Examkin

Tüm alıştırma soruları

2933 soru

Tüm türler2,933Çoktan seçmeli1,506Çoklu seçim653Sayısal68Eşleştirme70Sıralama636
Soru 2421Soru →

A 78-year-old client with pneumonia is admitted to the medical-surgical unit and begins exhibiting signs of acute confusion, repeatedly attempting to climb over the bed rails. The healthcare provider evaluates the client and prescribes a physical vest restraint. Which actions are appropriate for the practical nurse (PN) to include in the plan of care? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Secure the restraint ties to the stationary portion of the bed frame using a quick-release knot.; Verify that two fingers can comfortably slide between the vest restraint and the client's chest.; Release the restraint at least every 2 hours to perform range-of-motion exercises and assess skin integrity.

Cevap

The appropriate actions are to secure the restraint to a stationary bed frame with a quick-release knot, ensure a two-finger gap between the restraint and the client's chest, and release the restraint every 2 hours for assessment and care.
Proper and safe use of a physical restraint requires attaching the straps to a non-movable part of the bed frame (never the side rails) using a quick-release knot to allow for rapid removal. The nurse must verify that two fingers fit under the restraint to prevent impaired breathing or circulation. Furthermore, standard of care dictates that physical restraints must be released at least every 2 hours to provide skin care, assess neurovascular status, and allow for range-of-motion exercises.

Adım Adım Çözüm

1
Analyze the clinical scenario and the prescription.
The client has a valid provider prescription for a vest restraint due to acute confusion and safety risks.
Establishing the clinical foundation is required to determine appropriate nursing interventions.
2
Identify safe physical restraint application mechanics.
The vest restraint must be tied to a stationary frame with a quick-release knot, allowing two fingers of space.
This prevents asphyxiation and mechanical injury while ensuring rapid removal in a clinical emergency.
3
Determine ongoing monitoring and care requirements.
The restraint must be released at least every 2 hours for skin care, toileting, and range-of-motion exercises.
Continuous monitoring prevents complications such as skin breakdown and neurovascular compromise.
4
Evaluate remaining distractors for unsafe or illegal practices.
PRN orders, bypassing less restrictive alternatives, and normalizing acute confusion are identified as critical safety errors.
Eliminating choices that violate legal boundaries and standard clinical guidelines ensures safe client care.

Anahtar Kavram

Physical restraints require strict adherence to application safety (stationary frame, quick-release knot, two-finger gap), continuous monitoring (release every 2 hours), and legal parameters (no PRN orders, mandatory trial of alternatives).
Soru 2422Soru →

A practical nurse (PN) discovers a confused client actively pulling at their newly inserted chest tube. After calling for assistance and attempting verbal de-escalation without success, the charge nurse initiates the emergency application of soft wrist restraints. Arrange the following actions in the correct chronological sequence for safe restraint application and management.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence is: (1) Implement a manual hold to prevent immediate harm, (2) Apply padding to the wrists, (3) Secure ties to the movable bed frame with a quick-release knot, (4) Assess neurovascular status, and (5) Notify the provider for a formal evaluation and order.
The correct chronological sequence prioritizes the immediate preservation of life (stopping the removal of the chest tube via manual hold), followed by the safe physical application of the restraint (padding, then securing to the movable frame). Once the client is safely secured, immediate clinical assessment (neurovascular check) is required to ensure no physical harm was caused by the application. Finally, the administrative and legal requirement of notifying the provider for a formal order is fulfilled.

Adım Adım Çözüm

1
Prioritize immediate client safety.
A staff member manually holds the client's hands.
When a life-sustaining device like a chest tube is at risk, stopping the immediate mechanical action of pulling is the absolute first priority.
2
Prepare the extremity for device application.
Padding is applied to the client's wrists.
Protecting skin integrity is a foundational step before securing any restrictive mechanical device.
3
Apply and secure the restraint device safely.
Ties are secured to the movable bed frame with quick-release knots.
This positioning prevents injury if the head of the bed is raised or lowered, and the knot allows for rapid emergency release.
4
Evaluate the physiological impact of the applied restraints.
Neurovascular status (pulses, capillary refill) is assessed.
The nurse must verify that the applied device is not compromising blood flow or causing nerve damage.
5
Ensure legal and regulatory compliance.
The healthcare provider is notified.
Emergency application is legally permitted for immediate safety, but a provider must perform a face-to-face assessment and write the formal order immediately thereafter.

Anahtar Kavram

Emergency Restraint Application Sequence and Safety
Tahmini Süre:1m 30s
Soru 2423Soru →

A practical nurse is assisting with the admission of a client who has just returned to the nursing unit following a percutaneous liver biopsy. Which of the following positions should the nurse assist the client into?

