Tüm alıştırma soruları

2933 soru

Soru 2241Soru →

While assessing a client recovering from a chronic obstructive pulmonary disease (COPD) exacerbation, the practical nurse notes a sudden change in the client's baseline behavior. The 78-year-old client, who has been treated with high-dose intravenous corticosteroids for the past three days, is now highly agitated, disoriented, and reports a burning sensation in the epigastric region. The vital signs show a heart rate of 115 bpm, a blood pressure of 102/56 mm Hg, and an oxygen saturation of 89% on room air. What is the priority intervention for the practical nurse in this scenario?

Cevabı ve açıklamayı göster

Cevap: Initiate supplemental oxygen therapy and immediately notify the registered nurse of the changing condition.

Cevap

Initiate supplemental oxygen therapy and immediately notify the registered nurse of the changing condition.
The client is exhibiting signs of a severe gastrointestinal bleed, a known complication of high-dose corticosteroid therapy (indicated by the epigastric pain). The combination of agitation, tachycardia (115 bpm), borderline hypotension (102/56 mm Hg), and hypoxia (SpO2 89%) indicates impending hypovolemic shock and poor tissue perfusion. The practical nurse must prioritize ABCs (Airway, Breathing, Circulation) by applying oxygen to treat the hypoxia and immediately escalating the situation to the registered nurse for rapid medical intervention.

Adım Adım Çözüm

1
Analyze the clinical cues, including the history of corticosteroid use, epigastric pain, and new-onset agitation.
Identify that these findings suggest a potential gastrointestinal bleed.
Corticosteroids significantly increase the risk of peptic ulcers. Sudden bleeding can lead to decreased cerebral perfusion, causing the acute agitation.
2
Evaluate the current vital signs (Heart rate 115 bpm, Blood pressure 102/56 mm Hg, SpO2 89%).
Recognize that the client is experiencing hypoxia and early signs of hypovolemic shock.
Tachycardia and a narrowing or dropping blood pressure are compensatory mechanisms for volume loss, while hypoxia results from decreased oxygen-carrying capacity.
3
Determine the priority nursing action based on the ABC framework (Airway, Breathing, Circulation) and the practical nurse scope of practice.
Select the intervention that addresses oxygenation and rapidly involves the registered nurse.
Applying oxygen directly treats the breathing deficit, and a rapidly decompensating client requires immediate RN-level assessment and collaborative intervention.

Anahtar Kavram

Recognizing early signs of hypovolemic shock secondary to gastrointestinal bleeding and prioritizing ABCs (Airway, Breathing, Circulation).
Tahmini Süre:1m 30s
Soru 2242Soru →

A practical nurse is monitoring a client who recently returned from the post-anesthesia care unit following abdominal surgery. Which of the following assessment findings should the nurse identify as early indicators of hypovolemic shock? (Select all that apply.)

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Heart rate of 118118 beats per minute; Blood pressure decreasing from 128/82 mm Hg128/82\text{ mm Hg} to 98/60 mm Hg98/60\text{ mm Hg}; Client reports of sudden, severe thirst

Cevap

The findings that indicate early hypovolemic shock are a heart rate of 118 beats per minute, a blood pressure decreasing from 128/82 mm Hg to 98/60 mm Hg, and client reports of sudden, severe thirst.
Early signs of hypovolemic shock include compensatory mechanisms such as an elevated heart rate (tachycardia) and severe thirst as the body attempts to maintain circulating volume and cardiac output. A subsequent drop in blood pressure confirms that the cardiovascular system is struggling to adapt to the fluid loss. Recognizing this cluster of findings is crucial for early intervention.

Adım Adım Çözüm

1
Analyze the clinical scenario and the client's current risk factors.
The client is in the early postoperative phase, making them highly vulnerable to hemorrhage and subsequent fluid volume deficit.
Understanding the primary postoperative risks directs the nurse to monitor specific physiological adaptations.
2
Evaluate the assessment findings against the clinical signs of circulatory compromise.
Tachycardia, dropping blood pressure, and intense thirst are identified as classic signs of reduced circulating blood volume.
The body compensates for fluid loss by increasing the heart rate and triggering the thirst mechanism before ultimately failing to maintain blood pressure.
3
Differentiate acute signs of deterioration from expected postoperative findings.
Incisional pain and a low-grade temperature are excluded as indicators of shock because they are expected responses to surgical trauma.
This ensures the nurse prioritizes potentially life-threatening circulatory changes over routine, stable postoperative symptoms.

Anahtar Kavram

Early recognition of hypovolemic shock involves identifying compensatory cardiovascular changes such as tachycardia, hypotension, and systemic responses like thirst.
Soru 2243Soru →

An older adult client is recovering on a surgical unit two days after undergoing an abdominal procedure. The client, who was previously oriented and cooperative, now exhibits sudden restlessness and confusion about their current location. The latest vital signs reveal a heart rate of 114 beats/min and a blood pressure of 98/58 mm Hg. Which of the following is the priority action for the practical nurse?

Cevabı ve açıklamayı göster

Cevap: Measure the client's oxygen saturation and promptly report the status change to the registered nurse.

