Tüm alıştırma soruları

2933 soru

Soru 2001Soru →

A client recovering from surgery has an established diagnosis of post-traumatic stress disorder. Suddenly, a heavy equipment cart crashes loudly in the adjacent hallway. The client immediately drops to the floor, curls into a tight position, and begins hyperventilating. Which action is the priority for the practical nurse (PN) to take?

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Cevap: Stay in the room, keep a non-threatening stance, and calmly orient the client to the current setting

Cevap

The priority action is to remain in the room, maintain a non-threatening posture, and use a calm voice to orient the client to their current surroundings.
During an acute flashback or severe panic episode, the client's psychological grounding is the immediate priority. By remaining in the room, maintaining a safe posture, and calmly orienting the client to the present, the nurse provides a safe environment. This therapeutic approach helps the client regain a sense of reality without introducing physical touch, which could be misinterpreted as a threat, and establishes trust without invalidating their intense emotional experience.

Adım Adım Çözüm

1
Assess the client's immediate behavioral and physiological response to the trigger.
The client is exhibiting signs of an acute flashback and severe anxiety, indicated by dropping to the floor and hyperventilating.
Identifying the severity of the stress reaction determines the level of intervention required.
2
Determine the safest and most therapeutic initial nursing intervention.
The nurse must prioritize psychological grounding and safety over investigation, logic, or physical contact.
Clients experiencing acute trauma responses may perceive sudden movements, logical reasoning, or physical touch as an active threat.
3
Select the option that provides presence and reality orientation.
Staying in the room with a non-threatening stance and orienting the client to the present environment is the correct choice.
This approach uses the therapeutic technique of offering self and reality grounding without forcing rationalization or minimizing the client's feelings.

Anahtar Kavram

Crisis Intervention and Grounding Techniques in PTSD
Soru 2002Soru →

During a follow-up visit at an outpatient pediatric clinic, a mother brings in her 4-day-old neonate who was delivered at 37 weeks gestation. The mother states, "My baby is so sleepy, I have a hard time waking him up to breastfeed, and he has only had two wet diapers since yesterday." The practical nurse notes a yellowish tint to the neonate's sclera and chest, and a slightly depressed anterior fontanelle. Which of the following actions should the practical nurse take? Select all that apply.

Geçerli olan tümünü seçin

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Cevap: Measure the neonate's current naked weight and compare it to the documented birth weight.; Notify the supervising registered nurse or healthcare provider immediately regarding the clinical findings.; Obtain an axillary temperature and a capillary blood glucose level according to facility protocol.

Cevap

The correct actions are to measure the neonate's current weight, notify the supervising registered nurse or healthcare provider immediately, and obtain an axillary temperature and capillary blood glucose level.
The neonate is exhibiting clear signs of dehydration (depressed fontanelle, decreased urine output) and potential systemic issues like hypoglycemia or hyperbilirubinemia (lethargy, jaundice). The appropriate role of the practical nurse in this acute scenario is to collect pertinent baseline data—including weight, temperature, and blood glucose—and to immediately escalate these abnormal findings to the supervising registered nurse or provider so that timely medical intervention can occur.

Adım Adım Çözüm

1
Analyze the clinical findings presented in the vignette.
The neonate demonstrates lethargy (hard to wake), decreased urine output (two wet diapers), jaundice (yellowish sclera/chest), and a depressed fontanelle.
Identifying abnormal signs is the first step in prioritizing care.
2
Correlate the abnormal findings with potential pathophysiological conditions.
The findings suggest significant dehydration (depressed fontanelle, low urine output) and potential hyperbilirubinemia or hypoglycemia (lethargy, jaundice).
Understanding the underlying risk determines which data collection tasks are most urgent.
3
Select interventions that fall strictly within the practical nurse scope of practice.
Data collection (weight, temperature, blood glucose) and reporting abnormal findings to the RN/provider are selected, while independent care planning or dismissing symptoms are rejected.
The practical nurse must act safely within legal and professional boundaries while ensuring the neonate receives timely, appropriate care.

Anahtar Kavram

Neonatal dehydration, hyperbilirubinemia, and adherence to the practical nurse scope of practice regarding data collection and reporting.
Soru 2003Soru →

During a routine wellness visit, a practical nurse observes a 12-month-old client interacting with various objects on the examination table. Which specific behavior demonstrates that the infant has achieved an expected developmental milestone for this age?

Cevabı ve açıklamayı göster

Cevap: Grasping a small piece of cereal between the thumb and index finger

Cevap

Grasping a small piece of cereal between the thumb and index finger is the expected developmental milestone for a 12-month-old.
By 10 to 12 months of age, infants fully develop a mature, neat pincer grasp. This allows them to pick up small objects, such as a piece of cereal, using precise coordination between the tips of their thumb and index finger. This action confirms normal fine motor development for a 12-month-old.