Cevabı ve açıklamayı göster

Cevap: Right side-lying position with a small rolled towel placed under the puncture site

Cevap

Right side-lying position with a small rolled towel placed under the puncture site
The liver is a highly vascular organ located on the right side of the body. Placing the client in a right side-lying position, especially with a towel or small pillow under the lower ribs, uses the client's own body weight to apply direct pressure to the biopsy site. This targeted mechanical compression is critical for promoting hemostasis and preventing internal hemorrhage.

Adım Adım Çözüm

1
Identify the procedure performed and its primary anatomical location.
The client underwent a percutaneous liver biopsy; the liver is a highly vascular organ located on the right side of the abdomen.
Understanding the anatomy and the specific nature of the procedure is essential for anticipating potential complications.
2
Determine the highest priority post-procedure risk associated with this specific biopsy.
The greatest physiological risk following a liver biopsy is hemorrhage due to the liver's extensive blood supply.
Post-procedure nursing care must focus immediately on minimizing bleeding at the puncture site.
3
Select the position that physiologically mitigates the identified risk of hemorrhage.
Positioning the client on their right side with a towel under the site utilizes gravity and body weight to compress the liver against the chest wall.
Mechanical compression promotes hemostasis and prevents blood from pooling or hemorrhaging internally.

Anahtar Kavram

Post-Procedure Positioning for Hemostasis
Soru 2424Soru →

A facility policy requires staff to wear an isolation gown, an N95 respirator, a face shield, and clean gloves when providing tracheostomy care for a client on airborne and contact precautions. Which sequence should the practical nurse use to put on these protective items prior to the procedure?

Cevabı ve açıklamayı göster

Cevap: Isolation gown, N95 respirator, face shield, clean gloves

Cevap

The correct sequence is to first put on the isolation gown, followed by the N95 respirator, then the face shield, and finally the clean gloves.
According to the Centers for Disease Control and Prevention (CDC) guidelines, the safest sequence for donning full personal protective equipment ensures that the foundational body layers and respiratory protection are secured before applying outer barrier layers. The correct order is always gown first, followed by the mask or respirator, then goggles or face shield, and finally gloves. The gloves must be applied last so they can be pulled up to extend over the isolation gown's wrist cuffs, creating a continuous barrier, and ensuring all straps and ties were handled with bare, clean hands.

Adım Adım Çözüm

1
Put on the isolation gown and tie it securely at the neck and waist.
The nurse's clothing and exposed torso/arms are covered and protected.
The gown forms the foundational layer of protection and must be secured first with ungloved hands.
2
Don the N95 respirator, securing the elastic bands and fitting the flexible nose piece.
The respiratory tract is sealed against airborne pathogens.
Respiratory protection is critical and must be carefully adjusted to the face without interference from face shields or gloves.
3
Place the face shield over the face and eyes, adjusting the band over the head.
The eyes and mucous membranes are protected from potential splashes during tracheostomy care.
The shield is worn over the respirator as a secondary barrier for the face and eyes.
4
Put on the clean gloves, ensuring they extend over the wrist cuffs of the isolation gown.
The hands are protected and a complete continuous barrier is formed between the gown and the hands.
Gloves are always donned last so they can cover the gown cuffs, leaving no skin exposed, and ensuring that earlier equipment adjustments were made with clean, ungloved hands.

Anahtar Kavram

Proper Donning Sequence for Personal Protective Equipment (PPE)
Soru 2425Soru →

The nursing team on an oncology unit is organizing the workflow for the shift. Match each clinical task with the nursing team member who is legally and safely permitted to perform it based on standard scope of practice.

Soldaki öğeye tıklayın, sonra eşleşen sağdaki öğeye tıklayın

Öğeler

Formulating the initial plan of care for a newly admitted client experiencing neutropenia
Administering a scheduled subcutaneous anticoagulant to a stable client
Recording daily weight and measuring morning vital signs for a client awaiting discharge

Eşleşmeler

Cevabı ve açıklamayı göster

Cevap

Formulating the initial plan of care matches with the Registered Nurse (RN); administering a scheduled subcutaneous anticoagulant matches with the Licensed Practical/Vocational Nurse (LPN/VN); recording daily weight and vital signs matches with the Assistive Personnel (AP).
Each task aligns with the legal and educational boundaries of the respective nursing roles: the RN handles complex planning and initial comprehensive assessments, the LPN/VN manages routine medication administration and focused care for stable clients, and the AP performs basic, non-invasive data collection on stable clients.

