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2933 soru

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Soru 221Soru →

A 72-year-old client in a medical-surgical unit, who is normally fully independent and oriented, is found stumbling in the hallway at night. The client is suddenly disoriented, slurring words, and forcefully trying to push through a locked fire exit. To ensure safety and prevent injury, which action should the practical nurse (PN) implement first?

Cevabı ve açıklamayı göster

Cevap: Assist the client into a nearby chair or wheelchair to prevent a fall, initiate continuous observation, and obtain vital signs.

Cevap

Assist the client into a nearby chair or wheelchair to prevent a fall, initiate continuous observation, and obtain vital signs.
The immediate priority in an emergency involving an unsteady client is to secure their physical safety to prevent an accidental fall. Assisting the client into a chair addresses this immediate injury risk. Furthermore, sudden disorientation and slurred speech in a previously independent client strongly suggest an acute medical event (such as a stroke, hypoxia, or severe infection). The nurse must initiate close observation and gather baseline vital signs to help determine the root cause of the acute delirium.

Adım Adım Çözüm

1
Recognize the immediate physical hazard to the client.
The client is unsteady (stumbling) and at high risk for an accidental fall.
Wandering with physical instability requires immediate stabilization (sitting the client down) to prevent traumatic injury.
2
Identify the sudden change in baseline condition.
The acute onset of disorientation and slurred speech indicates a potential medical emergency, not normal aging.
Acute delirium or neurological deficits require urgent assessment (vital signs) to identify reversible or life-threatening causes.
3
Determine the safest priority intervention within the PN scope of practice.
Securing the client's physical safety and performing a baseline physiological assessment.
Restraints are a last resort, and administering IV push medications exceeds the standard PN scope of practice.

Anahtar Kavram

Prioritizing immediate physical safety and recognizing acute physiological changes over improper delegation or premature restraint use.
Soru 222Soru →

A client on a cardiac step-down unit is scheduled for the insertion of a permanent pacemaker. When the practical nurse prepares to witness the signature on the informed consent document, the client states, "I remember the doctor explaining things, but I am still not sure if this device will shock me if my heart stops." Which action should the practical nurse take?

Cevabı ve açıklamayı göster

Cevap: Inform the healthcare provider that the client requires further clarification before signing.

Cevap

Inform the healthcare provider that the client requires further clarification before signing.
Informed consent requires that the client fully understands the procedure, its risks, benefits, and alternatives. The practical nurse's role is strictly limited to witnessing the signature and ensuring the client is signing voluntarily. If a client expresses confusion or asks questions about the medical details of the procedure, the nurse must halt the signing process and notify the healthcare provider. It is the provider's legal obligation to explain the procedure and resolve any misunderstandings before consent is finalized.

Adım Adım Çözüm

1
Evaluate the client's statement regarding the upcoming procedure.
The client indicates confusion about the function of the pacemaker and whether it will deliver shocks.
Identifying a knowledge deficit is crucial before witnessing a legal consent document.
2
Determine the scope of practice for the practical nurse regarding informed consent.
The practical nurse may only witness the signature and verify that the client is signing voluntarily without coercion.
Answering procedural questions or explaining medical interventions exceeds the practical nurse's scope in this context.
3
Select the appropriate intervention.
The nurse must delay witnessing the signature and contact the healthcare provider to answer the client's questions.
Only the provider performing the procedure can legally provide the necessary clarification to ensure the consent is truly informed.

Anahtar Kavram

Advance Directives and Informed Consent
Soru 223Soru →

A practical nurse is utilizing a mobile computer workstation to document vital signs in a semi-private client room. The client's roommate currently has several family members visiting. Which actions by the nurse appropriately protect the confidentiality of the client's health information in this setting? (Select all that apply.)

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Positioning the computer monitor so the screen is angled away from the roommate and the visitors; Drawing the privacy curtain between the two beds and speaking in a lowered voice when discussing upcoming treatments; Logging out of the electronic health record system completely before stepping out of the room to retrieve fresh linens

Cevap

The correct actions include positioning the screen away from visitors, drawing the privacy curtain while lowering the voice, and fully logging out of the system before leaving the room.
The correct actions represent standard nursing interventions to protect both electronic data (angling screens, logging out) and verbal data (drawing curtains, speaking softly) in a shared clinical environment. These steps successfully mitigate the risk of incidental disclosure to the roommate's visitors.

