-pharmacological comfort measure that alters the perception of breathlessness, acting as an excellent adjunct while the medication begins to work.
4
Explain to the family members that these measures will help ease the client's breathing.
The family receives reassurance and education about the dying process.
Psychosocial support is crucial in end-of-life care, but according to Maslow's hierarchy of needs, physiological stability of the client must be secured before addressing the family's emotional needs.
5
Document the respiratory episode and the client's response to the interventions.
The client's medical record is accurately updated.
Documentation is necessary for legal and communication purposes but is always the lowest priority during an acute symptom crisis.

Anahtar Kavram

Prioritization of physiological and psychosocial interventions for terminal dyspnea.
Soru 190Soru →

A client is recovering from a lumbar laminectomy. The nursing care plan requires turning the client every two hours. Which sequence of actions should the practical nurse implement to reposition this client safely from a supine to a lateral position?

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The nurse must first flatten the bed, prepare the client's body alignment by placing a pillow between the legs and crossing the arms, execute the turn as a single unit, and finally support the new lateral position with pillows.
Safe repositioning after spinal surgery requires the 'logrolling' technique. This procedural sequence ensures that the spine remains in strict alignment throughout the entire movement by flattening the bed, securing the extremities, turning the body as one solid unit, and providing postoperative support.

Adım Adım Çözüm

1
Flatten the bed completely.
The client's spine rests perfectly horizontal.
Any elevation can cause twisting or bending of the spinal column during movement.
2
Place a pillow between the client's legs and have them cross their arms.
The hips, pelvis, and upper body are stabilized.
This maintains the alignment of the spine and prevents the extremities from causing rotation during the turn.
3
Roll the client as a single, straight unit.
The client is turned onto their side without twisting.
Moving the head, shoulders, and hips simultaneously (logrolling) prevents any torsion on the surgical site.
4
Position supportive pillows along the back and under the limbs.
The client rests securely and comfortably in the lateral position.
Proper support maintains spinal alignment and prevents the client from inadvertently rolling back.

Anahtar Kavram

Spinal alignment and logrolling technique
Soru 191Soru →

During an annual wellness visit, a female client asks the practical nurse for a review on how to check her breasts for lumps at home. How should the nurse sequence the instructions for this screening procedure? Arrange the steps in the correct chronological order.

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Cevap

The correct sequence for breast self-examination begins with three visual inspection steps (arms at sides, arms raised, hands on hips), followed by assuming a supine position to evenly distribute the tissue, and concludes with systematic palpation using the finger pads.
Breast self-examination is an important secondary prevention strategy that requires a specific sequence for maximum effectiveness. The procedure starts with a comprehensive visual inspection in three distinct postures to identify superficial changes, dimpling, or asymmetry. Following the visual inspection, the client must transition to a supine position. Lying down is critical because it evenly flattens the breast tissue against the chest wall, enhancing the ability to palpate deeper structures. Finally, systematic palpation using the sensitive pads of the middle fingers ensures that all breast tissue is thoroughly evaluated.

Adım Adım Çözüm

1
Stand facing a mirror with arms resting naturally at the sides to inspect for visible changes.
The client observes the baseline appearance of the breasts.
Visual inspection in a relaxed position allows for the detection of obvious superficial changes.
2
Raise both arms straight up overhead to look for dimpling or contour abnormalities.
The client inspects the breasts with altered suspensory ligament tension.
Raising the arms pulls the skin and ligaments, which can reveal dimpling indicative of an underlying mass.
3
Press hands firmly on the hips to flex the chest muscles and observe for asymmetry.
The client inspects the breasts with contracted pectoral muscles.
Flexing the chest muscles highlights subtle skin retractions that may not be visible when muscles are relaxed.
4
Assume a supine position and place a folded towel under the shoulder of the side being examined.
The client is positioned optimally for palpation.
Lying supine flattens and spreads the breast tissue evenly over the chest wall, making it easier to detect deeper lumps.
5
Palpate the breast tissue systematically using the flat pads of the three middle fingers.
The client thoroughly palpates all quadrants of the breast tissue.
The finger pads are highly sensitive, and using a structured pattern ensures a comprehensive assessment.