Cevap

The correct action is to measure the client's oxygen saturation and promptly report the status change to the registered nurse.
The correct response prioritizes the 'Airway, Breathing, Circulation' (ABC) framework in a client exhibiting sudden acute changes. Restlessness and confusion, combined with borderline vital signs (tachycardia and mild hypotension), are early indicators of hypoxia, shock, or sepsis in a post-operative client. The practical nurse must immediately gather relevant oxygenation data and escalate these critical findings to the registered nurse for prompt intervention.

Adım Adım Çözüm

1
Analyze the clinical cues presented by the client.
The client has a sudden onset of restlessness and confusion, alongside a heart rate of 114 beats/min and blood pressure of 98/58 mm Hg.
Identifying sudden changes in mental status and borderline hemodynamics is crucial for recognizing early deterioration.
2
Prioritize the cues using the ABC (Airway, Breathing, Circulation) framework.
Sudden restlessness is a classic early sign of hypoxia (Breathing), and the tachycardia with mild hypotension suggests compensatory mechanisms for shock or poor perfusion (Circulation).
Life-threatening physiological issues must be addressed before secondary concerns like pain or routine charting.
3
Determine the most appropriate action within the practical nursing scope of practice.
The practical nurse must collect focused data, such as oxygen saturation, and immediately escalate the findings to the registered nurse for rapid medical intervention.
Acute decompensation requires collaborative management and timely intervention beyond routine practical nurse monitoring.

Anahtar Kavram

Early recognition of shock and hypoxia in older adults
Soru 2244Soru →

A practical nurse is providing basic care for a client who is 3 days postoperative following a surgical evacuation of a subdural hematoma. The client has residual right-sided hemiplegia and severe dysphagia, requiring maximum assistance with activities of daily living. Which care interventions should the nurse implement? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Place the client's right arm on a pillow in slight abduction and external rotation while they are supine.; Guide the client to tuck their chin downward toward the chest when swallowing pureed foods.; Begin putting garments on the right side of the client's body first when assisting with dressing.

Cevap

The appropriate interventions include placing the affected arm in slight abduction and external rotation, guiding the client to tuck their chin when swallowing, and dressing the affected right side first.
Supporting the flaccid limb in slight abduction and external rotation prevents adduction contractures and painful shoulder subluxation. Tucking the chin during swallowing protects the airway by widening the valleculae and directing food away from the trachea, preventing aspiration. When assisting a client with hemiplegia to dress, putting garments on the affected side first prevents unnecessary stretching, pulling, and potential dislocation of the paralyzed joints.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
The client has right-sided hemiplegia (paralysis) and severe dysphagia (difficulty swallowing) following a neurosurgical procedure.
Understanding the specific deficits dictates the requirements for safe mobility, hygiene, and nutritional support.
2
Evaluate the positioning and mobility interventions for hemiplegia.
The affected right arm needs support in abduction/external rotation. The wheelchair must be placed on the strong left side for transfers. Firm objects should not be placed in the spastic hand.
Proper joint alignment prevents subluxation and contractures. Transferring toward the strong side ensures the client can bear weight safely. Stimulating the palm triggers the grasp reflex, worsening contractures.
3
Evaluate the nutritional and feeding interventions for dysphagia.
The chin-tuck maneuver should be utilized. Straws must be avoided.
Tucking the chin protects the airway from aspiration. Straws bypass the oral preparatory phase and deliver fluids too quickly to the pharynx, risking aspiration.
4
Evaluate the hygiene and dressing sequence.
The affected right side must be dressed first.
Dressing the weak side first minimizes the need to bend or awkwardly pull on flaccid limbs, protecting the joints from injury.

Anahtar Kavram

Basic care for clients with hemiplegia and dysphagia requires synthesizing principles of joint alignment, airway protection during feeding, and maximizing safety during ADLs.
Tahmini Süre:1m 30s
Soru 2245Soru →

A practical nurse is providing care for a client who returned to the nursing unit one hour ago following a percutaneous liver biopsy. Which interventions should the nurse implement to promote comfort and ensure client safety? (Select all that apply)

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Position the client on the right side with a small rolled towel beneath the puncture site.; Provide a bedpan for elimination needs to maintain strict bed rest requirements.; Dim the room lights and minimize external noise to facilitate a restful environment.

Cevap

The nurse should position the client on the right side with a towel under the puncture site, provide a bedpan to maintain bed rest, and dim the lights to create a restful environment.
Following a liver biopsy, preventing hemorrhage is the primary physiological goal. Positioning the client on the right side applies direct, continuous pressure to the puncture site. Maintaining strict bed rest with the use of a bedpan ensures physical exertion is minimized, further reducing bleeding risks. Finally, controlling the environment by dimming lights addresses the client's basic comfort needs without compromising safety.

Adım Adım Çözüm

1
Analyze the procedure and potential complications.
A percutaneous liver biopsy carries a high risk of internal hemorrhage due to the high vascularity of the liver.
Understanding the primary risk determines the necessary safety interventions.
2
Determine the appropriate postoperative positioning.
The client must be placed on their right side with a pillow or towel under the puncture site.
This specific position applies external physical pressure directly to the liver capsule to aid in hemostasis.
3
Identify the required activity level for the client.
The client must remain on strict bed rest and use a bedpan for elimination.
Physical exertion or ambulation increases abdominal pressure and heart rate, which can dislodge clots and cause bleeding.
4
Select basic comfort measures that do not interfere with safety.
Dimming lights and reducing noise promotes necessary rest.
Environmental control provides comfort while supporting the physiological need for bed rest.