Adım Adım Çözüm

1
Identify the client's chronological age in the scenario.
The client is exactly 12 months (1 year) old.
Developmental milestones are assessed based on chronological age expectations.
2
Recall the expected motor milestones for a 12-month-old infant.
Expected skills include a neat pincer grasp, pulling to a stand, standing momentarily without support, and potentially taking first steps.
Accurate knowledge of age-specific milestones is required to evaluate normal development.
3
Evaluate each answer choice against the expectations for a 12-month-old.
The pincer grasp matches the 12-month expectation. Building a six-block tower, drawing a circle, and undressing are advanced skills that emerge during toddlerhood and preschool years.
This process of elimination isolates the correct age-appropriate behavior.

Anahtar Kavram

Infant Developmental Milestones
Soru 2004Soru →

A practical nurse is providing basic care for a client who is on strict bed rest following a right femoral cardiac catheterization. Which of the following actions should the nurse include in the client's care? Select all that apply.

Geçerli olan tümünü seçin

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Cevap: Keep the client's right leg straight and minimize movement of the extremity.; Provide a bedpan or urinal to assist the client with elimination needs.; Encourage the client to drink plenty of oral fluids, if not contraindicated.

Cevap

The correct actions are keeping the right leg straight, providing a bedpan or urinal, and encouraging oral fluid intake.
Appropriate care involves keeping the affected leg straight to prevent bleeding, providing a bedpan since the client is on strict bed rest, and encouraging fluids to clear the procedural contrast dye.

Adım Adım Çözüm

1
Analyze the client's situation and primary safety needs.
The client is on strict bed rest post-femoral cardiac catheterization, which poses a high risk for bleeding at the puncture site.
Understanding the procedural risks guides the selection of safe basic care interventions.
2
Evaluate each care intervention against post-procedure protocols and basic care standards.
Keeping the leg straight, assisting with the bedpan, and encouraging fluids are safe and supportive. High-Fowler's position, delegating assessments, and delaying reports of unstable vital signs compromise safety.
Nursing care must prevent complications while meeting the client's basic hydration and elimination needs.

Anahtar Kavram

Basic care following a femoral cardiac catheterization requires maintaining the affected extremity straight, meeting elimination needs on bed rest, and promoting hydration, while adhering to safe positioning and delegation.
Soru 2005Soru →

A client is transferred to the surgical unit following a right modified radical mastectomy that included an axillary lymph node dissection. When implementing basic care and comfort measures, which action should the practical nurse take regarding the client's right arm?

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Cevap: Elevate the arm on pillows so it rests consistently above the level of the client's heart.

Cevap

The practical nurse should elevate the client's right arm on pillows so it rests consistently above the level of the heart.
Elevating the affected arm above the level of the heart promotes venous and lymphatic return through gravity. This basic care intervention is essential for preventing fluid accumulation (lymphedema) and promoting comfort after the removal of axillary lymph nodes.

Adım Adım Çözüm

1
Analyze the surgical procedure and its physiological impact on the client.
A mastectomy with axillary lymph node removal disrupts normal lymphatic drainage pathways, creating a high risk for lymphedema in the affected extremity.
Understanding the physiological risk factors dictates the necessary basic care and comfort interventions.
2
Evaluate each nursing action for safety, scope of practice, and therapeutic benefit.
Elevating the arm uses gravity to assist fluid drainage. The other options introduce significant risks: lying on the arm increases swelling, restraints are an unethical first response to protect drains, and delegating initial post-op joint exercises is unsafe.
Basic care must prioritize non-invasive, safe physiological adaptation while adhering to legal delegation guidelines.
3
Select the action that best promotes fluid return and client comfort.
Supporting the affected arm on pillows above heart level is identified as the correct evidence-based intervention.
This specific positioning directly mitigates the risk of edema and enhances post-procedure comfort without compromising circulation.

Anahtar Kavram

Basic care and comfort positioning to prevent lymphedema following axillary lymph node dissection.
Tahmini Süre:1m 15s
Soru 2006Soru →

A practical nurse is preparing 0900 medications for a client with stage 4 chronic kidney disease. The electronic health record indicates the client is prescribed oral carvedilol, lisinopril, and calcium acetate. Morning laboratory results reveal a serum potassium level of 6.2 mEq/L6.2\text{ mEq/L} and a serum calcium level of 8.1 mg/dL8.1\text{ mg/dL}. The client's vital signs are blood pressure 142/88 mm Hg142/88\text{ mm Hg}, heart rate 64 bpm64\text{ bpm}, and respiratory rate 18/min18/\text{min}. Which action is most appropriate for the practical nurse to take?

Cevabı ve açıklamayı göster

Cevap: Withhold the lisinopril and promptly notify the registered nurse of the laboratory findings.