Adım Adım Çözüm

1
Identify the clinical setting and potential confidentiality risks.
The setting is a semi-private room with unauthorized visitors present, creating risks for both visual (screen viewing) and verbal information breaches.
Recognizing environmental risks is the first step in applying appropriate information security measures.
2
Evaluate each proposed action for compliance with electronic and physical security standards.
Angling the screen, logging out completely, and using curtains with lowered voices are compliant. Minimizing a screen or sharing information with concerned but unauthorized visitors are non-compliant.
Practical nurses are required by law (e.g., HIPAA) and facility policy to actively prevent both intentional and incidental disclosures of protected health information.

Anahtar Kavram

Information Security in Shared Clinical Spaces
Tahmini Süre:1m 15s
Soru 224Soru →

A practical nurse (PN) is reviewing the plan of care and delegated tasks for a group of clients on a medical-surgical unit. Which of the following actions by the PN represents safe and appropriate practice?

Cevabı ve açıklamayı göster

Cevap: Reinforcing the registered nurse's initial teaching regarding incision care for a client preparing for discharge.

Cevap

Reinforcing the registered nurse's initial teaching regarding incision care for a client preparing for discharge.
The correct answer identifies an action that falls perfectly within the practical nurse's legal scope of practice. While registered nurses must perform initial comprehensive assessments and initial client education, practical nurses are responsible for reinforcing that teaching, collecting ongoing data, and reporting findings to the supervising RN.

Adım Adım Çözüm

1
Evaluate each action against the legal scope of practice for a practical nurse (PN) and standards of safe care.
Identify tasks that are appropriate for a PN versus those that require a registered nurse (RN) or provider, or violate safety protocols.
Ensuring client safety requires delegating and accepting tasks that align with licensure and established safety guidelines.
2
Analyze the option regarding informed consent.
Determine that explaining procedure risks is the provider's responsibility, not the PN's.
The PN may only witness the signature on the consent form.
3
Analyze the option regarding unstable clients and IV push medications.
Determine that unstable clients and IV push administration exceed the PN's scope of practice.
These require the advanced assessment and clinical judgment of an RN.
4
Analyze the option regarding physical restraints.
Determine that applying restraints before trying alternatives violates safety protocols.
Less restrictive measures must always be attempted and documented first.
5
Analyze the option regarding reinforcing teaching.
Determine that reinforcing teaching is appropriate for the PN.
While the RN performs initial education, the PN is permitted and expected to reinforce established teaching plans.

Anahtar Kavram

The practical nurse's scope of practice emphasizes care for stable clients with predictable outcomes, reinforcing established teaching, and adhering to standard safety protocols (such as using least restrictive measures and properly witnessing informed consent).
Soru 225Soru →

A practical nurse (PN) is caring for a 75-year-old client who was admitted with severe viral gastroenteritis. During morning care, the PN notes that the client is extremely lethargic and difficult to wake up. The client's heart rate is 116 beats per minute and blood pressure is 92/56 mm Hg. What is the priority action for the PN?

Cevabı ve açıklamayı göster

Cevap: Notify the registered nurse (RN) immediately about the changes in vital signs and mental status.

Cevap

The correct action is to immediately notify the registered nurse (RN) about the abnormal vital signs and lethargy.
The client is exhibiting clear signs of hypovolemic shock due to fluid loss from severe gastroenteritis, including tachycardia, hypotension, and altered mental status. The practical nurse must recognize these critical changes as a failure of physiological adaptation and immediately escalate the findings to the registered nurse for prompt medical intervention.

Adım Adım Çözüm

1
Analyze the client's vital signs and mental status.
The heart rate of 116 bpm and blood pressure of 92/56 mm Hg indicate hemodynamic instability. The extreme lethargy indicates decreased brain perfusion.
Recognizing deviations from normal physiological baselines is the first step in clinical judgment.
2
Identify the underlying physiological process.
The client has a history of severe gastroenteritis, making fluid volume deficit and hypovolemic shock the primary concern.
Connecting the symptoms to the admitting diagnosis helps determine the urgency of the situation.
3
Determine the appropriate nursing intervention within the PN scope of practice.
The PN must report these critical findings to the RN immediately.
Acute physiological decompensation requires rapid escalation to the RN or provider for advanced assessment and treatment orders.

Anahtar Kavram

Recognizing and Escalating Hypovolemic Shock
Soru 226Soru →

A practical nurse (PN) at an outpatient surgical center is caring for a client scheduled for an elective inguinal hernia repair. The surgeon has discussed the procedure with the client and left the room. The client is now reviewing the informed consent document. Which of the following actions by the PN are appropriate? (Select all that apply.)