Anahtar Kavram

Post-procedure basic care, comfort, and positioning to prevent hemorrhage.
Soru 2246Soru →

A practical nurse is caring for an adult client with heart failure who is scheduled to receive a morning dose of oral digoxin. During the pre-administration assessment, the client's apical pulse is 5454 beats/min, and the client reports feeling nauseous and seeing yellow halos around the lights in the room. Which of the following actions should the practical nurse take first?

Cevabı ve açıklamayı göster

Cevap: Withhold the dose of digoxin and immediately notify the registered nurse.

Cevap

Withhold the dose of digoxin and immediately notify the registered nurse.
The client is exhibiting classical clinical signs of digoxin toxicity, which include gastrointestinal distress (nausea) and visual disturbances (yellow halos). Furthermore, the client's apical pulse is below the standard adult parameter of 60 beats/min. The safest and most appropriate action within the practical nurse scope of practice is to withhold the medication and escalate these critical findings to the registered nurse for further evaluation.

Adım Adım Çözüm

1
Analyze the client's pre-administration assessment findings.
The apical pulse is 54 beats/min, which is below the safe threshold of 60 beats/min for an adult. The client is also experiencing nausea and visual disturbances (yellow halos).
Before administering cardiac glycosides like digoxin, the nurse must ensure the heart rate is safe and evaluate for any symptoms that could indicate medication toxicity.
2
Determine the appropriate clinical intervention based on the practical nurse scope of practice.
The medication must be withheld and the findings immediately reported to the supervising registered nurse or healthcare provider.
Administering the medication would worsen the bradycardia and toxicity. Changing the dose independently is not permitted, making withholding and escalating the only safe and legal action.

Anahtar Kavram

Digoxin toxicity recognition and safe medication administration parameters.
Soru 2247Soru →

A practical nurse is caring for an adult client who was recently diagnosed with a respiratory tract infection. The healthcare provider prescribes oral azithromycin 0.5 g0.5\text{ g} to be administered once daily. The pharmacy dispenses a reconstituted oral suspension labeled 250 mg/5 mL250\text{ mg}/5\text{ mL}. How many milliliters (mL\text{mL}) should the nurse administer to the client for each dose?

Cevabı ve açıklamayı göster

Cevap: 10 mL10\text{ mL}

Cevap

The nurse should administer 10 mL10\text{ mL} of the oral suspension per dose.
The correct dose is 10 mL10\text{ mL}. To determine this, the practical nurse must first convert the prescribed 0.5 g0.5\text{ g} to 500 mg500\text{ mg}. Using the standard formula of (Desired / Have) \times Volume, the equation becomes (500 mg/250 mg500\text{ mg} / 250\text{ mg}) \times 5\text{ mL}.Thissimplifiesto. This simplifies to 2 \times 5\text{ mL},whichequals, which equals 10\text{ mL}$.

Adım Adım Çözüm

1
Convert the prescribed dose from grams to milligrams to ensure units match the supplied medication.
0.5 g=500 mg0.5\text{ g} = 500\text{ mg}
Units of measurement must be identical before a dosage calculation can be accurately performed.
2
Set up the dosage calculation using the standard formula: (Desired dose / Available dose) x Volume.
(500 mg/250 mg500\text{ mg} / 250\text{ mg}) \times 5\text{ mL}$
This formula accounts for both the concentration of the medication and the volume of liquid it is suspended in.
3
Perform the division and multiplication to find the final volume to administer.
2×5 mL=10 mL2 \times 5\text{ mL} = 10\text{ mL}
Solving the equation provides the precise volume required to safely deliver the prescribed amount of medication.

Anahtar Kavram

Medication Dosage Calculation and Unit Conversion
Soru 2248Soru →

A practical nurse (PN) is preparing to administer a prescribed dose of cefdinir oral suspension to a pediatric client with acute otitis media. The client's weight is 27 pounds 8 ounces. The provider's prescription reads: cefdinir 14 mg/kg/day by mouth, divided in equal doses every 12 hours. The pharmacy supplies a bottle of cefdinir powder for oral suspension. The reconstitution instructions on the label state: "Add 38 mL of sterile water to the bottle to yield a final concentration of 125 mg/5 mL." How many milliliters (mL) should the PN administer for a single dose? (Record answer to the nearest tenth. Do not include units in answer.)

Cevabı ve açıklamayı göster

Cevap: 3.5

Cevap

3.5
To determine the correct volume to administer, the nurse must execute four specific calculations. First, convert the weight of 27 pounds 8 ounces to kilograms (27.5 lbs÷2.2=12.5 kg27.5\text{ lbs} \div 2.2 = 12.5\text{ kg}). Second, calculate the total daily dose (12.5 kg×14 mg/kg/day=175 mg/day12.5\text{ kg} \times 14\text{ mg/kg/day} = 175\text{ mg/day}). Third, divide the daily dose by the frequency (every 12 hours = 2 doses per day; 175 mg÷2=87.5 mg/dose175\text{ mg} \div 2 = 87.5\text{ mg/dose}). Finally, use dimensional analysis with the reconstituted concentration (125 mg125\text{ mg} in 5 mL5\text{ mL}) to find the volume: (87.5 mg125 mg\frac{87.5\text{ mg}}{125\text{ mg}}) ×5 mL=3.5 mL\times 5\text{ mL} = 3.5\text{ mL}. The 38 mL38\text{ mL} of diluent is distractor information required only during the actual mixing process.