Cevap

The practical nurse should withhold the lisinopril and immediately notify the registered nurse of the hyperkalemia.
The client has a critically elevated serum potassium level of 6.2 mEq/L6.2\text{ mEq/L} (normal is 3.53.5 to 5.0 mEq/L5.0\text{ mEq/L}). Lisinopril is an ACE inhibitor, a class of drugs known to cause potassium retention. Administering this medication would further dangerously elevate the client's potassium, increasing the risk of fatal cardiac dysrhythmias. The practical nurse's priority within their scope of practice is to withhold the medication and immediately report the critical finding to the registered nurse.

Adım Adım Çözüm

1
Analyze the morning laboratory results against normal reference ranges.
The potassium level is 6.2 mEq/L6.2\text{ mEq/L} (critically high) and the calcium level is 8.1 mg/dL8.1\text{ mg/dL} (mildly low).
Identifying abnormal laboratory values is a mandatory safety check before administering pharmacological therapies.
2
Evaluate the prescribed medications for contraindications based on the laboratory findings.
Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor, which retains potassium and is highly contraindicated with a potassium level of 6.2 mEq/L6.2\text{ mEq/L}.
Administering a potassium-sparing medication to a hyperkalemic client can lead to lethal cardiac dysrhythmias.
3
Determine the most appropriate intervention within the practical nurse scope of practice.
The nurse must withhold the contraindicated medication (lisinopril) and immediately escalate the critical lab value to the supervising registered nurse.
The practical nurse cannot independently alter medical orders or administer intravenous push medications, but has a duty to withhold harmful medications and report critical findings.

Anahtar Kavram

Recognizing pharmacological contraindications (ACE inhibitors exacerbating hyperkalemia) and adhering to the practical nurse scope of practice when managing critical laboratory values.
Soru 2007Soru →

During a morning medication pass on a medical-surgical unit, a client with heart failure is scheduled to receive oral digoxin 0.25 mg0.25\text{ mg} and oral furosemide 40 mg40\text{ mg}. The client reports experiencing new-onset nausea and states, 'I have not had any appetite since yesterday.' The morning laboratory report indicates a serum potassium level of 2.9 mEq/L2.9\text{ mEq/L}, and the current apical pulse is 62 beats per minute. Which action should the practical nurse take?

Cevabı ve açıklamayı göster

Cevap: Withhold both the digoxin and furosemide, and immediately notify the registered nurse of the client's symptoms and laboratory value.

Cevap

The correct action is to withhold both medications and immediately report the findings to the registered nurse.
The client is exhibiting early signs of digoxin toxicity (nausea, anorexia) combined with a critically low potassium level of 2.9 mEq/L2.9\text{ mEq/L}. Hypokalemia sensitizes the myocardium to digoxin, significantly increasing the risk of life-threatening dysrhythmias. Furthermore, furosemide is a potassium-wasting diuretic that would worsen the hypokalemia. The appropriate action within the practical nurse's scope is to withhold both medications and immediately notify the registered nurse so the healthcare provider can be alerted.

Adım Adım Çözüm

1
Evaluate the morning laboratory results and vital signs.
The potassium level is critically low at 2.9 mEq/L2.9\text{ mEq/L} (normal is 3.53.5 to 5.0 mEq/L5.0\text{ mEq/L}), and the apical pulse is 62 beats per minute.
Identifying abnormal baseline data is the first step in pre-administration safety checks.
2
Analyze the client's reported symptoms.
The client is experiencing new-onset nausea and a complete loss of appetite.
Gastrointestinal symptoms are often the earliest clinical indicators of digoxin toxicity.
3
Correlate the prescribed medications with the clinical findings.
Furosemide depletes potassium, and hypokalemia directly increases the risk of digoxin toxicity. Administering either drug would cause further harm.
Understanding pharmacokinetic interactions is essential for safe medication administration.
4
Determine the appropriate nursing intervention within the practical nurse scope of practice.
The medications must be withheld and the registered nurse immediately notified.
The practical nurse must hold medications that pose an immediate risk and report critical findings to the supervising nurse for medical escalation.

Anahtar Kavram

Recognizing Digoxin Toxicity and Hypokalemia within the Practical Nurse Scope of Practice
Soru 2008Soru →

A practical nurse (PN) at a community clinic is caring for a 19-year-old client who discloses frequently mixing large amounts of alcohol with highly caffeinated energy drinks at weekend parties, which recently resulted in a blackout. Which of the following actions by the PN are appropriate? Select all that apply.

Geçerli olan tümünü seçin

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Cevap: State, "Let's discuss strategies to ensure your physical safety when you attend these weekend parties."; Ask, "Can you tell me more about what typically happens during these weekend parties?"; Explain that mixing alcohol with caffeine masks the signs of intoxication and increases the risk of alcohol poisoning.