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Sign the consent document as a witness to the client's physical signature.; Verify that the client is signing the informed consent document voluntarily.; Contact the surgeon prior to witnessing the signature if the client has lingering questions about the procedure.

Cevap

The appropriate actions for the PN are to sign the document as a witness, verify the client is signing voluntarily, and contact the surgeon if the client has lingering questions.
In the informed consent process, the practical nurse acts strictly as an advocate and witness. The nurse's legal responsibilities are to verify that the client is competent, ensure the consent is given voluntarily without coercion, and witness the client's physical signature. Additionally, if the nurse assesses that the client has lingering questions or does not fully understand the procedure, they must pause the signing process and contact the healthcare provider to return and clarify.

Adım Adım Çözüm

1
Identify the legal scope of practice for a practical nurse regarding informed consent.
The nurse's role is limited to advocating for the client, verifying voluntary consent, and witnessing the physical signature.
Understanding legal boundaries prevents the PN from practicing outside their scope.
2
Evaluate the options describing witnessing the signature and verifying voluntary consent.
Both of these actions correctly align with the PN's role as a witness.
A nurse's signature on a consent form legally attests that the correct client voluntarily signed the form.
3
Evaluate the option regarding contacting the surgeon if the client has questions.
This is a correct action because true informed consent has not been achieved if the client remains confused.
The nurse acts as a client advocate to ensure the provider answers all questions before the client signs.
4
Evaluate the options involving explaining surgical risks or accepting a delegation to obtain consent.
These actions are incorrect.
Only the healthcare provider performing the procedure can legally explain risks and obtain the initial consent. The nurse must not accept delegated tasks outside this scope.

Anahtar Kavram

The practical nurse's role in informed consent is limited to witnessing the client's signature, verifying the client is signing voluntarily, and assessing client understanding to advocate for further provider explanation if needed.
Soru 227Soru →

A practical nurse (PN) is caring for a client with newly diagnosed end-stage renal disease on a medical-surgical unit. The provider has just discussed the need for hemodialysis and left the consent form at the bedside for the client to sign. When the PN enters the room, the client states, "The doctor said I need a catheter placed in my chest, but I am terrified of having a tube near my heart. What if I just take medication instead?" Which of the following is the most appropriate action for the PN to take?

Cevabı ve açıklamayı göster

Cevap: Notify the healthcare provider that the client requires further clarification about treatment alternatives.

Cevap

Notify the healthcare provider that the client requires further clarification about treatment alternatives.
The client is asking a specific question about medical treatment alternatives. It is the legal responsibility of the healthcare provider performing the procedure to explain risks, benefits, and alternatives. The most appropriate action is to advocate for the client by notifying the provider so they can address these concerns before the consent document is signed.

Adım Adım Çözüm

1
Analyze the client's statement.
The client is asking a specific question regarding medical treatment alternatives (medication versus hemodialysis).
Identifying the nature of the client's concern dictates the appropriate nursing response.
2
Determine the scope of practice regarding informed consent.
The practical nurse can witness a signature and verify voluntariness, but only the healthcare provider can explain risks, benefits, and alternatives.
Nurses must practice within their legal scope of practice.
3
Select the action that aligns with legal and ethical guidelines.
The provider must be notified to return and address the client's questions before the consent form is signed.
The informed consent process is incomplete until the client's questions about alternatives are answered by the provider.

Anahtar Kavram

During the informed consent process, it is the sole responsibility of the healthcare provider to explain the procedure, its risks, benefits, and any alternatives. The nurse's role is to act as a witness and advocate by notifying the provider if the client has questions.
Soru 228Soru →

A practical nurse (PN) is caring for a client who is 24 hours postpartum. The client reports feeling slightly dizzy when sitting up. The PN notes the heart rate is 102 beats per minute, blood pressure is 98/60 mm Hg, and the perineal pad is completely saturated with bright red blood. Which action should the PN take first?

Cevabı ve açıklamayı göster

Cevap: Palpate the uterine fundus and notify the registered nurse (RN) immediately.

Cevap

The priority action is to palpate the uterine fundus and notify the registered nurse (RN) immediately to address the active hemorrhage.
The client is exhibiting clear signs of postpartum hemorrhage (saturated pad, bright red blood) leading to early hypovolemic shock (dizziness, tachycardia, borderline hypotension). The immediate priority is to physically intervene by palpating and massaging the fundus to stimulate uterine contraction, while simultaneously alerting the RN for emergency medical management.