Adım Adım Çözüm

1
Convert the client's weight from pounds and ounces to kilograms.
12.5
Weight-based dosing requires the client's weight in kilograms. 88 ounces is 0.50.5 pounds (8÷168 \div 16), making the total weight 27.527.5 pounds. Dividing 27.527.5 by 2.22.2 yields 12.5 kg12.5\text{ kg}.
2
Calculate the total daily dose in milligrams.
175
Multiply the prescribed dose of 14 mg/kg/day14\text{ mg/kg/day} by the client's weight of 12.5 kg12.5\text{ kg} to get 175 mg/day175\text{ mg/day}.
3
Calculate the single dose amount.
87.5
The total daily dose is divided every 12 hours, which means 2 doses per day. 175 mg175\text{ mg} divided by 2 equals 87.5 mg87.5\text{ mg} per dose.
4
Calculate the volume of the single dose using the final concentration.
3.5
Using the final reconstituted concentration of 125 mg125\text{ mg} per 5 mL5\text{ mL}: 87.5 mg125 mg×5 mL=3.5 mL\frac{87.5\text{ mg}}{125\text{ mg}} \times 5\text{ mL} = 3.5\text{ mL}.

Anahtar Kavram

Pediatric Weight-Based Dosage Calculation with Reconstitution
Soru 2249Soru →

A practical nurse (PN) is assigned to care for a 7474-year-old client who is prescribed daily oral lithium carbonate for the management of bipolar disorder. The client's morning laboratory panel reveals a serum lithium level of 1.91.9 mEq/L and a serum sodium level of 130130 mEq/L. During data collection, the PN notes that the client is exhibiting a coarse hand tremor, ataxia, and new-onset acute confusion. Which of the following is the priority action for the PN?

Cevabı ve açıklamayı göster

Cevap: Withhold the scheduled medication dose and immediately notify the registered nurse (RN) of the clinical findings.

Cevap

The correct action is to withhold the scheduled medication dose and immediately notify the registered nurse (RN) of the clinical findings.
The client is exhibiting clear physiological and laboratory signs of lithium toxicity, which constitutes a medical emergency. The therapeutic range for maintenance lithium is 0.60.6 to 1.21.2 mEq/L; a level of 1.91.9 mEq/L is highly toxic. Furthermore, the client's hyponatremia (sodium level of 130130 mEq/L) causes the kidneys to resorb lithium instead of excreting it, worsening the toxicity. The safest and most appropriate action within the PN scope of practice is to withhold the scheduled dose and immediately report these critical, life-threatening findings to the supervising RN or provider.

Adım Adım Çözüm

1
Analyze the client's laboratory results in the context of the prescribed medication.
The serum lithium level of 1.91.9 mEq/L is critically high (therapeutic range is 0.60.6 to 1.21.2 mEq/L). The serum sodium level of 130130 mEq/L indicates hyponatremia.
Hyponatremia causes the kidneys to retain lithium, significantly increasing the risk and severity of lithium toxicity.
2
Correlate the laboratory data with the client's physical assessment findings.
The client exhibits coarse hand tremors, ataxia, and acute confusion.
These are classic, dangerous neurological manifestations of advanced lithium toxicity that require immediate medical intervention.
3
Determine the safest appropriate intervention within the practical nurse (PN) scope of practice.
The PN must withhold the medication to prevent further harm and urgently report the findings to the RN or healthcare provider.
Administering the medication would worsen the toxicity, and managing a toxic overdose requires RN and provider-level interventions.

Anahtar Kavram

Monitoring Narrow Therapeutic Index Medications and Scope of Practice
Tahmini Süre:1m 30s
Soru 2250Soru →

A practical nurse is preparing to collect a urine specimen for culture and sensitivity from a client who has an indwelling urinary catheter. Arrange the following steps for this procedure in the correct chronological sequence.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence is to first clamp the drainage tubing, then scrub the collection port, aspirate the urine with a sterile syringe, transfer it to a sterile container, and finally unclamp the drainage tubing.
The proper procedure for collecting a sterile urine specimen from a closed urinary drainage system minimizes the risk of introducing pathogens and ensures accurate laboratory results. Clamping the tube allows fresh urine to collect. Scrubbing the port maintains sterility. Aspirating and transferring the specimen completes the sterile collection, and unclamping the tube ensures client safety by restoring normal urinary drainage.

Adım Adım Çözüm

1
Clamp the drainage tubing.
Fresh urine accumulates near the collection port.
Urine collected from the drainage bag is not sterile; fresh urine must be collected directly from the catheter tubing.
2
Scrub the collection port with an antiseptic wipe.
The surface of the port is disinfected.
This prevents bacteria from being pushed into the catheter system or contaminating the sample during aspiration.
3
Aspirate urine using a sterile syringe.
The required volume of fresh urine is obtained.
A sterile syringe maintains the closed system while safely extracting the sample.
4
Transfer the urine to a sterile specimen container.
The specimen is safely secured for transport.
Maintaining the sterility of the container's interior ensures accurate laboratory culture results.
5
Unclamp the drainage tubing.
Continuous urine flow into the drainage bag is restored.
Prolonged clamping can cause severe bladder distention and increases the risk of urinary tract infection.