Cevap

The correct actions include promoting harm reduction, using open-ended questions to gather more data, and providing factual education about the physical risks of mixing alcohol with caffeine.
The correct actions focus on safety, education, and therapeutic communication. Discussing strategies for physical safety is a crucial harm reduction approach. Asking open-ended questions encourages the client to share more about their high-risk environment without feeling judged. Explaining the factual risks of mixing alcohol and caffeine fulfills the nurse's role in health promotion and education.

Adım Adım Çözüm

1
Identify the high-risk behaviors reported by the client.
The client mixes large amounts of alcohol with energy drinks, leading to blackouts.
Recognizing the specific high-risk behaviors is essential to provide targeted health promotion and safety education.
2
Select appropriate therapeutic communication techniques.
Open-ended questions and objective statements are chosen over judgmental 'why' questions.
Therapeutic communication fosters trust and encourages the client to share more information without feeling defensive.
3
Determine the appropriate scope of practice for the practical nurse (PN).
The PN reinforces education, gathers data, and collaborates, but does not independently create the initial care plan.
Ensuring actions remain within the PN scope of practice is a critical safety and legal standard.

Anahtar Kavram

Addressing high-risk behaviors requires therapeutic communication, harm reduction strategies, and factual education while adhering strictly to scope of practice and confidentiality standards.
Soru 2009Soru →

A client receives a new diagnosis of advanced pancreatic cancer from the healthcare provider. Later that afternoon, the client presents the practical nurse (PN) with a binder of medical research articles and spends the interaction calmly asking highly technical questions about the cellular mechanisms of various chemotherapy agents. Which of the following is the most appropriate action by the PN?

Cevabı ve açıklamayı göster

Cevap: Acknowledge the client's need for information and offer to document their specific questions for the healthcare provider.

Cevap

Acknowledge the client's need for information and offer to document their specific questions for the healthcare provider.
The correct action acknowledges the client's emotional state by safely supporting their current coping strategy (intellectualization). By offering to write down the questions for the healthcare provider, the nurse acts as a patient advocate while strictly remaining within the legal scope of practice for a practical nurse, which excludes initial, complex education on new treatment modalities.

Adım Adım Çözüm

1
Analyze the client's behavior and identify the underlying coping strategy.
The client is focusing entirely on complex, factual data rather than the emotional impact of a terminal diagnosis. This indicates the use of the defense mechanism known as intellectualization.
Recognizing the defense mechanism helps the nurse understand that the behavior is currently protecting the client from overwhelming emotional distress.
2
Determine the appropriate therapeutic communication approach.
The nurse should support the client by validating their need for information without aggressively stripping away their emotional defense or offering false reassurance.
Challenging a defense mechanism too early can increase severe anxiety, while false reassurance blocks therapeutic trust.
3
Evaluate the options against the practical nurse (PN) scope of practice.
Teaching complex new pharmacology is outside the PN scope. The PN should facilitate communication by gathering the questions for the provider.
Maintaining safe delegation and scope of practice boundaries is a critical component of every client interaction.

Anahtar Kavram

Coping Mechanisms (Intellectualization) and PN Scope of Practice
Soru 2010Soru →

A practical nurse (PN) enters the room of a client who was recently admitted to a hospice facility. The client's sibling is sitting at the bedside crying and states, "I do not know what I am going to do without them. We have lived together for over 60 years." Arrange the PN's actions in the most appropriate therapeutic sequence. All options must be used.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The most appropriate therapeutic sequence begins with establishing a supportive presence, followed by validating the sibling's feelings, actively listening to their stories, assessing for personal support systems, and finally offering interdisciplinary resources.
In psychosocial interventions involving acute anticipatory grief, the nursing process prioritizes immediate emotional safety and therapeutic presence. Nonverbal communication (offering tissues, sitting quietly) establishes trust and a safe environment. Next, verbal validation (using reflection) acknowledges the significance of the relationship and encourages the expression of feelings. Active listening allows the individual to process their grief. Only after the immediate emotional peak has stabilized and feelings have been expressed should the nurse transition to assessing personal support systems (family or friends) and offering interdisciplinary interventions (chaplain or bereavement counselor).

Adım Adım Çözüm

1
Provide a box of tissues and sit quietly at the bedside.
Establishes a therapeutic, non-judgmental presence.
Immediate nonverbal support and therapeutic silence take priority in an acute emotional crisis.
2
State, "It sounds like you and your sibling share a very deep bond."
Validates the sibling's feelings and acknowledges their pain.
Reflection encourages the individual to open up and establishes trust.
3
Utilize active listening while the sibling shares stories about their shared life.
Facilitates the expression of anticipatory grief.
Allowing the client to verbalize memories helps them process the impending loss without interruption.
4
Ask the sibling if there are other family members or friends they would like to call.
Assesses personal support networks.
Once the immediate emotional need is addressed, practical and personal support systems should be evaluated.
5
Offer to arrange a visit from the facility's chaplain or bereavement counselor.
Provides long-term interdisciplinary resources.
Connecting the family with specialized professionals ensures ongoing psychosocial support as part of the care plan.