Adım Adım Çözüm

1
Analyze the client's symptoms and vital signs.
The client has dizziness, tachycardia, mild hypotension, and a saturated perineal pad.
Identifying these findings recognizes the classic presentation of postpartum hemorrhage and early hypovolemic shock.
2
Determine the most critical physiological need.
The immediate threat is excessive blood loss affecting circulation.
According to the ABCs (Airway, Breathing, Circulation) framework, active bleeding is a circulation emergency.
3
Select the nursing intervention that directly addresses the emergency.
Palpating and massaging the fundus helps the uterus contract, and notifying the RN escalates the critical situation.
Direct action to stop the bleeding and escalating to the RN are within the PN scope of practice for emergent stabilization.

Anahtar Kavram

Recognition and initial management of postpartum hemorrhage
Soru 229Soru →

A nursing supervisor is evaluating the clinical practices of a newly licensed practical nurse (PN) working on an infectious disease unit. Which action by the PN demonstrates a correct understanding of standard and transmission-based precautions?

Cevabı ve açıklamayı göster

Cevap: Placing a standard medical mask on a client who is under airborne precautions for suspected tuberculosis before transporting them to the radiology department.

Cevap

Placing a standard medical mask on a client who is under airborne precautions for suspected tuberculosis before transporting them to the radiology department.
When a client on airborne precautions must leave their negative-pressure room for essential procedures, they must wear a standard medical (surgical) mask. This acts as source control to contain respiratory secretions and prevent the spread of infectious droplet nuclei into the hospital corridors. Healthcare workers wear N95 respirators to protect themselves from inhalation, but clients wear standard masks to trap the pathogens they exhale.

Adım Adım Çözüm

1
Evaluate each nursing action against established infection control guidelines, privacy laws, and the practical nurse scope of practice.
Identify which action adheres to all safety and professional standards.
Transmission-based precautions must be integrated with client safety, privacy, and scope of practice.
2
Analyze the transport protocol for a client on airborne precautions.
Determine that the client must wear a standard medical mask during transport to contain respiratory secretions.
The standard mask acts as source control, preventing infectious droplet nuclei from entering the hospital environment.

Anahtar Kavram

Airborne Precautions and Client Transport
Soru 230Soru →

A practical nurse is assisting a client with right-sided hemiplegia who is sitting on the edge of the bed to transfer into a wheelchair. In what order should the nurse perform the following actions? Arrange the steps from first to last.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence prioritizes environmental safety and leading with the strong side: Position the wheelchair on the left side, lock the wheels, apply a transfer belt, brace the right knee during the stand, and instruct the client to reach with their left hand.
Safe transfer of a client with hemiplegia requires moving toward the strong side. The environment is secured first (chair positioned on the strong left side, brakes locked). Next, the client is secured with a gait belt. During the pivot, the nurse protects the weak side by bracing the right knee, allowing the client to use their strong left arm and leg to guide the transfer safely.

Adım Adım Çözüm

1
Analyze the client's deficit and prepare the environment.
The nurse identifies the left side as the strong side, positions the wheelchair on the left at a 45-degree angle, and locks all wheels.
Transfers must always be directed toward the unaffected side to maximize client participation and safety. Securing the environment prevents equipment from shifting during weight transfer.
2
Secure the client for physical movement.
The nurse applies a transfer (gait) belt around the client's waist.
The belt provides a secure grip for the nurse to control the client's descent if they begin to fall, avoiding pulling on the client's arms or shoulders.
3
Provide support to the compromised extremity during the lift.
The nurse braces the client's right knee with their own knee/foot while assisting the client to stand.
Right-sided hemiplegia means the right leg lacks motor control and strength; bracing it prevents the knee from buckling under the client's weight.
4
Utilize the strong side to complete the pivot and transfer.
The client reaches for the wheelchair armrest with their functional left hand before sitting.
Reaching with the strong arm maintains spatial orientation and provides a final point of stability as the client lowers into the chair.