Anahtar Kavram

Sterile Specimen Collection and Risk Reduction
Soru 2251Soru →

A client with severe chronic obstructive pulmonary disease (COPD) and bilateral lower extremity edema is confined to bed rest 72 hours after undergoing surgical stabilization of a pelvic fracture. To promote optimal comfort, preserve skin integrity, and accommodate all underlying physiological needs, which positioning strategy should the practical nurse execute?

Cevabı ve açıklamayı göster

Cevap: Maintain a semi-Fowler's position and place soft pillows lengthwise under the calves to suspend the heels.

Cevap

The correct approach is to maintain a semi-Fowler's position and place soft pillows lengthwise under the calves to suspend the heels.
Maintaining a semi-Fowler's position allows gravity to pull the diaphragm downward, maximizing lung expansion for the client with COPD. Placing pillows lengthwise under the calves promotes venous return to reduce dependent edema while simultaneously offloading pressure from the heels and avoiding popliteal vein compression. This holistic approach safely accommodates the pelvic fracture restrictions while providing optimal basic care.

Adım Adım Çözüm

1
Analyze the respiratory requirements of the client.
The client has severe COPD, which requires the head of the bed to be elevated to facilitate lung expansion and ease the work of breathing.
Gravity pulls abdominal organs downward, allowing the diaphragm to fully contract during inspiration.
2
Evaluate the surgical restrictions related to the pelvic fracture.
Extreme hip flexion, weight-bearing, or unsupported dangling of the lower extremities must be avoided.
These actions place severe stress on the newly stabilized pelvic bones and hardware.
3
Address the circulatory and integumentary risks associated with edema and bed rest.
The lower extremities must be elevated to reduce edema, but without creating sharp bends behind the knees. The heels must also be protected from pressure.
Sharp knee gatching impedes venous return and increases deep vein thrombosis (DVT) risk. Floating the heels prevents decubitus ulcers.
4
Synthesize the findings to select the optimal position.
A semi-Fowler's position with lengthwise calf pillows safely meets respiratory, circulatory, and post-surgical requirements simultaneously.
It addresses all three competing physiological needs without violating any safety contraindications.

Anahtar Kavram

Synthesizing competing physiological needs in positioning (Airway/Breathing, Circulatory Return, and Post-Surgical Restrictions)
Soru 2252Soru →

A practical nurse is planning morning hygiene and comfort care for a client who is 1 day postoperative following a right-sided total hip arthroplasty (posterior approach). The client reports mild joint stiffness and requests assistance with a bed bath and repositioning. Which action should the nurse take?

Cevabı ve açıklamayı göster

Cevap: Place an abduction wedge between the client's legs and obtain assistance to turn the client onto the unaffected left side

Cevap

Place an abduction wedge between the client's legs and obtain assistance to turn the client onto the unaffected left side.
Following a total hip arthroplasty with a posterior approach, the client is at high risk for hip dislocation. To prevent this, the nurse must maintain the affected leg in a neutral, abducted position and strictly avoid hip adduction, internal rotation, and flexion greater than 90 degrees. Placing an abduction wedge between the legs prevents adduction, and turning the client onto the unaffected (left) side while maintaining alignment is the safest way to provide back care and reposition the client for comfort.

Adım Adım Çözüm

1
Analyze the client's surgical procedure.
The client had a right-sided total hip arthroplasty via a posterior approach.
Different surgical approaches have specific postoperative movement restrictions that dictate safe basic care.
2
Identify the positioning constraints for this procedure.
Posterior THA requires preventing hip flexion greater than 90 degrees, internal rotation, and adduction.
These specific movements can cause the newly placed prosthetic joint to dislocate posteriorly.
3
Evaluate the proposed nursing actions against surgical constraints and the LPN/VN scope of practice.
Using an abduction wedge and turning to the unoperated side maintains proper alignment. High-Fowler's position violates the flexion restriction. IVP medication administration violates the PN scope of practice.
Basic care must simultaneously align with safety protocols, therapeutic communication standards, and legal scope of practice.

Anahtar Kavram

Postoperative Positioning and Safety in Total Hip Arthroplasty
Soru 2253Soru →

A client is recovering on the surgical unit following a right total hip arthroplasty utilizing a posterior approach. The practical nurse is preparing to turn the client to assess the sacral area. Which action represents the safest technique for this client?

Cevabı ve açıklamayı göster

Cevap: Keep an abduction wedge placed between the client's legs while rolling them onto their left side

Cevap

Keep an abduction wedge placed between the client's legs while rolling them onto their left side.
For a client with a posterior approach total hip arthroplasty, the hip must remain in an abducted, neutral position to prevent prosthesis dislocation. Using an abduction wedge between the legs while turning the client onto the unaffected (left) side maintains this alignment and safely prevents the surgical hip from crossing the midline (adducting) or internally rotating.