Anahtar Kavram

Therapeutic Communication Sequence in Anticipatory Grief
Tahmini Süre:1m 30s
Soru 2011Soru →

Following a total knee arthroplasty, an older adult client's baseline preoperative vital signs were a blood pressure of 132/78132/78 mm Hg and a resting heart rate of 7070 beats per minute. Four hours postoperatively, the practical nurse assesses the client and notes a blood pressure of 102/60102/60 mm Hg, a heart rate of 114114 beats per minute, and a respiratory rate of 2222 breaths per minute. The surgical dressing has a moderate amount of sanguineous drainage. Which action should the nurse take next?

Cevabı ve açıklamayı göster

Cevap: Notify the supervising registered nurse immediately regarding the changes in vital signs.

Cevap

Notify the supervising registered nurse immediately regarding the changes in vital signs.
The correct action is to notify the registered nurse immediately. The client is exhibiting classic early signs of hypovolemic shock—specifically tachycardia and a drop in blood pressure compared to their baseline—along with active bleeding indicated by the sanguineous drainage. These findings require immediate escalation to ensure patient safety and to initiate rapid medical intervention.

Adım Adım Çözüm

1
Compare the client's current postoperative vital signs to the preoperative baseline.
The client's blood pressure has decreased significantly (from 132/78132/78 to 102/60102/60 mm Hg), and the heart rate has increased (from 7070 to 114114 beats per minute).
Identifying deviations from the baseline is critical for recognizing early postoperative complications.
2
Analyze the significance of the vital sign trends alongside the physical assessment.
The combination of tachycardia, hypotension, and sanguineous drainage strongly suggests early hypovolemic shock or active bleeding.
Early recognition of shock mechanisms allows for prompt, life-saving interventions before the condition becomes irreversible.
3
Determine the most appropriate and safe nursing action within the practical nurse's scope of practice.
The practical nurse must immediately escalate these critical findings to the registered nurse.
The registered nurse is responsible for performing advanced assessments, contacting the healthcare provider, and initiating complex interventions for shock.

Anahtar Kavram

Reduction of Risk Potential: Early Recognition of Shock
Soru 2012Soru →

Staff members at an assisted living center report that an older adult resident, who is typically cooperative and oriented, has spent the morning pacing the hallways, acting aggressively toward peers, and speaking in disorganized sentences. An unlicensed assistive personnel remarks, "I guess age is finally catching up to her mind." Which action is the priority for the practical nurse to take?

Cevabı ve açıklamayı göster

Cevap: Obtain a complete set of vital signs and assess for indications of an acute infection.

Cevap

Obtain a complete set of vital signs and assess for indications of an acute infection.
The correct answer acknowledges that sudden, acute confusion and agitation in an older adult are not normal parts of the aging process. These are classic signs of delirium, which in the older adult population is frequently caused by underlying physiological issues such as infections (e.g., urinary tract or respiratory), hypoxia, or adverse medication effects. The priority is to assess the client's physical status to identify potential life-threatening physical causes before intervening behaviorally.

Adım Adım Çözüm

1
Analyze the client's baseline versus current presentation.
The client has experienced a sudden, acute change in mental status from their typical cooperative baseline.
Differentiating between chronic cognitive decline (dementia) and acute confusion (delirium) is an essential concept in geriatric care.
2
Identify the physiological basis for sudden confusion in older adults.
Due to changes in the aging process, acute confusion is often the first, atypical sign of a physiological problem such as a urinary tract infection, hypoxia, or medication toxicity.
The aging immune and nervous systems may not produce classic illness signs like high fever, making altered mental status a primary indicator of physical illness.
3
Determine the priority nursing intervention.
The nurse must perform a physiological assessment to rule out life-threatening physical causes before assuming the behavior is psychological.
Identifying and treating the underlying physical cause of delirium is a priority over behavioral management or documentation.

Anahtar Kavram

Atypical presentation of illness in the aging process (Delirium vs. normal aging)
Soru 2013Soru →

A client with advanced diabetic retinopathy is hospitalized for a systemic infection. In the middle of the night, while the hospital room is entirely dark, the client becomes intensely agitated, attempts to climb over the side rails, and shouts, 'The room is flooding with water, I need to swim out!' Which action should the practical nurse (PN) take first?