Anahtar Kavram

Safe mobility and transfer techniques for clients with hemiplegia
Soru 231Soru →

A practical nurse (PN) and an assistive personnel (AP) are preparing to move a client up in bed using a draw sheet. The client has limited mobility but can follow commands. In what order should the PN perform the following actions to ensure safety and proper body mechanics? Arrange the steps in the correct chronological sequence.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

First, place the bed in a flat position at waist height. Second, remove the pillow and place it against the headboard. Third, instruct the client to cross their arms and bend their knees. Fourth, roll the draw sheet close to the client's sides. Fifth, shift weight from the back foot to the front foot to complete the move.
The correct sequence ensures maximum safety for both the client and the caregivers. Preparing the environment (bed height and positioning the pillow) must occur first to prevent strain and head injury. Next, preparing the client's body posture reduces friction and allows the client to assist. Finally, establishing a firm grip and utilizing leg muscles for the weight shift ensures the move is executed with proper ergonomics.

Adım Adım Çözüm

1
Place the bed in a flat position and elevate it to the caregivers' waist height.
The environment is ergonomically optimized for the caregivers.
This establishes a safe center of gravity and prevents the nurses from fighting against the incline of the bed.
2
Remove the pillow from under the client's head and position it upright against the headboard.
The hard surface of the headboard is padded.
This vital safety step prevents accidental head trauma if the client is pulled upward too quickly.
3
Ask the client to cross their arms over their chest and bend their knees.
The client is positioned to minimize friction and assist with the move.
Having the client fold their arms prevents them from dragging on the bed, and bent knees allow the client to push off the mattress, reducing the physical load on the nurses.
4
Roll the draw sheet closely alongside the client's body and grasp it firmly.
The caregivers secure a strong, controlled grip.
Holding the sheet as close to the client as possible maintains the load near the nurses' center of gravity, which is a key principle of body mechanics.
5
Stand with a wide base of support and shift weight from the back foot to the front foot while moving the client.
The client is safely shifted toward the head of the bed.
Relying on the large muscles of the legs (shifting weight) rather than the smaller muscles of the lower back prevents musculoskeletal injuries.

Anahtar Kavram

Proper body mechanics and sequence of steps during patient positioning.
Soru 232Soru →

A practical nurse (PN) is participating in the care of a client recovering from a colonoscopy with polyp removal performed earlier in the day. The client rings the call bell and reports severe, unrelenting abdominal cramping and nausea. Upon data collection, the PN notes the client's skin is cool to the touch, and the radial pulse is 118 beats per minute and thready. Which action should the PN take immediately?

Cevabı ve açıklamayı göster

Cevap: Notify the registered nurse (RN) about the assessment findings.

Cevap

Notify the registered nurse (RN) about the assessment findings.
The client is exhibiting signs of a potential bowel perforation and internal bleeding (severe cramping, cool skin, tachycardia, thready pulse). Because this is a life-threatening emergency requiring advanced assessment and medical intervention, the priority action within the practical nurse's scope of practice is to immediately escalate the findings to the registered nurse.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
The client has severe abdominal cramping, cool skin, and a rapid, thready pulse following an invasive procedural intervention.
Identifying abnormal physiological findings is the first step in clinical decision-making.
2
Determine the potential underlying complication.
These manifestations strongly suggest bowel perforation and developing hypovolemic shock, which is a medical emergency.
Early recognition of life-threatening procedural complications is essential for client safety and physiological adaptation.
3
Select the appropriate PN intervention based on the scope of practice.
The PN must immediately communicate these critical findings to the RN.
The client requires RN-level assessment and likely emergency medical intervention that exceeds the PN scope of practice.

Anahtar Kavram

Recognizing Procedural Complications and Shock
Soru 233Soru →

A licensed practical nurse is observing an assistive personnel (AP) conclude morning care for a client on contact precautions for a Methicillin-resistant *Staphylococcus aureus* (MRSA) infection. Which action by the AP requires immediate correction by the nurse?

Cevabı ve açıklamayı göster

Cevap: Removing gloves, exiting the client's room, and then removing the isolation gown in the hallway.

Cevap

The action that requires immediate correction is removing gloves, exiting the client's room, and then removing the isolation gown in the hallway.
The correct answer identifies that the assistive personnel is inappropriately removing personal protective equipment outside the client's room. To prevent the spread of infectious microorganisms, all personal protective equipment (except for respirators) must be removed and discarded inside the client's isolation room before transitioning to the hallway.