Adım Adım Çözüm

1
Identify the surgical procedure and the associated post-operative precautions.
The client had a right total hip arthroplasty (posterior approach).
Different surgical approaches have specific movement restrictions to prevent prosthesis dislocation.
2
Recall the specific mobility restrictions for a posterior approach total hip arthroplasty.
Precautions include avoiding hip flexion greater than 90 degrees, avoiding adduction (crossing the midline), and avoiding internal rotation of the affected leg.
These specific movements force the newly placed femoral head out of the acetabular cup.
3
Evaluate each nursing action against the identified safety precautions.
Using an abduction wedge prevents adduction. The other actions promote extreme flexion, internal rotation, or adduction.
Basic care must be performed without violating the prescribed positional limitations.
4
Select the action that safely facilitates basic care.
Turning the client onto the unaffected (left) side with an abduction wedge is the safest technique.
This maintains neutral alignment of the operative hip while allowing access to the sacral area.

Anahtar Kavram

Postoperative Positioning and Joint Precautions for Total Hip Arthroplasty
Soru 2254Soru →

A practical nurse (PN) enters the room of a client receiving total parenteral nutrition (TPN) and discovers that the central venous catheter tubing has accidentally disconnected from the hub. The client is suddenly gasping for air, clutching their chest, and appears cyanotic. In what order should the PN perform the following actions? Arrange the actions in the correct sequence from first to last.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct priority sequence is to first clamp the catheter, then position the client on their left side with the head lowered, followed by administering oxygen, and finally collecting vital signs.
In the event of a central venous catheter disconnection leading to an air embolism, the PN must follow strict prioritized steps. The very first action is to clamp the catheter to stop further air from being drawn into the venous system by negative intrathoracic pressure. Second, the client must be placed in the left lateral Trendelenburg position; this uses gravity to trap the air in the right atrium or right ventricle, preventing it from blocking the pulmonary artery. Third, high-flow oxygen is administered to combat the resulting severe hypoxia and help wash out nitrogen from the air bubble. Finally, once these immediate life-saving actions are complete, the PN collects a full set of vital signs to provide crucial hemodynamic data to the rapid response team and healthcare provider.

Adım Adım Çözüm

1
Clamp the open lumen of the central venous catheter.
Further air entry is immediately halted.
The direct cause of the emergency (an open line into the central venous system) must be eliminated before any other intervention to prevent a larger, more lethal air embolism.
2
Turn the client onto their left side with the head of the bed lowered.
The air bubble is physically trapped.
The left lateral Trendelenburg position utilizes gravity to keep the air bubble in the apex of the right ventricle or atrium, preventing it from traveling into the pulmonary artery and causing a right ventricular outflow tract obstruction.
3
Administer high-flow supplemental oxygen via a non-rebreather mask.
Tissue hypoxia is treated.
The air embolism causes severe ventilation/perfusion mismatch and hypoxia; high-flow oxygen helps reverse the hypoxemia and may assist in resorbing the nitrogen gas bubble.
4
Collect a complete set of vital signs to report to the rapid response team.
Baseline data is gathered for the arriving team.
Hemodynamic status must be evaluated after initial life-saving measures to report to the registered nurse and emergency providers.

Anahtar Kavram

Emergency management of a suspected central line air embolism prioritizes immediately stopping air entry, then utilizing positional gravity to trap the air, followed by oxygenation and hemodynamic monitoring.
Tahmini Süre:1m 30s
Soru 2255Soru →

A practical nurse is monitoring a client who began receiving a packed red blood cell (PRBC) transfusion 15 minutes ago. The client suddenly reports severe lower back pain, acute chills, and a sensation of chest tightness. Arrange the following nursing actions in the correct sequence of priority from first to last.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence prioritizes immediate cessation of the offending agent, followed by securing safety (new IV line), escalating care (notifying RN), collecting critical data (vital signs), and finally completing diagnostic protocols (returning blood, collecting urine).
The sequence follows the airway, breathing, circulation (ABC) and nursing process prioritization frameworks. Stopping the transfusion immediately removes the life-threatening trigger. Changing the tubing ensures the client receives necessary IV fluids without receiving the residual incompatible blood left in the old line. Notifying the RN brings advanced life support. Taking vital signs provides necessary data to the RN upon arrival. Returning the blood bag and collecting a urine sample are diagnostic and administrative tasks that must wait until the client is stabilized.

Adım Adım Çözüm

1
Halt the transfusion
Prevents further administration of incompatible red blood cells.
The client is exhibiting classic signs of an acute hemolytic transfusion reaction (lower back pain, chills, dyspnea). Removing the offending agent is the primary life-saving action.
2
Maintain intravenous access with new tubing and normal saline
Keeps the vein open for emergency drugs without infusing residual blood.
Flushing the old tubing would push more incompatible blood into the client. New tubing ensures safety while maintaining a route for vascular support.
3
Alert the registered nurse and emergency response team
Initiates advanced medical support.
The client will require medications and interventions beyond the practical nurse's scope of practice to manage potential shock and acute renal failure.
4
Assess vital signs and cardiopulmonary status
Provides critical baseline data regarding the severity of the reaction.
This data guides the incoming rapid response team in diagnosing the extent of hemodynamic instability or respiratory compromise.
5
Secure the blood bag and tubing for the laboratory
Preserves evidence for blood bank analysis.
The laboratory must crossmatch the blood again to determine the exact cause and type of the hemolytic reaction.
6
Obtain a urine specimen
Provides a sample to test for hemoglobinuria.
Hemolyzed red blood cells release free hemoglobin, which is filtered by the kidneys and can cause acute tubular necrosis. This confirms the systemic impact.