Cevabı ve açıklamayı göster

Cevap: Illuminate the room, state the nurse's name clearly, and reassure the client of their immediate safety

Cevap

The correct priority action is to illuminate the room, state the nurse's name clearly, and reassure the client of their immediate safety.
The client is experiencing a perceptual alteration likely caused by a combination of acute delirium (from the systemic infection) and severe sensory deprivation (from the dark room and underlying diabetic retinopathy). The priority nursing action is to implement the least restrictive intervention that ensures safety and addresses the sensory deficit. Illuminating the room removes the sensory deprivation and ambiguity that contributes to illusions or hallucinations. Stating the nurse's name and offering reassurance immediately reorients the client to reality and decreases severe anxiety.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
The client has a severe visual impairment and is in a dark room, creating intense sensory deprivation. The systemic infection increases the risk for acute delirium, manifesting here as a severe perceptual alteration (hallucination or illusion).
Identifying the root cause of the perceptual alteration guides the appropriate and most effective nursing intervention.
2
Prioritize interventions based on safety and the least restrictive alternative.
Environmental modification (turning on the lights) directly addresses the sensory deprivation by maximizing remaining vision, while verbal reassurance provides immediate reorientation.
Client safety must be achieved using the least restrictive alternatives before considering physical restraints or escalation.

Anahtar Kavram

Sensory and Perceptual Alterations
Soru 2014Soru →

A practical nurse is providing care for a client who recently returned to the unit following an esophagogastroduodenoscopy (EGD) with moderate sedation. Which of the following nursing actions should the nurse take to reduce the risk of potential complications? (Select all that apply)

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Verify the return of the client's gag reflex prior to offering any oral fluids or medications.; Monitor the client's respiratory rate and oxygen saturation closely.; Assess the client for sudden, severe abdominal pain or a rigid abdomen.

Cevap

The nurse must verify the return of the gag reflex, monitor respiratory status, and assess for signs of perforation such as severe abdominal pain.
After an EGD, the client's throat is numb from local anesthetics, and they have received moderate sedation. Checking the gag reflex prevents aspiration, while monitoring respirations ensures the sedation is not dangerously depressing the central nervous system. Assessing for a rigid abdomen or severe pain is critical to quickly identify a gastrointestinal perforation.

Adım Adım Çözüm

1
Identify the procedure and its associated risks.
An EGD involves sedation and instrumentation of the upper gastrointestinal tract, creating risks for aspiration, respiratory depression, and perforation.
Understanding procedure-specific risks is necessary to plan appropriate preventative care.
2
Evaluate each action against safety standards and the practical nurse's scope of practice.
Checking the gag reflex, monitoring respirations, and assessing for pain directly reduce post-procedure risks. Delegating initial assessments, dismissing borderline vital signs, and delaying critical lab reporting are unsafe practices.
Risk reduction requires proactive monitoring and prompt escalation of abnormal findings.

Anahtar Kavram

Post-Procedure Risk Reduction
Soru 2015Soru →

A client admitted to a medical-surgical unit with pneumonia informs the nurse that they want to cancel their scheduled bronchoscopy and go home. Shortly after, the client's sibling approaches the nurses' station asking for an update on the client's condition. Which actions should the practical nurse take to uphold client rights and maintain confidentiality? (Select all that apply)

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Notify the registered nurse and healthcare provider about the client's decision to cancel the procedure.; Check the electronic health record to verify if the sibling is authorized to receive medical information.; Close the privacy curtain and speak softly when assessing the client's reasons for wanting to leave.

Cevap

The correct actions are notifying the healthcare team of the client's refusal, verifying the sibling's authorization in the medical record before sharing information, and closing the privacy curtain to discuss the client's concerns confidentially.
Upholding client rights in this scenario requires a multi-faceted approach: respecting the client's autonomy to refuse treatment by notifying the provider, ensuring confidentiality by verifying the sibling's access rights, and utilizing physical privacy measures when discussing sensitive concerns. These actions keep the practical nurse firmly within their scope of practice while actively advocating for the client.

Adım Adım Çözüm

1
Analyze the client's request to cancel the procedure and leave.
Identify that a competent client has the legal right to refuse treatment and leave against medical advice.
Recognizing the right to refusal dictates that the practical nurse must advocate for the client by notifying the healthcare provider and registered nurse, rather than coercing the client.
2
Evaluate the sibling's request for medical information.
Determine that authorization must be verified before any information is shared.
HIPAA and confidentiality guidelines require explicit client consent before disclosing protected health information to family members.
3
Review the communication and environmental actions.
Select the action that provides a private environment (closing the curtain) and reject actions that involve non-therapeutic communication (asking 'why') or public disclosures (hallway conversations).
Maintaining a therapeutic environment requires active listening without judgment and strict adherence to privacy protocols.