Anahtar Kavram

Secondary Prevention: Client education on proper technique for breast self-examination (BSE).
Tahmini Süre:1m 30s
Soru 192Soru →

An adult client is prescribed an intramuscular injection of iron dextran. To minimize tissue irritation and prevent medication leakage into subcutaneous layers, the practical nurse administers the medication using the Z-track technique. Arrange the steps of this procedure in the correct chronological sequence.

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Cevap

The correct sequence is to first displace the skin laterally, then insert the needle at a 90-degree angle, followed by injecting the medication slowly. After injecting, wait 10 seconds before finally withdrawing the needle and releasing the skin simultaneously.
The Z-track method is designed specifically to prevent medication leakage and tissue irritation. Displacing the skin first creates an offset track. Inserting the needle and injecting slowly ensures proper muscle delivery. Waiting 10 seconds allows the medication to disperse so it does not follow the needle out. Finally, releasing the skin exactly as the needle is withdrawn creates a zigzag tissue seal that traps the medication in the muscle.

Adım Adım Çözüm

1
Displace the skin laterally.
Creates an offset, zigzag path through the underlying tissue layers.
This is the foundational step of the Z-track method to prevent medication leakage.
2
Dart the needle into the muscle.
Needle enters the deep muscle tissue while the skin is held displaced.
Proper placement ensures intramuscular, rather than subcutaneous, delivery.
3
Inject the medication slowly.
Medication is deposited deep into the muscle.
Allows muscle fibers to accommodate the volume, reducing pain and tissue trauma.
4
Wait for 10 seconds before removing the needle.
Medication begins to disperse into the surrounding muscle tissue.
Prevents the medication from being forced back up the track upon immediate needle removal.
5
Withdraw the needle and release the skin simultaneously.
Tissue planes slide back into their original, unaligned positions.
Seals the needle track, securely trapping the medication inside the deep muscle layer.

Anahtar Kavram

Safe administration of intramuscular injections using the Z-track technique
Soru 193Soru →

A client with type 1 diabetes mellitus begins to experience diaphoresis, palpitations, and hand tremors. The client is alert and oriented. In what order should the practical nurse implement the following interventions? Arrange the actions in the correct sequence from first to last.

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Cevap

The correct sequence is to first assess the blood glucose, treat with a fast-acting carbohydrate, recheck in 15 minutes, and finally provide a stabilizing snack.
When a conscious client exhibits signs of hypoglycemia, the practical nurse should follow the 'Rule of 15'. The sequence begins with assessment (checking blood glucose), followed by immediate treatment (giving a fast-acting carbohydrate), evaluation of the intervention (rechecking the glucose in 15 minutes), and long-term stabilization (providing a complex carbohydrate and protein snack).

Adım Adım Çözüm

1
Obtain a fingerstick blood glucose reading.
The nurse confirms the presence of hypoglycemia.
Assessment is always the priority when a client exhibits new symptoms, ensuring the correct problem is treated.
2
Administer 4 ounces of a fast-acting carbohydrate.
The client's blood sugar begins to rise rapidly.
Simple carbohydrates are quickly absorbed to resolve the acute hypoglycemic state.
3
Recheck the blood glucose level after 15 minutes.
The nurse verifies if the initial treatment was effective.
Continuous evaluation is necessary to determine if further simple carbohydrates are needed, following the standard 'Rule of 15'.
4
Provide a snack containing a complex carbohydrate and protein.
The client's blood sugar remains stable over time.
Complex carbohydrates and proteins digest slowly, preventing a secondary crash in blood sugar.

Anahtar Kavram

Management of Acute Hypoglycemia (Rule of 15)
Soru 194Soru →

A practical nurse (PN) is preparing to delegate routine morning care tasks to an assistive personnel (AP) on a medical-surgical unit. Place the following actions in the correct chronological sequence to ensure a safe and effective delegation process.