Adım Adım Çözüm

1
Analyze the task of formulating an initial plan of care.
Identified as an independent RN function.
Initial assessment and care planning are strictly within the RN's scope of practice.
2
Analyze the task of administering a scheduled subcutaneous medication.
Identified as appropriate for the LPN/VN.
LPN/VNs are licensed to administer non-intravenous routine medications to stable clients.
3
Analyze the task of recording weight and vital signs.
Identified as delegable to the AP.
Basic data collection on stable clients is a standard competency for Assistive Personnel.

Anahtar Kavram

Nursing Scope of Practice and Task Delegation
Soru 2426Soru →

A practical nurse is assigned to care for a client who is 18 hours postpartum following a forceps-assisted vaginal delivery at 40 weeks of gestation, along with her newborn. Which of the following actions by the practical nurse are appropriate? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Initiating gentle fundal massage immediately upon palpating a soft, boggy uterus; Reinforcing previous teaching regarding expected lochia rubra characteristics and perineal care; Swaddling the newborn and providing a pacifier for comfort during a routine heel stick for blood glucose monitoring

Cevap

The appropriate actions are initiating gentle fundal massage for a boggy uterus, reinforcing previous teaching regarding lochia and perineal care, and swaddling the newborn with a pacifier during a heel stick.
The practical nurse operates safely within their scope of practice by performing independent interventions like fundal massage for a boggy uterus, which is the immediate first-line response to prevent hemorrhage. Furthermore, the practical nurse correctly reinforces existing educational plans regarding lochia and perineal care, and utilizes standard non-pharmacological comfort measures such as swaddling and offering a pacifier during minor neonatal procedures.

Adım Adım Çözüm

1
Evaluate the clinical findings and the practical nurse scope of practice for each option.
Identified that fundal massage, teaching reinforcement, and non-pharmacological newborn pain management are correct.
These actions address safe, independent practical nurse interventions for a postpartum client and newborn dyad.
2
Identify findings that represent normal physiology versus true complications.
Determined that saturating 1 pad in 3 hours and exhibiting a positive Babinski reflex are both normal expected findings.
Recognizing normal postpartum and neonatal progression prevents inappropriate escalation of care.
3
Filter interventions that exceed the practical nurse's legal scope of practice.
Excluded the administration of intravenous push medications.
The administration of intravenous push medications is strictly reserved for the registered nurse or provider.

Anahtar Kavram

Practical Nurse Scope of Practice in Postpartum and Newborn Care
Tahmini Süre:1m 30s
Soru 2427Soru →

A practical nurse (PN) is caring for a client who is scheduled for an elective surgical procedure in two hours. The surgeon previously discussed the procedure with the client and left the consent form on the chart. When the PN prepares to witness the client's signature, the client states, "I know I need the surgery, but the doctor mentioned some alternative treatments and I cannot remember what they were." Which action is legally required of the PN?

Cevabı ve açıklamayı göster

Cevap: Withhold the consent form and notify the surgeon that the client requires further clarification before signing.

Cevap

Withhold the consent form and notify the surgeon that the client requires further clarification before signing.
The legal standard for informed consent mandates that the client must fully understand the procedure, including its risks, benefits, and alternatives, before signing. The nurse's role is to act as a witness to the signature and to verify that the client is competent and comprehends the information. If the client asks questions that indicate a lack of understanding, the nurse cannot legally provide this medical information. The nurse must act as an advocate by pausing the consent process and notifying the healthcare provider, who is responsible for providing the necessary clarification.

Adım Adım Çözüm

1
Assess the client's level of understanding prior to witnessing the signature.
The client indicates a lack of memory regarding the alternative treatments discussed by the provider.
Valid informed consent requires the client to fully comprehend the procedure, risks, benefits, and alternatives.
2
Determine the scope of practice for the practical nurse in this scenario.
The PN identifies that explaining medical alternatives is outside the nursing scope of practice.
The provider performing the procedure is legally responsible for providing the initial education and answering questions about alternatives.
3
Take the legally required action to protect client rights.
The PN stops the signing process and contacts the surgeon.
The nurse acts as an advocate to ensure the client is fully informed before giving consent.

Anahtar Kavram

Informed Consent and Scope of Practice
Soru 2428Soru →

A spouse hurriedly approaches the unit desk, visibly upset after speaking with the healthcare provider. The spouse demands that nursing staff administer an anti-anxiety medication to their partner, stating, 'They just refused any further chemotherapy, but they need it to survive! Just give them a pill so we can get them to the infusion center.' The client is awake, oriented, and possesses the legal capacity to make healthcare decisions. Which action should the practical nurse take in response to this demand?

Cevabı ve açıklamayı göster

Cevap: Explain that medication cannot be administered to facilitate a treatment the client has explicitly declined.