Anahtar Kavram

Client Rights, Confidentiality, and Practical Nurse Scope of Practice
Soru 2016Soru →

A practical nurse (PN) is co-leading a group activity on an inpatient psychiatric unit. A client suddenly stands up, begins hyperventilating, grips their chest, and says, "I am having a heart attack and I am going to die!" Medical causes have been previously ruled out, and the PN recognizes an acute panic attack. In what order should the PN perform the following actions? Arrange the interventions in the correct sequence from first to last.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence of actions is: 1) Remain with the client, 2) Escort to a quiet environment, 3) Communicate with short phrases, 4) Coach deep breathing, and 5) Document the event.
When managing an acute panic attack, prioritizing safety and immediate presence is paramount. The nurse first stays with the client to ensure safety, then alters the environment by removing them from high stimuli. Next, communication is adjusted to short, simple phrases because the client's perceptual field is severely narrowed. This clear communication paves the way to successfully coach physical interventions like deep breathing. Finally, post-crisis documentation is completed once the client is stable.

Adım Adım Çözüm

1
Remain with the client.
The client's immediate safety is ensured.
Clients in panic states should never be left alone due to extreme fear and risk of injury.
2
Move the client to a quiet area.
Environmental triggers are minimized.
Decreasing sensory input helps lower the client's overall anxiety level.
3
Use short, simple sentences.
The client comprehends the nurse's instructions.
Severe anxiety narrows the perceptual field, making complex sentences impossible to process.
4
Coach deep breathing.
Hyperventilation is corrected.
Physiological symptoms of panic must be managed with direct, guided interventions once the client can focus.
5
Document the incident.
The healthcare team is informed.
Post-crisis documentation is required by nursing standards of practice.

Anahtar Kavram

Nursing Management of Acute Panic Attacks
Soru 2017Soru →

A practical nurse is reinforcing teaching for a client who has a right fractured tibia and is prescribed strict non-weight-bearing status. The client is using axillary crutches and needs to ascend a flight of stairs. In what order should the nurse instruct the client to perform these actions? (Arrange the steps from first to last.)

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Cevap

The client should first assume a tripod position, shift weight onto the crutches, step up with the unaffected left leg, transfer weight to that left leg, and finally bring the crutches and affected right leg up.
When ascending stairs with axillary crutches, the core principle is to lead with the strong leg (often remembered as 'up with the good'). The client must first establish balance in a tripod stance and support their weight entirely on the crutches. This enables the strong, unaffected leg to step up first and provide the necessary power to lift the body's mass. Once the weight is safely transferred to the strong leg on the higher step, the crutches and the affected leg can follow together without bearing weight.

Adım Adım Çözüm

1
Assume the tripod position facing the bottom of the stairs.
A stable base of support is established.
Safety requires a solid foundation before initiating a complex transfer.
2
Shift body weight securely onto the handgrips of both crutches.
Weight is offloaded from the lower extremities.
This allows the client to freely lift the unaffected leg without losing balance.
3
Advance the unaffected left leg up onto the next stair tread.
The strong leg is positioned on the higher step.
The unaffected leg must lead the upward movement to provide lifting power.
4
Transfer body weight from the crutches to the unaffected left leg.
The center of gravity is moved to the higher step.
This stabilizes the body on the new step and frees the crutches to be moved.
5
Bring both crutches and the non-weight-bearing right leg up to the stair.
The sequence for one step is completed.
The crutches always move with the affected leg to maintain non-weight-bearing status and provide continuous support.

Anahtar Kavram

Crutch walking on stairs (Ascending)
Soru 2018Soru →

A practical nurse is preparing to administer a combination of regular insulin and neutral protamine Hagedorn (NPH) insulin to a client with diabetes mellitus. Arrange the following steps for preparing the mixed insulin injection in the correct chronological order.

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Cevap

The correct chronological sequence is to roll the NPH vial, inject air into the NPH vial, inject air into the regular insulin vial, withdraw the regular insulin, and finally withdraw the NPH insulin.
The 'clear before cloudy' procedure is a standard pharmacological safety protocol. It ensures that the short-acting (clear) regular insulin is not contaminated by the intermediate-acting (cloudy) NPH insulin. Contamination would unpredictably change the pharmacokinetics of the regular insulin remaining in the vial.

Adım Adım Çözüm

1
Roll the NPH insulin vial.
The intermediate-acting insulin suspension is thoroughly mixed.
NPH is a suspension that settles when standing; rolling mixes it without creating bubbles that could lead to inaccurate dosing.
2
Inject air into the NPH insulin vial and remove the needle.
The NPH vial is pressurized.
Injecting air equal to the prescribed dose prevents a vacuum from forming when the medication is withdrawn later.
3
Inject air into the regular insulin vial and keep the needle inserted.
The regular insulin vial is pressurized and ready for withdrawal.
Pressurizing the vial allows the medication to flow easily into the syringe.
4
Invert the regular insulin vial and withdraw the prescribed dose.
The clear insulin is loaded into the syringe.
Drawing the clear insulin first ensures that no cloudy NPH insulin can accidentally enter and contaminate the regular insulin vial.
5
Insert the needle into the NPH vial and withdraw the prescribed dose.
The exact total volume of mixed insulin is achieved.
The cloudy insulin is added last to complete the mixture, ensuring the 'clear before cloudy' safety principle is maintained.