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Cevap

The correct sequence follows the Five Rights of Delegation: First, evaluate client stability (Right Circumstance). Second, verify AP competency (Right Person). Third, communicate clear instructions (Right Direction). Fourth, monitor progress (Right Supervision). Finally, review documented outcomes (Right Evaluation).
Safe delegation follows a systematic process based on the Five Rights of Delegation. The nurse must first assess the client's stability (Right Circumstance) before determining if the AP is competent for the task (Right Person). Clear instructions must then be provided (Right Direction/Communication) prior to task execution. Finally, the nurse provides ongoing monitoring (Right Supervision) followed by reviewing the outcomes (Right Evaluation).

Adım Adım Çözüm

1
Identify the first requirement of the delegation process.
The nurse must determine if the task and circumstances are appropriate.
Delegation cannot proceed without confirming the client's stability (Right Task/Circumstance).
2
Determine the next requirement before assigning the task.
The nurse must verify the AP's qualifications.
The AP must be competent to perform the task safely (Right Person).
3
Identify the action taken immediately before the AP begins the task.
The nurse provides clear, specific instructions.
The AP needs to know exactly what to do and when to report back (Right Direction/Communication).
4
Determine the nurse's role while the task is being performed.
The nurse monitors the AP's progress.
The nurse retains accountability and must ensure the task is done correctly (Right Supervision).
5
Identify the final step after the task is completed.
The nurse reviews the outcomes and client responses.
The delegation process concludes with evaluating the results and documentation (Right Evaluation).

Anahtar Kavram

NCSBN Five Rights of Delegation
Tahmini Süre:1m 0s
Soru 195Soru →

While conducting hourly rounds, a practical nurse (PN) observes that a client with a history of asthma is suddenly leaning forward, visibly distressed, and wheezing audibly. Arrange the following nursing actions in the correct priority sequence from first to last.

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Cevap

The correct sequence prioritizes immediate airway positioning, followed by oxygenation, pharmacological intervention, and finally, reassessment of the client's respiratory status.
In an acute respiratory distress scenario, nursing actions must follow the ABC (Airway, Breathing, Circulation) framework and the nursing process. Assisting the client into an upright position (Airway) is the most immediate action that can be performed in seconds to facilitate lung expansion. Applying oxygen (Breathing) directly addresses hypoxemia. Administering a bronchodilator treats the underlying condition, and finally, reassessment (Evaluation) determines if the interventions were successful.

Adım Adım Çözüm

1
Assist the client into a high-Fowler's position.
Lung expansion is mechanically maximized.
This is the fastest, most immediate action to ease respiratory effort and support the airway.
2
Apply supplemental oxygen as prescribed.
Hypoxemia is addressed.
Meets the immediate physiological demand for oxygen (Breathing) during distress.
3
Administer the prescribed short-acting bronchodilator via nebulizer.
Bronchial smooth muscles relax.
Treats the acute bronchospasm that is causing the wheezing and distress.
4
Auscultate lung sounds and measure oxygen saturation.
Post-intervention baseline is established.
Evaluates the client's physiological adaptation and response to the applied interventions.

Anahtar Kavram

Prioritization of Acute Respiratory Interventions (Airway, Breathing, Interventions, Evaluation)
Soru 196Soru →

A practical nurse (PN) is caring for a client who is receiving intravenous fluids via a central venous catheter. The client suddenly grasps their chest, gasps for air, and becomes rapidly cyanotic. Suspecting an air embolism, arrange the following emergency risk reduction actions in the priority order the PN should implement them.

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Cevap

The correct sequence is to first clamp the catheter, then place the client in a left lateral Trendelenburg position, administer high-flow oxygen, activate the rapid response team, and finally obtain vital signs while remaining with the client.
When a central venous air embolism is suspected, the immediate focus is on stopping the entry of air and preventing it from blocking pulmonary circulation. Clamping the line stops the source. The left lateral Trendelenburg position uses gravity to trap air in the right ventricle, preventing it from entering the pulmonary artery. Oxygen treats hypoxia and shrinks the bubble. Calling for advanced help and continuous monitoring follow these immediate life-saving physical interventions.