Cevap

The practical nurse must refuse the spouse's request and explain that medication cannot be given to force a treatment the competent client has declined.
The correct response protects the client's autonomy. Every competent adult has the legal and ethical right to refuse any medical treatment, including life-sustaining therapy. Administering an anti-anxiety medication to sedate the client and force compliance against their will is a severe violation of their rights and constitutes a chemical restraint.

Adım Adım Çözüm

1
Identify the client's legal status regarding healthcare decision-making.
The scenario states the client is awake, oriented, and possesses legal capacity.
Establishing capacity determines who has the legal right to make or refuse medical decisions.
2
Determine the ethical and legal implications of the spouse's request.
Administering a sedative to force a refused treatment is a violation of autonomy, constitutes chemical restraint, and is legally considered battery.
Nurses are legally mandated to protect clients from unauthorized interventions and chemical restraints.
3
Select the action that upholds the client's rights.
The nurse must advocate for the client by clearly informing the spouse that the medication cannot be administered against the client's wishes.
Client advocacy requires the nurse to defend the client's right to self-determination, even when family members disagree.

Anahtar Kavram

Client Autonomy and Right to Refuse Treatment
Soru 2429Soru →

A practical nurse is preparing to assess the uterine involution of a multiparous client who is 12 hours postpartum. In which order should the nurse perform the following actions to safely and accurately assess the fundus? (Arrange the steps in the correct sequence from first to last.)

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence is: Instruct the client to empty her bladder, assist her into a supine position with flexed knees, don gloves and observe the perineal pad, stabilize the lower uterine segment, and finally palpate the fundus.
A safe and accurate fundal assessment must follow a strict, logical sequence. First, the bladder must be empty to avoid uterine displacement. Second, the client must be positioned correctly (supine with knees flexed) to relax the abdomen. Third, the nurse applies gloves and checks current lochia as a baseline. Finally, when performing the physical palpation, the nurse must always stabilize the lower uterine segment with one hand before pressing on the fundus with the other hand to prevent uterine inversion.

Adım Adım Çözüm

1
Ensure physiological readiness
The client empties her bladder.
A full bladder interferes with accurate assessment by pushing the uterus up and to the side, potentially causing false findings of a boggy uterus.
2
Position for comfort and access
The client is placed supine with flexed knees.
This specific position relieves tension on the abdominal muscles, making it easier to feel the uterus and more comfortable for the client.
3
Implement standard precautions and baseline observation
The nurse dons gloves and visualizes the perineal pad.
This protects the nurse from bodily fluids and allows assessment of bleeding before the uterus is manipulated, which could suddenly expel pooled blood.
4
Perform the bimanual palpation technique safely
The lower segment is supported while the top is palpated.
Supporting the bottom portion of the uterus prevents the life-threatening complication of uterine inversion while evaluating fundal tone.

Anahtar Kavram

Postpartum Fundal Assessment Technique
Soru 2430Soru →

An adult client who was recently diagnosed with bacterial conjunctivitis is prescribed ciprofloxacin ophthalmic solution. The practical nurse enters the client's room to instill the medication. In which order should the nurse perform the following actions? Arrange the steps in the correct chronological sequence from first to last.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence for administering ophthalmic drops is: Perform hand hygiene and put on gloves, position the client's head backward, expose the conjunctival sac by pulling the lower eyelid down, instill the drops into the sac, and finally apply pressure to the inner canthus.
Administering eye drops requires a strict aseptic technique and specific steps to ensure localized medication delivery. First, the nurse must perform hand hygiene and don gloves to prevent infection. Next, positioning the client with the head tilted back and eyes looking upward minimizes the blink reflex. The nurse then pulls the lower eyelid down to expose the conjunctival sac, which is the proper anatomical location for receiving drops. After instilling the drops into the sac, applying gentle pressure to the inner canthus prevents the medication from flowing into the tear duct, thereby avoiding unwanted systemic absorption.

Adım Adım Çözüm

1
Perform hand hygiene and don clean gloves.
Infection control measures are established before contact.
The eye is highly susceptible to infection, making hand hygiene the critical first action.
2
Position the client by having them tilt their head back and look upward.
The client is in the optimal position for administration.
Looking up and tilting the head back moves the cornea away from the lower lid and reduces the natural blink reflex.
3
Pull the lower eyelid down to reveal the conjunctival sac.
A small pocket is created for the medication.
Drops should never be placed directly on the cornea because it can cause trauma and discomfort.
4
Instill the drops into the conjunctival sac.
The medication is safely and accurately delivered.
Dropping the medication into the sac ensures proper distribution across the eye surface when the client gently closes their eye.
5
Apply pressure to the inner canthus (nasolacrimal duct).
Systemic absorption of the eye drops is prevented.
Occluding the nasolacrimal duct keeps the medication localized to the eye and prevents it from entering the systemic circulation.