Adım Adım Çözüm

1
Evaluate the scenario and the specific requirements for contact precautions.
Identify that the client has MRSA, requiring a gown and gloves for room entry, which must be safely removed before exiting the patient environment.
Understanding the mode of transmission is essential for applying the correct infection control protocols.
2
Analyze the action of removing the isolation gown in the hallway after exiting the room.
Determine that this behavior violates standard infection control principles because it transports contaminated equipment into a clean corridor.
Contaminated personal protective equipment must be removed and discarded inside the isolated environment to contain pathogens.
3
Assess the remaining actions (glove removal technique, gown rolling, and task delegation) for clinical accuracy.
Conclude that the glove and gown removal techniques are safe, and emptying a drainage bag is an appropriately delegated task.
Eliminating correct clinical actions isolates the single behavior that compromises unit safety and requires immediate nursing intervention.

Anahtar Kavram

Standard and Transmission-Based Precautions
Soru 234Soru →

A practical nurse (PN) is monitoring an adult client who underwent a large-volume therapeutic paracentesis 22 hours ago. The client's baseline blood pressure was 138/82138/82 mm Hg and heart rate was 7676 beats/min. The client now reports mild lightheadedness and nausea. The PN notes the client's skin is slightly pale and cool. Current vital signs are: blood pressure 102/68102/68 mm Hg, heart rate 108108 beats/min, and respiratory rate 2020 breaths/min. The abdominal dressing is dry and intact. Which of the following is the priority nursing action?

Cevabı ve açıklamayı göster

Cevap: Place the client in a supine position and immediately notify the registered nurse.

Cevap

The priority action is to place the client in a supine position and immediately notify the registered nurse.
Although the client's systolic blood pressure is technically above 100100 mm Hg, it represents a significant drop from the baseline. This drop, accompanied by tachycardia, pallor, and lightheadedness, indicates early, subtle hypovolemic shock caused by intravascular fluid shifts following large-volume fluid removal. The priority is to maximize venous return to the vital organs by placing the client flat (supine) and to immediately escalate these critical findings to the registered nurse for rapid emergency intervention.

Adım Adım Çözüm

1
Analyze the client's current clinical presentation and compare it to baseline findings.
The client has a significant drop in blood pressure (from 138/82138/82 to 102/68102/68 mm Hg), tachycardia (108108 beats/min), pallor, and lightheadedness.
Identifying changes from baseline is essential to recognize developing complications rather than relying solely on absolute numeric thresholds.
2
Interpret the clinical significance of these assessment findings.
The findings indicate early hypovolemic shock resulting from rapid intravascular fluid shifts, a known complication of large-volume fluid removal.
Recognizing the pathophysiology of the complication determines the urgency of the response.
3
Determine the priority nursing action based on the airway, breathing, circulation (ABC) framework.
The priority is addressing the circulation deficit. The PN must maximize venous return by placing the client flat and immediately escalate to the RN.
Immediate physical intervention (positioning) and escalation are required to prevent severe cardiovascular collapse.

Anahtar Kavram

Hypovolemic Shock Recognition and Escalation Post-Paracentesis
Tahmini Süre:1m 30s
Soru 235Soru →

An emergency department practical nurse (PN) is caring for a client who requires an urgent chest tube insertion for a pneumothorax. The emergency provider explains the procedure, hands the consent form to the PN to obtain the signature, and steps out of the room to gather supplies. The client then asks the PN, "Will this tube completely fix my collapsed lung, or is there a chance it could happen again?" Which action should the PN take?

Cevabı ve açıklamayı göster

Cevap: Inform the provider that the client has further questions about the procedure's outcomes before signing.

Cevap

The practical nurse should halt the signing process and inform the provider that the client requires further clarification about the procedure's expected outcomes.
The provider performing the procedure is legally responsible for explaining the risks, benefits, and expected outcomes. The practical nurse's role is solely to witness the signature and verify the client understands the information provided. If the client asks medical questions about the procedure itself, the PN must pause the signing process and notify the provider to return and clarify.

Adım Adım Çözüm

1
Identify the PN's role in informed consent.
The PN's role is strictly limited to witnessing the client's signature and ensuring the client is signing voluntarily.
Nursing scope of practice dictates that nurses do not obtain the initial consent or explain the procedure's medical risks and benefits.
2
Evaluate the client's statement.
The client is asking a specific question about the expected medical outcome of the procedure ("Will this completely fix my collapsed lung?").
This indicates that the client does not have a complete understanding of the procedure, which invalidates informed consent.
3
Determine the appropriate intervention.
The PN must not allow the client to sign the form yet and must ask the provider to return to the room.
Only the healthcare provider performing the procedure is legally authorized to answer questions regarding surgical outcomes, risks, and alternatives.