Anahtar Kavram

Safe Preparation and Mixing of Insulins (Clear Before Cloudy)
Tahmini Süre:1m 30s
Soru 2019Soru →

A practical nurse at a community clinic is participating in a health education session for preadolescent females and their caregivers. When reinforcing teaching about the expected physiological transitions of female puberty, the nurse describes the sequence of developmental milestones. Place the following physiological milestones in the chronological order in which they typically occur. (Arrange from first to last)

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Cevap

The correct chronological sequence of female pubertal milestones is: development of breast buds, followed by the appearance of initial pubic hair, then the period of most rapid linear growth, and finally the occurrence of the first menstrual period.
The established developmental sequence of female puberty begins with thelarche (breast budding), which is followed by pubarche (pubic hair growth). Following these changes, the adolescent experiences peak height velocity (a rapid growth spurt), and the sequence concludes with menarche (the first menstrual period).

Adım Adım Çözüm

1
Identify the initial physiological sign of female puberty.
The development of breast buds (thelarche) is the first milestone.
This transition marks the beginning of pubertal changes and is the earliest physical manifestation.
2
Determine the milestone that directly follows breast development.
The appearance of initial pubic hair (pubarche) occurs next.
The growth of pubic hair typically begins a few months after thelarche.
3
Identify the timing of the adolescent growth spurt.
The period of most rapid linear growth (peak height velocity) is placed third.
The growth spurt reaches its peak approximately 1 to 2 years after the onset of breast development and typically concludes before menarche.
4
Determine the final transition in this sequence.
The occurrence of the first menstrual period (menarche) is the final milestone.
Menarche is a late event in the sequence of female puberty, reliably occurring roughly 2 to 2.5 years after breast buds first appear.

Anahtar Kavram

The typical chronological sequence of physiological milestones during female puberty is thelarche (breast development), pubarche (pubic hair growth), peak height velocity (rapid linear growth), and menarche (first menstruation).
Soru 2020Soru →

A practical nurse (PN) is reviewing the morning data for a 72-year-old client who is 24 hours post-operative following a right total hip arthroplasty. The client is scheduled to receive a morning dose of subcutaneous enoxaparin.

Assessment ParameterPreoperative BaselineCurrent Morning Data
Blood Pressure138/82 mm Hg104/62 mm Hg
Heart Rate76 beats/min98 beats/min
Hemoglobin13.5 g/dL10.1 g/dL

The client reports feeling dizzy when sitting on the edge of the bed and rates incisional pain as a 4 on a 0 to 10 scale. Based on these findings, which action represents the most appropriate risk reduction strategy for the PN to take?

Cevabı ve açıklamayı göster

Cevap: Withhold the subcutaneous enoxaparin and immediately notify the registered nurse of the client's clinical trends.

Cevap

The most appropriate action is to withhold the subcutaneous enoxaparin and immediately notify the registered nurse of the client's clinical trends.
The client is demonstrating subtle signs of early hypovolemic shock and active bleeding, evidenced by a 3.4 g/dL drop in hemoglobin, a significant decrease in blood pressure from baseline, compensatory tachycardia, and orthostatic dizziness. Administering an anticoagulant like enoxaparin in the presence of active bleeding poses a severe, life-threatening risk. The priority for the practical nurse is to reduce risk by withholding the contraindicated medication and immediately escalating the findings to the registered nurse for intervention.

Adım Adım Çözüm

1
Analyze the vital sign trends from baseline to current.
Blood pressure has dropped significantly (narrowing pulse pressure) and heart rate has increased by 22 beats per minute.
Absolute vital signs may appear normal, but a significant deviation from baseline indicates physiological stress or compensation.
2
Evaluate the laboratory data changes.
Hemoglobin dropped by 3.4 g/dL in 24 hours.
A rapid drop in hemoglobin, even if the current value is not critically low, signifies substantial acute blood loss.
3
Interpret the clinical symptoms in context.
Dizziness upon sitting up indicates orthostatic hypotension.
Orthostatic changes strongly support a fluid volume deficit, correlating with the suspected blood loss.
4
Synthesize findings to identify the primary risk.
The client is exhibiting early compensatory signs of hypovolemic shock due to internal postoperative bleeding.
Recognizing early shock is critical to preventing progression to irreversible organ damage.
5
Determine the safest nursing action within the PN scope of practice.
The PN decides to withhold the scheduled anticoagulant and escalate the findings.
Administering enoxaparin would exacerbate the active bleeding. The PN must mitigate this risk by holding the medication and reporting the unstable condition to the RN.

Anahtar Kavram

Early recognition of hypovolemic shock and mitigation of bleeding risks
Tahmini Süre:2m 0s
ÖncekiSayfa 101 / 147Sonraki
Tüm alıştırma soruları — NCLEX-PN | Examkin