Anahtar Kavram

Safe Administration of Ophthalmic Medications
Tahmini Süre:1m 0s
Soru 2431Soru →

A client undergoing treatment for severe pneumonia is on the second day of hospitalization and begins displaying coarse tremors, diaphoresis, and severe agitation. The client repeatedly attempts to remove their peripheral intravenous (IV) catheter. With the registered nurse (RN) temporarily unavailable, which action should the practical nurse (PN) take first to protect the client from self-injury?

Cevabı ve açıklamayı göster

Cevap: Request an unlicensed assistive personnel (UAP) to provide continuous one-to-one bedside observation.

Cevap

Request an unlicensed assistive personnel (UAP) to provide continuous one-to-one bedside observation.
Providing a bedside sitter (UAP) is a safe, effective, and least restrictive alternative to physical restraints. It falls within the PN's scope of practice to delegate this monitoring task, ensuring the client's immediate safety from self-injury while the RN is unavailable. This intervention addresses the immediate hazard without violating restraint protocols or exceeding practice boundaries.

Adım Adım Çözüm

1
Assess the client's immediate safety risk and level of agitation.
The client is at high risk for self-injury by dislodging the IV catheter due to altered mental status and agitation.
Identifying the immediate threat guides the selection of the most appropriate and least restrictive intervention.
2
Evaluate available interventions within the practical nurse (PN) scope of practice.
The PN must select a safe, non-invasive method to protect the IV line while adhering to the principle of least restrictive restraints.
Nurses are legally and ethically required to use alternatives before applying physical or chemical restraints.
3
Implement the least restrictive safety measure.
A UAP is assigned to sit with the client to provide continuous monitoring and redirection.
One-to-one observation ensures immediate safety without violating restraint protocols or exceeding the PN's scope of practice.

Anahtar Kavram

Accident, Error, and Injury Prevention (Restraint Alternatives and Scope of Practice)
Tahmini Süre:1m 30s
Soru 2432Soru →

A client is in the preoperative holding area of an ambulatory surgery center preparing for an elective procedure. The surgeon has just left the cubicle after discussing the surgery. As the practical nurse (PN) approaches to finalize the preoperative checklist and witness the informed consent, the client states, "The doctor talked to me, but I am still not entirely sure what happens if I choose not to have this done." Which of the following actions are legally and ethically appropriate for the PN to take? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Delay witnessing the client's signature on the informed consent document until their questions are fully resolved.; Contact the surgeon to return to the bedside to clarify the medical implications of refusing the surgical intervention.; Document the client's expressed uncertainty and the specific interventions taken by the nursing staff to address the concern.

Cevap

The appropriate actions are to delay witnessing the signature, contact the surgeon to return to the bedside, and document the client's uncertainty alongside the nursing interventions taken.
Informed consent requires the client to fully understand the procedure, its risks, benefits, and the consequences of refusal before signing the legal document. When a client expresses uncertainty, the consent is not truly informed. The practical nurse's role is to act as a client advocate by delaying the signature, notifying the provider (surgeon) to return and clarify the medical information, and documenting the client's concerns and the nursing actions taken. The nurse serves only as a witness to the signature and must verify that the client is voluntarily agreeing with a clear and complete understanding.

Adım Adım Çözüm

1
Analyze the client's statement regarding the surgical procedure.
The client indicates a lack of understanding regarding the alternatives or consequences of refusing the procedure.
Informed consent requires the client to fully understand the risks, benefits, and alternatives before signing.
2
Identify the practical nurse's legal scope of practice regarding informed consent.
The PN can only witness the signature and verify voluntary agreement; explaining medical consequences is the provider's exclusive responsibility.
Explaining risks, benefits, and alternatives is a non-delegable duty of the healthcare provider.
3
Determine the appropriate nursing interventions based on scope and client advocacy.
The PN must stop the consent process, advocate for the client by recalling the surgeon to the bedside, and document the event accurately in the medical record.
This ensures client safety, upholds ethical standards, and maintains strict legal compliance with nursing boundaries.

Anahtar Kavram

The practical nurse's role in informed consent is limited to witnessing the signature, verifying voluntary agreement, and advocating for the client if they express knowledge deficits.
Soru 2433Soru →

An alert, oriented, and independently mobile resident in a skilled nursing facility tells the practical nurse (PN), "I am packing my bags. I am leaving this place today to move in with my sibling." The resident's adult child recently instructed the staff, "Do not let my parent leave the building under any circumstances." Which action is most appropriate for the PN to take?