Adım Adım Çözüm

1
Identify the suspected air embolism and clamp the central venous catheter immediately.
The entry point for the air is closed off.
This is the most critical initial step to prevent additional air from entering the bloodstream and worsening the condition.
2
Place the client in a left lateral Trendelenburg position.
The air bubble is trapped in the right ventricle.
This specific position uses gravity to keep the air away from the pulmonary valve, preventing a pulmonary embolism.
3
Administer high-flow oxygen.
The client receives maximum oxygenation.
Oxygen treats the immediate respiratory distress and helps dissolve the nitrogen in the air bubble.
4
Activate the rapid response team and notify the RN.
Advanced help is dispatched to the client's room.
The client requires advanced life support and potentially transfer to the intensive care unit.
5
Obtain a complete set of vital signs.
Baseline data during the event is established.
This information is vital for the rapid response team to determine the next medical interventions.

Anahtar Kavram

Emergency Management of a Central Venous Air Embolism
Soru 197Soru →

A practical nurse is preparing to administer a scheduled subcutaneous injection of enoxaparin using a prefilled syringe. Arrange the following steps of the procedure in the correct chronological order.

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The correct chronological sequence is: Verify the client's identity, prepare the site with gloves and alcohol, uncap the needle while retaining the air bubble, pinch the skin to insert the needle, and finally administer the medication and activate the safety device.
Chronological adherence to standard medication administration protocols ensures client safety. Enoxaparin has specific administration requirements, including using the abdomen as the preferred site, retaining the prefilled air bubble, and injecting into a pinched fold of skin to prevent bruising and ensure proper tissue absorption.

Adım Adım Çözüm

1
Verify client identity.
The correct client is identified.
Ensures adherence to the 'right client' principle of medication administration.
2
Don gloves and cleanse the abdominal site.
The site is properly disinfected.
Maintains asepsis and utilizes the preferred site (the abdomen) for enoxaparin administration.
3
Remove the needle cap.
The syringe is ready for immediate injection.
The air bubble must not be expelled, as the manufacturer includes it to push all medication into the tissue and prevent tracking.
4
Pinch a fold of skin and insert the needle.
The needle enters the correct tissue layer.
Pinching elevates the subcutaneous tissue, preventing an accidental and painful intramuscular injection.
5
Inject the medication and secure the needle.
The dose is fully administered and the sharp is safely contained.
Prevents tracking of the medication and protects the nurse from needlestick injuries.

Anahtar Kavram

Safe administration sequence for subcutaneous enoxaparin
Soru 198Soru →

A practical nurse is providing immediate care for a newly born infant who suddenly regurgitates mucus and appears to be gagging. The nurse prepares to use a bulb syringe to clear the infant's airway. In what order should the nurse perform the following actions? (Arrange the steps from first to last.)

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First, compress the bulb fully; second, place the tip into one side of the mouth; third, release the bulb gradually; fourth, empty the secretions onto a tissue; and fifth, suction the nares one at a time.
The safe and effective sequence for bulb syringe suctioning relies on two critical principles: the bulb must be compressed before insertion, and the mouth must be cleared before the nose. Compressing prior to insertion prevents forcing secretions deeper into the respiratory tract. Suctioning the mouth first prevents the infant from aspirating oral secretions if they reflexively gasp when their nares are suctioned.

Adım Adım Çözüm

1
Compress the bulb of the syringe fully.
The air is expelled from the bulb syringe.
Compressing before insertion prevents pushing secretions deeper into the airway.
2
Place the tip of the syringe into one side of the infant's mouth.
The syringe is positioned to suction the mouth without triggering a gag reflex.
The mouth is always suctioned first (M before N) to prevent aspiration if the infant gasps.
3
Release the pressure on the bulb gradually to draw up the secretions.
Mucus and fluid are pulled into the bulb syringe.
Gradual release creates the gentle suction needed to clear the airway safely.
4
Empty the gathered secretions from the syringe onto a tissue.
The syringe is cleared of mucus.
The syringe must be empty to create suction for the next step.
5
Suction the infant's nares one at a time.
The nasal passages are cleared of remaining fluid.
The nares are suctioned last using the same technique (compress, insert, release) to fully clear the upper airway.