Anahtar Kavram

Prioritization of care during an acute hemolytic transfusion reaction requires immediate cessation of the blood product, maintaining venous access with sterile equipment, and rapid escalation of care before proceeding with secondary assessments and diagnostics.
Soru 2256Soru →

A practical nurse is collecting data from a client who is 2 hours postoperative following an abdominal hysterectomy. The client's vital signs are: blood pressure 98/60 mm Hg, heart rate 114 beats per minute, respiratory rate 18 breaths per minute, and oxygen saturation 96% on room air. The client reports incisional pain as 6 on a 0 to 10 pain scale. Which action should the practical nurse take first?

Cevabı ve açıklamayı göster

Cevap: Notify the registered nurse about the vital signs immediately

Cevap

Notify the registered nurse about the vital signs immediately
The correct action is to notify the registered nurse immediately because a heart rate of 114 beats per minute and a blood pressure of 98/60 mm Hg are early indicators of hypovolemic shock and potential internal hemorrhage following major surgery. Rapid escalation is essential for client safety.

Adım Adım Çözüm

1
Analyze the client's vital signs against expected postoperative baselines.
The heart rate of 114 beats per minute and blood pressure of 98/60 mm Hg are abnormal.
Identifying deviations from normal values is required to recognize early complications.
2
Apply the Airway, Breathing, Circulation (ABC) prioritization framework.
The vital signs indicate a potential issue with circulation (hypovolemia or hemorrhage).
Circulatory compromise is life-threatening and takes priority over managing the client's pain.
3
Determine the appropriate scope of practice for the practical nurse in this scenario.
The practical nurse must immediately report these critical findings to the registered nurse for further assessment and intervention.
Practical nurses must escalate sudden signs of instability to the RN or provider for advanced clinical judgment.

Anahtar Kavram

Early recognition of hypovolemic shock and appropriate escalation.
Soru 2257Soru →

During a routine medication pass at an outpatient recovery clinic, a client receiving treatment for severe opioid use disorder becomes tearful. The client states, 'I cannot handle the intense guilt of what I put my family through while I was using. Sometimes I think it would be easier to just go back to the drugs.' Which response by the practical nurse is the most appropriate?

Cevabı ve açıklamayı göster

Cevap: It sounds like you are feeling overwhelmed by the guilt of how your substance use affected your family.

Cevap

The most appropriate response is to use reflection to validate the client's feelings by stating that it sounds like they are feeling overwhelmed by guilt.
The correct response utilizes reflection and validation, which are highly effective therapeutic communication techniques. By restating the client's feelings without offering false reassurance or unsolicited advice, the practical nurse encourages further open dialogue and helps the client process the complex emotions associated with recovery and relapse triggers.

Adım Adım Çözüm

1
Analyze the client's statement to identify the primary nursing problem.
The client is expressing deep guilt and thoughts of relapse as an ineffective coping mechanism.
Understanding the core emotion helps determine the appropriate therapeutic intervention.
2
Evaluate the practical nurse's scope of practice regarding behavioral health crises.
The practical nurse must provide immediate psychosocial support using therapeutic communication and report significant findings to the RN.
The PN cannot independently conduct comprehensive assessments or alter care plans, but must ensure immediate emotional safety.
3
Assess each response option for therapeutic value and adherence to legal/ethical standards.
Reflecting the client's feelings is therapeutic. Asking 'why' is non-therapeutic. Altering the care plan is out of scope. Leaving a detailed voicemail violates confidentiality.
Selecting the response that maintains safety, stays within scope, and uses evidence-based communication techniques is required.

Anahtar Kavram

Therapeutic Communication in Substance Use Disorders
Soru 2258Soru →

A 78-year-old client is admitted to the medical unit with a history of melena and fatigue. While collecting vital signs, the practical nurse notes a resting heart rate of 112 beats per minute, a blood pressure of 96/62 mm Hg, and acute disorientation to the current location. Which of the following actions should the nurse implement? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Notify the registered nurse immediately regarding the change in status.; Ensure the patency of the client's peripheral intravenous access.; Apply supplemental oxygen per the facility's standing emergency protocol.

Cevap

The nurse should immediately notify the registered nurse, ensure the patency of the intravenous access, and apply supplemental oxygen.
The client is demonstrating classic signs of compensatory hypovolemic shock and resulting cerebral hypoxia, indicated by tachycardia, borderline low blood pressure, and acute confusion. The practical nurse must prioritize circulation and oxygenation by securing intravenous access, providing supplemental oxygen, and immediately escalating the situation to the registered nurse for advanced intervention.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
The combination of tachycardia, borderline low blood pressure, and acute confusion in a client with melena indicates early hypovolemic shock and hypoxia.
Recognizing physiological deterioration is the first step in prioritizing appropriate nursing care.
2
Prioritize interventions based on the ABCs (Airway, Breathing, Circulation).
Applying supplemental oxygen addresses breathing, while securing IV access and notifying the RN addresses circulation and necessary medical escalation.
Life-threatening physiological issues must be managed before routine or secondary tasks.
3
Identify inappropriate actions that would delay care.
Withholding notification for a lower blood pressure, assuming confusion is age-related, and prioritizing oral pain medication must be avoided.
These actions dangerously misinterpret subtle signs of shock and ignore immediate ABC priorities.