Cevabı ve açıklamayı göster

Cevap: Acknowledge the resident's right to leave and immediately notify the charge nurse and healthcare provider.

Cevap

The correct action is to acknowledge the resident's right to leave and notify the charge nurse and healthcare provider.
A competent adult client retains the right to self-determination, which includes the right to leave a healthcare facility against medical advice. Family members cannot legally override a competent client's autonomy. The practical nurse advocates for the client by acknowledging their decision and acts within their scope of practice by promptly notifying the charge nurse and healthcare provider, who will discuss the implications of leaving with the client.

Adım Adım Çözüm

1
Determine the client's cognitive status.
The client is alert, oriented, and competent.
Competent clients maintain the right to self-determination, including the right to leave a facility.
2
Evaluate the family's instructions against client rights.
The adult child's demands cannot override the competent client's autonomy.
Family members do not have the legal authority to detain a competent adult client against their will.
3
Determine the appropriate practical nurse (PN) intervention.
The PN must support the client's choice while escalating the situation through the appropriate chain of command.
Notifying the charge nurse and provider ensures the client is informed of any risks of leaving while the PN remains within their scope of practice.

Anahtar Kavram

Client Autonomy and the Right to Refuse Care
Soru 2434Soru →

A practical nurse is assigned to care for a client who is on contact precautions for a vancomycin-resistant enterococcus (VRE) infection. When preparing to measure the client's vital signs, which action should the nurse take to maintain proper infection control?

Cevabı ve açıklamayı göster

Cevap: Leave a dedicated stethoscope and blood pressure cuff in the client's room for the duration of the stay.

Cevap

Leave a dedicated stethoscope and blood pressure cuff in the client's room for the duration of the stay.
The correct action is to use dedicated client equipment. For clients on contact precautions due to infections like VRE, dedicating noncritical equipment (such as a stethoscope and blood pressure cuff) to a single client prevents the transfer of microorganisms to other clients and environmental surfaces. If dedicated equipment is unavailable, shared equipment must be thoroughly disinfected before leaving the room.

Adım Adım Çözüm

1
Identify the transmission route for the specific pathogen.
Vancomycin-resistant enterococcus (VRE) is transmitted through direct or indirect contact.
Knowing the mode of transmission determines which specific infection control precautions are required.
2
Determine the requirements for contact precautions.
Contact precautions require a private room (or cohorting), gown and gloves upon entry, and dedicated client care equipment.
These measures block the physical transfer of microorganisms from the client or their environment to the nurse or other areas.
3
Evaluate the timing and location for donning and doffing personal protective equipment (PPE).
PPE must be donned before entering the room and removed inside the room just prior to exiting.
Strict adherence to the PPE sequence prevents environmental contamination of clean areas like hallways.
4
Select the action that aligns with these standards.
Using dedicated equipment that remains in the room is the correct infection control practice.
This eliminates the need to carry potentially contaminated items in and out of the isolation environment.

Anahtar Kavram

Standard and Transmission-Based Precautions
Soru 2435Soru →

An older adult client is receiving morning care 48 hours after undergoing a right above-the-knee amputation. When implementing hygiene, mobility, and comfort measures, which actions are appropriate for the practical nurse to take? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Assist the client into a prone position for 20 to 30 minutes multiple times a day.; Wash the residual limb with mild soap and water, ensuring the skin is patted completely dry.; Instruct the client to perform active range-of-motion exercises on the unaffected extremities.

Cevap

The appropriate actions are assisting the client into a prone position periodically, washing and thoroughly drying the residual limb, and instructing the client to perform active range-of-motion exercises on unaffected extremities.
Correct basic care for an amputation after 24 hours prioritizes the prevention of contractures and the maintenance of skin integrity. Periodic prone positioning directly stretches the hip flexor muscles, counteracting the tendency for the joint to contract. Gentle hygiene with thorough drying prevents skin breakdown and fungal growth. Encouraging range-of-motion on unaffected limbs promotes systemic circulation and preserves the strength needed for future transfers and ambulation.

Adım Adım Çözüm

1
Evaluate the client's postoperative timeframe and surgical type.
The client is 48 hours post-op from an above-the-knee amputation (AKA).
Timeframe dictates positioning rules; after 24 hours, preventing contractures becomes the primary positioning goal.
2
Identify positioning interventions that prevent hip flexion contractures.
Prone positioning is indicated; elevation on pillows and prolonged high-Fowler's positioning are contraindicated.
Hip flexors must be stretched (prone) rather than continuously flexed (sitting or elevated) to ensure future ambulation with a prosthesis.
3
Select appropriate basic hygiene and mobility measures.
Gentle washing with thorough drying and active range-of-motion for unaffected limbs are selected.
These measures safely maintain skin integrity and prevent complications of immobility within the LPN scope of practice.