Anahtar Kavram

Airway clearance using a bulb syringe in a newborn
Soru 199Soru →

A practical nurse is preparing to administer a prescribed intramuscular injection of phytonadione to a 2-hour-old neonate. In which order should the nurse perform the following actions?

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The correct sequence is to first verify the neonate's identity and the prescription, then don gloves and locate the vastus lateralis muscle, cleanse the site, insert the needle at a 90-degree angle, and finally inject the medication while applying gentle pressure afterward.
Safe medication administration in the neonate follows a strict chronological protocol: verification of identity and orders always comes first, followed by anatomical preparation (locating the vastus lateralis), infection control (cleansing), procedural execution (insertion), and post-procedure safety (pressure for hemostasis).

Adım Adım Çözüm

1
Verify the prescription, medication, and the neonate's identification bands.
Ensures the correct neonate receives the correct dose of phytonadione.
Client safety protocols require absolute verification before physical contact or medication preparation begins.
2
Don clean gloves and identify the vastus lateralis muscle on the anterolateral thigh.
The correct anatomical site is isolated using standard precautions.
The vastus lateralis is the safest and most developed muscle for intramuscular injections in neonates.
3
Cleanse the selected injection site with an alcohol swab using a circular motion.
The injection site is sanitized.
Reduces the risk of introducing pathogens into the deeper tissue layers.
4
Grasp the muscle tissue gently but firmly and insert the needle at a 90-degree angle.
The needle successfully enters the muscle layer.
A 90-degree angle ensures the medication reaches the intramuscular space rather than pooling in the subcutaneous tissue.
5
Inject the medication slowly and apply gentle pressure to the site with a dry gauze pad.
Medication is delivered and localized bleeding is minimized.
Applying gentle pressure promotes hemostasis, which is especially important before the Vitamin K (phytonadione) takes full physiological effect.

Anahtar Kavram

Newborn Intramuscular Medication Administration Sequence
Soru 200Soru →

During a routine morning assessment, a practical nurse notes that a client recently admitted to a semi-private room is exhibiting hemoptysis, night sweats, and a persistent productive cough. Suspecting potential active pulmonary tuberculosis, the nurse must initiate immediate precautions. Arrange the following nursing actions in the correct prioritized sequence to minimize the risk of pathogen transmission.

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The correct sequence prioritizes source control first by masking the client, followed by protecting the immediate bystander (roommate), protecting the nurse (donning the N95), ensuring definitive environmental isolation (AIIR transfer), and finally documenting the event.
Infection control prioritization dictates that when a healthcare worker is already at the bedside and discovers an airborne risk, source control (masking the client) is the fastest and most effective first step. This is followed by removing bystanders, protecting oneself with appropriate PPE, establishing long-term environmental controls (AIIR), and concluding with documentation.

Adım Adım Çözüm

1
Place a standard surgical mask over the client's nose and mouth.
The client's infectious respiratory secretions are contained.
Immediate source control is the highest priority to stop the spread of droplet nuclei into the shared environment.
2
Instruct the client's roommate to leave the room and wait in a safe area.
The secondary contact is removed from the contaminated environment.
Protecting the most immediately vulnerable bystander from further exposure is the next crucial step in infection control.
3
Exit the room temporarily to perform hand hygiene and don a fit-tested N95 respirator.
The nurse is properly protected against airborne pathogens.
Proper personal protective equipment must be obtained and donned before any further prolonged direct contact or assessment occurs.
4
Coordinate with the nursing supervisor to transfer the client to an airborne infection isolation room (AIIR).
Definitive environmental isolation is arranged.
Airborne precautions require negative-pressure ventilation, which cannot be achieved in a standard semi-private room.
5
Document the client's respiratory findings and the initiation of isolation measures in the health record.
An accurate medical and legal record is created.
Documentation must reflect the findings and interventions but is always performed after physical safety is secured.

Anahtar Kavram

Prioritization of Airborne Precautions and Immediate Infection Control
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