Anahtar Kavram

Early Recognition and Management of Hypovolemic Shock
Soru 2259Soru →

An older adult client with a history of heart failure is prescribed a daily dose of oral furosemide. The most recent comprehensive metabolic panel reveals a serum potassium level of 2.62.6 mEq/L (2.62.6 mmol/L). Which action should the practical nurse take?

Cevabı ve açıklamayı göster

Cevap: Withhold the furosemide and immediately report the potassium level to the supervising registered nurse.

Cevap

The nurse must withhold the diuretic medication and immediately notify the supervising registered nurse about the critically low potassium level.
The normal serum potassium level is 3.53.5 to 5.05.0 mEq/L (3.53.5 to 5.05.0 mmol/L). A level of 2.62.6 mEq/L (2.62.6 mmol/L) indicates severe hypokalemia. Furosemide is a potassium-wasting loop diuretic. Administering it would further lower the potassium level, placing the client at high risk for lethal cardiac dysrhythmias. The practical nurse must prioritize client safety by withholding the dose and escalating the critical finding immediately.

Adım Adım Çözüm

1
Interpret the serum potassium laboratory result.
The value of 2.62.6 mEq/L is significantly below the normal adult range of 3.53.5 to 5.05.0 mEq/L, indicating severe hypokalemia.
Recognizing abnormal laboratory values is the first essential step in clinical risk reduction.
2
Analyze the relationship between the prescribed medication and the critical laboratory value.
Furosemide is a loop diuretic that causes the kidneys to excrete potassium. Giving this medication will worsen the client's already severe hypokalemia.
Understanding medication mechanism of action prevents the administration of contraindicated drugs.
3
Determine the safest nursing intervention within the practical nurse scope of practice.
The safest action is to withhold the dose and escalate the critical finding to the registered nurse or healthcare provider.
The practical nurse must act promptly to prevent harm and communicate critical data to the supervising team.

Anahtar Kavram

Identifying Critical Laboratory Values and Preventing Complications
Tahmini Süre:1m 0s
Soru 2260Soru →

A client diagnosed with bipolar disorder has been managed on a daily maintenance dose of oral lithium. Three days ago, the healthcare provider prescribed oral hydrochlorothiazide for newly diagnosed hypertension. During the morning assessment, the practical nurse notes the client is experiencing vomiting, profound muscle weakness, and new-onset coarse hand tremors. The client's morning serum sodium level is 128 mEq/L128\text{ mEq/L} (128 mmol/L128\text{ mmol/L}). Which action should the practical nurse take first?

Cevabı ve açıklamayı göster

Cevap: Withhold the morning doses of both lithium and hydrochlorothiazide and immediately notify the registered nurse.

Cevap

The priority action is to withhold the morning doses of both lithium and hydrochlorothiazide and immediately notify the registered nurse.
The correct answer synthesizes three critical clinical points: the drug-drug interaction between lithium and thiazide diuretics, the interpretation of a critically low sodium level (128 mEq/L128\text{ mEq/L}), and the recognition of advanced lithium toxicity symptoms (coarse tremors, vomiting, profound weakness). Thiazide diuretics cause sodium depletion. Because lithium has a similar chemical structure to sodium, the kidneys compensate for hyponatremia by reabsorbing lithium, rapidly leading to toxicity. The safest and most appropriate action within the practical nursing scope of practice is to withhold both the diuretic and the lithium, and immediately escalate the situation to the registered nurse.

Adım Adım Çözüm

1
Analyze the client's medication regimen and recent additions.
The client is taking lithium (a mood stabilizer) and was recently started on hydrochlorothiazide (a thiazide diuretic).
Identifying drug classes helps predict potential adverse interactions.
2
Evaluate the morning laboratory results.
The serum sodium level is 128 mEq/L128\text{ mEq/L}, which indicates severe hyponatremia (normal range is typically 135135 to 145 mEq/L145\text{ mEq/L}).
Thiazide diuretics promote the excretion of sodium and water, directly causing this low sodium level.
3
Correlate the client's physical symptoms with the physiological effects of the medications.
Because lithium is a salt, the kidneys will reabsorb lithium in the presence of low sodium. This leads to lithium accumulation and toxicity, manifesting as vomiting, profound weakness, and coarse hand tremors.
Recognizing the connection between hyponatremia and lithium toxicity is critical for prioritizing care.
4
Determine the safest priority action within the practical nurse's scope of practice.
The nurse must withhold the interacting medications to prevent further harm and urgently report the critical lab values and toxic symptoms to the registered nurse.
LPNs/LVNs must monitor for adverse effects, ensure medication safety, and escalate acute deteriorations to the RN or provider.

Anahtar Kavram

Lithium toxicity precipitated by thiazide diuretic-induced hyponatremia
Tahmini Süre:1m 30s
ÖncekiSayfa 113 / 147Sonraki
Tüm alıştırma soruları — NCLEX-PN | Examkin