Anahtar Kavram

Postoperative Basic Care and Comfort: Amputation Positioning and Hygiene
Soru 2436Soru →

A practical nurse (PN) is caring for a client with a right fractured femur who is placed in Buck's skin traction. Upon entering the room, the PN notes that the client has slid down toward the foot of the bed, causing the traction weights to rest against the bed frame. Which action by the PN demonstrates correct ergonomic principles and safe use of traction equipment?

Cevabı ve açıklamayı göster

Cevap: Lower the head of the bed flat, request assistance from a colleague, and use a draw sheet to slide the client upward while they pull on the overhead trapeze.

Cevap

The correct action is to lower the head of the bed flat, get assistance from another staff member, and use a draw sheet in combination with the client using an overhead trapeze to move upward.
Moving a client in traction requires strict adherence to both ergonomic principles and equipment safety rules. Lowering the bed flat works with gravity rather than against it, reducing strain. Using a draw sheet with a colleague's assistance minimizes shear forces on the client's skin and protects the nurses' backs. Having the client use an overhead trapeze maximizes client participation. Throughout this safe movement, the continuous line of pull from the traction is maintained.

Adım Adım Çözüm

1
Assess the equipment and client alignment.
Identified that the traction weights are resting on the bed frame, rendering the traction ineffective.
Weights must hang freely to provide the continuous pull required to relieve muscle spasms and maintain alignment of the fractured femur.
2
Determine the safest ergonomic method to reposition the client.
Planned to lower the bed, use a draw sheet, involve a second staff member, and utilize the overhead trapeze.
Lowering the bed removes the force of gravity working against the transfer. The draw sheet reduces friction, the second staff member divides the physical load, and the trapeze utilizes the client's upper body strength, protecting the nurse's back.
3
Execute the repositioning without interrupting the traction.
The client is moved up in bed while the weights remain attached and unsupported by staff.
Traction must be continuous. Lifting or removing the weights disrupts the therapeutic pull and can cause severe muscle spasms or misalignment of the fracture.

Anahtar Kavram

Ergonomic principles in patient repositioning and safe maintenance of orthopedic traction equipment.
Soru 2437Soru →

A practical nurse (PN) works in an outpatient clinic. A coworker takes a selfie at the nursing station and posts it to a personal social media account. The PN notices that an electronic health record (EHR) screen is visible in the background of the photo, clearly displaying a client's full name and date of birth. The coworker states, 'My account is completely private, so only my friends can see it.' Which of the following actions should the PN take?

Cevabı ve açıklamayı göster

Cevap: Report the social media post to the clinic supervisor immediately.

Cevap

The correct action is to report the social media post to the clinic supervisor immediately.
Under the Health Insurance Portability and Accountability Act (HIPAA), any unauthorized disclosure of Protected Health Information (PHI), which includes a client's name and date of birth, is a legal violation. The practical nurse has an ethical and legal obligation to report this breach immediately to the facility's management or privacy officer. A social media account's private settings do not protect against HIPAA violations, as the information has still been disclosed to unauthorized individuals.

Adım Adım Çözüm

1
Identify the legal violation occurring in the scenario.
The photo contains Protected Health Information (PHI), specifically the client's name and date of birth, which is a HIPAA violation.
Recognizing what constitutes a privacy breach is the first step in ethical nursing practice.
2
Evaluate the coworker's rationale regarding social media privacy.
Social media privacy settings do not exempt healthcare workers from HIPAA regulations; any unauthorized sharing of PHI is a breach.
Nurses must understand that digital platforms inherently carry risks of unauthorized disclosure.
3
Determine the required nursing action based on ethical and legal standards.
The PN must fulfill the duty to report the violation to the appropriate administrative authority.
Reporting ensures client protection, facility compliance, and appropriate mitigation of the privacy breach.

Anahtar Kavram

Client Confidentiality and HIPAA Regulations
Soru 2438Soru →

A nurse is evaluating a client on the maternity unit who delivered a term newborn 10 hours ago via an uncomplicated vaginal birth. Which of the following findings should the nurse identify as expected and normal during this time? (Select all that apply.)

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: A firm uterus palpated at the level of the umbilicus; Moderate amount of dark red vaginal discharge; Reports of mild, intermittent uterine cramping while breastfeeding

Cevap

The expected and normal findings are a firm uterus at the umbilicus, a moderate amount of dark red vaginal discharge, and mild uterine cramping during breastfeeding.
In the initial 24 hours following childbirth, the body undergoes expected physiological adaptations. The uterus should remain firm and central, near the umbilicus, to compress blood vessels and prevent bleeding. Lochia rubra (dark red discharge) in moderate amounts is expected. Additionally, the release of oxytocin during breastfeeding causes the uterus to contract, leading to normal but sometimes painful afterpains.