Anahtar Kavram

The healthcare provider performing a procedure is solely responsible for explaining its risks, benefits, and expected outcomes; the nurse's role is to witness the signature and notify the provider if the client has lingering questions.
Tahmini Süre:1m 0s
Soru 236Soru →

A client who underwent a transverse colectomy three days ago has a morning hemoglobin result of 7.9 g/dL. During the morning assessment, the nurse notes a heart rate of 115 beats per minute, a respiratory rate of 22 breaths per minute, and a blood pressure of 94/60 mm Hg. The client complains of new-onset lightheadedness when resting in bed. Which action is the priority for the nurse to implement?

Cevabı ve açıklamayı göster

Cevap: Notify the registered nurse immediately about the vital signs and laboratory results.

Cevap

The priority action is to immediately notify the registered nurse regarding the client's vital signs and hemoglobin levels.
The correct action demonstrates an understanding of risk reduction by promptly identifying clinical indicators of hypovolemic shock—such as a critically low hemoglobin, tachycardia, hypotension, and lightheadedness—and escalating the situation to the registered nurse for rapid medical intervention.

Adım Adım Çözüm

1
Analyze the client's laboratory results and vital signs.
The hemoglobin is critically low (7.9 g/dL), accompanied by tachycardia, hypotension, and lightheadedness.
Recognizing the combination of these findings indicates an acute complication such as internal bleeding or hypovolemic shock.
2
Determine the scope of practice for the practical nurse in an emergent situation.
The practical nurse must immediately escalate the findings to the registered nurse or healthcare provider.
Acute physiological deterioration requires immediate RN-level assessment and potential medical intervention (such as blood transfusions or fluid resuscitation) to stabilize the client.

Anahtar Kavram

Identifying early signs of hypovolemia and escalating critical findings
Soru 237Soru →

A practical nurse is preparing to administer a scheduled oral liquid medication to a 2-year-old toddler. Upon approaching the child in the unit's playroom, the nurse notices the child is not wearing an identification band. The parents have temporarily left the unit and are not present. Which action must the nurse take to prevent a medication error?

Cevabı ve açıklamayı göster

Cevap: Verify the child's identity with another licensed nurse familiar with the client, then apply a new identification band before administration.

Cevap

The correct action is to verify the child's identity with another licensed nurse familiar with the client, then apply a new identification band before administration.
Safe medication administration requires the verification of two distinct client identifiers. When an infant or toddler loses their identification band and a parent or guardian is not present, the safest protocol is to have a coworker who is familiar with the client (such as the primary nurse or charge nurse) visually verify the child's identity. Once verified, a new identification band must be placed on the child before the medication is administered to ensure continuous safety compliance.

Adım Adım Çözüm

1
Recognize the absence of an identification band.
The nurse identifies that standard medication safety checks cannot be performed on the toddler.
Two acceptable client identifiers are required prior to any medication administration.
2
Evaluate the available resources for client identification.
The nurse determines that the child cannot self-identify due to their developmental age, and parents are not present.
Toddlers do not possess the cognitive ability to reliably confirm their full name.
3
Implement an alternative, safe identification protocol.
The nurse utilizes another licensed staff member who knows the child to verify their identity.
Peer verification by a knowledgeable licensed nurse is an accepted standard when primary identification methods are unavailable.
4
Restore standard safety measures.
A new identification band is applied to the child.
A physical identification band must be in place to scan or check against the medication administration record before giving the dose.

Anahtar Kavram

Client Identification and Medication Safety
Soru 238Soru →

A practical nurse is initiating a 24-hour urine collection for a client on the medical-surgical unit to evaluate kidney function. In what chronological order should the nurse implement the steps for this diagnostic procedure? (Arrange from first to last)

Öğeleri doğru sıraya koymak için sürükleyin

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Cevap

The correct sequence is to first discard the initial void, document the start time, collect all subsequent urine on ice for 24 hours, obtain a final void at the exactly 24-hour mark, and then transport the labeled container to the laboratory.
A 24-hour urine collection must measure only the urine produced within a strict 24-hour window. Therefore, the procedure begins by starting with an empty bladder (discarding the first void) and documenting that exact time. Over the next 24 hours, all subsequent urine must be collected and kept cold to preserve the specimen. At exactly 24 hours from the start time, the client voids one last time to empty the bladder of any urine produced during the final moments of the period. Finally, the complete and correctly labeled specimen is transported to the laboratory for analysis.