Adım Adım Çözüm

1
Analyze each assessment finding against normal physiological adaptations in the first 24 hours postpartum.
Identified that lochia rubra, a firm midline uterus, and breastfeeding-induced afterpains are all normal adaptations.
Differentiating between expected physiological changes and potential complications is essential for safe postpartum care.
2
Identify the abnormal findings that signify potential postpartum complications.
Recognized that tachycardia and rapid pad saturation are signs of hemorrhage or shock.
Early identification of danger signs allows for prompt nursing intervention and escalation of care.

Anahtar Kavram

Normal postpartum physiological adaptations versus danger signs of hemorrhage.
Soru 2439Soru →

A practical nurse (PN) is assigned to care for a client with active tuberculosis who is in a negative-pressure isolation room. Upon approaching the room to administer scheduled oral medications, the PN observes through the hallway window that the client is experiencing sudden, severe agitation and is attempting to climb over the raised bed rails. Which is the priority action for the PN to prevent client injury and maintain safety?

Cevabı ve açıklamayı göster

Cevap: Don a fitted N95 respirator, enter the room to verbally redirect the client back to bed, and utilize the emergency call system for staff assistance.

Cevap

The priority is to don a fitted N95 respirator, enter the room to verbally redirect the client, and call for emergency assistance.
The correct answer balances the critical need for infection control with immediate client safety. Standard safety protocols mandate that healthcare workers must don appropriate personal protective equipment (PPE) before entering a hazardous environment, even during an emergency. Once protected, the nurse can safely enter to provide least-restrictive interventions (verbal redirection) and summon necessary help.

Adım Adım Çözüm

1
Analyze the competing safety priorities in the clinical scenario.
The nurse faces an immediate physical threat (client climbing out of bed) and an immediate environmental/infectious threat (active airborne pathogen).
Prioritization requires identifying which risk must be mitigated first to allow for safe delivery of care.
2
Apply the principle of environmental safety and personal protection.
The nurse must don the appropriate PPE (N95 respirator) before crossing the threshold of the negative-pressure room.
If the nurse becomes exposed or incapacitated, they cannot assist the client. Personal safety and infection control cannot be bypassed.
3
Determine the appropriate, least-restrictive physical intervention.
Verbal redirection and calling for additional staff assistance.
This addresses the immediate fall risk safely without resorting to inappropriate delegation or unauthorized restraints.

Anahtar Kavram

Prioritizing Infection Control and Immediate Client Safety
Soru 2440Soru →

While providing care on a high-acuity step-down unit, a licensed practical/vocational nurse (LPN/VN) must prioritize various clinical demands. Which of the following actions by the LPN/VN is legally appropriate and within their scope of practice?

Cevabı ve açıklamayı göster

Cevap: Reinforcing previously taught infection control guidelines with a client preparing for discharge with a central venous catheter

Cevap

The legally appropriate action is reinforcing previously taught infection control guidelines with a client preparing for discharge with a central venous catheter.
Reinforcing previously established education is within the LPN/VN scope of practice. The RN is responsible for the initial teaching and assessment of the client's learning needs, while the LPN/VN safely reinforces this information to promote client understanding and safe care prior to discharge.

Adım Adım Çözüm

1
Evaluate the LPN/VN's role in client education and discharge planning.
The initial teaching and assessment of learning needs must be performed by the Registered Nurse (RN), but the LPN/VN can safely reinforce this established education.
This distinguishes the LPN/VN's data collection and reinforcement role from the RN's comprehensive teaching and evaluation role.
2
Analyze the LPN/VN's scope regarding unstable clients and care plan modifications.
A client developing sudden dyspnea is unstable. The LPN/VN cannot independently formulate or modify the care plan for new acute issues.
Acute changes in condition require immediate escalation for a comprehensive RN assessment and clinical judgment.
3
Assess the nurse's legal responsibility during the informed consent process.
The nurse acts only as a witness to ensure the signature is authentic and voluntary.
Explaining surgical risks and alternative treatments is strictly the responsibility of the healthcare provider performing the procedure.
4
Review confidentiality and HIPAA standards regarding sharing protected health information.
Information cannot be shared over the phone based merely on verbal claims of relation.
The facility's privacy protocols (such as verifying a passcode) must be followed to prevent an unintentional confidentiality breach.

Anahtar Kavram

LPN/VN Scope of Practice, Delegation, and Legal Responsibilities
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Tüm alıştırma soruları — NCLEX-PN | Examkin