Adım Adım Çözüm

1
Discard the initial void.
The bladder is emptied of urine formed prior to the testing period.
Including prior urine would falsely elevate the 24-hour analyte values.
2
Document the precise start time.
The 24-hour clock officially begins.
A precise start time is required to ensure the collection window lasts exactly 24 hours.
3
Collect all subsequent urine and keep it cold.
All urine produced during the testing window is preserved.
Missing any urine invalidates the test; refrigeration prevents chemical breakdown.
4
Obtain one last void at exactly 24 hours.
The 24-hour collection period is officially concluded.
This captures the very last amount of urine produced within the exact 24-hour timeframe.
5
Label and send the container to the laboratory.
The specimen is securely handed off for diagnostic processing.
Timely transport maintains specimen integrity.

Anahtar Kavram

24-Hour Urine Specimen Collection Protocol
Soru 239Soru →

While providing morning care for an older adult client 48 hours after an open reduction and internal fixation of a fractured right femur, the practical nurse notes a sudden change in status. The client is highly restless, unable to state their location, and has a respiratory rate of 24 breaths/minute with an oxygen saturation of 92% on room air. Furthermore, scattered pinpoint, non-blanching red spots are visible across the client's anterior chest. Which action is the priority for the practical nurse to take?

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Cevap: Elevate the head of the bed, apply supplemental oxygen, and urgently notify the registered nurse.

Cevap

The priority action is to elevate the head of the bed, apply supplemental oxygen, and urgently notify the registered nurse.
The client is exhibiting the classic clinical triad of fat embolism syndrome (hypoxemia, neurologic abnormalities, and a petechial rash), which is a severe medical emergency strongly associated with long bone fractures. The priority action for the practical nurse is to immediately support the client's airway and breathing by applying supplemental oxygen and to escalate the care by notifying the registered nurse or provider for urgent medical intervention.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
The client presents with hypoxia (SpO2 92%, RR 24), neurological compromise (restlessness, disorientation), and a petechial rash on the chest.
Identifying symptom clusters is essential to determine the underlying pathophysiology.
2
Connect the symptom cluster to the client's medical history.
The triad of hypoxemia, neurological changes, and a petechial rash in a client with a recent long bone (femur) fracture indicates fat embolism syndrome (FES).
Fat embolism syndrome is a specific, life-threatening complication of orthopedic trauma that requires immediate recognition.
3
Determine the priority nursing intervention based on the ABCs (Airway, Breathing, Circulation).
The practical nurse must address the compromised breathing and oxygenation first by applying oxygen and elevating the head of the bed, followed by immediate escalation to the registered nurse.
Systemic life-threatening emergencies must be treated before localized assessments or routine data collection.

Anahtar Kavram

Fat Embolism Syndrome Recognition and ABC Prioritization
Soru 240Soru →

A practical nurse is planning care for a client who is 12 hours post-operative following a lumbar laminectomy. Which interventions should the nurse include to promote comfort and maintain safety? (Select all that apply.)

Geçerli olan tümünü seçin

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Cevap: Use a logrolling technique with the assistance of another staff member when turning the client.; Place a pillow between the client's legs prior to turning them onto their side.; Offer a fracture bedpan for elimination needs to minimize lifting of the lower back.

Cevap

The correct interventions are using a logrolling technique with assistance, placing a pillow between the legs before turning, and offering a fracture bedpan for elimination.
Following a lumbar laminectomy, the primary goal of basic care is to maintain the spine in neutral alignment to prevent injury to the surgical site. Using a logrolling technique with a second staff member and placing a pillow between the legs ensures the client's body moves as a single unit without twisting. Utilizing a fracture bedpan prevents the client from having to lift their hips, which would flex the lumbar spine.

Adım Adım Çözüm

1
Identify the client's surgical procedure and post-operative constraints.
The client had a lumbar laminectomy, which requires strict maintenance of spinal alignment.
Understanding the procedure dictates the necessary positioning and mobility precautions.
2
Evaluate each proposed intervention against spinal precautions and the practical nurse's scope of practice.
Logrolling, using a leg pillow, and using a fracture bedpan maintain spinal alignment. High Fowler's position violates positioning rules, and delegating an initial assessment violates scope of practice.
All care must ensure client safety and fall within legal nursing boundaries.

Anahtar Kavram

Post-operative basic care and positioning for spinal surgery
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