Examkin

Tüm alıştırma soruları

2933 soru

Tüm türler2,933Çoktan seçmeli1,506Çoklu seçim653Sayısal68Eşleştirme70Sıralama636
Soru 2501Soru →

An adolescent diagnosed with pertussis (whooping cough) requires a diagnostic procedure in another department of the facility. Which infection control measure should the licensed practical nurse ensure is in place during the transfer?

Cevabı ve açıklamayı göster

Cevap: Apply a standard medical mask over the adolescent's nose and mouth prior to exiting the current room.

Cevap

The practical nurse should apply a standard medical mask over the adolescent's nose and mouth before initiating the transport.
Pertussis (whooping cough) requires Droplet Precautions because it is spread through large respiratory secretions. When transporting a client on Droplet Precautions outside of their designated room, the primary intervention is to place a standard medical mask (surgical mask) on the client to contain their coughing and secretions, thereby preventing transmission to others in the facility.

Adım Adım Çözüm

1
Identify the transmission route and appropriate isolation category for the given diagnosis.
Pertussis is transmitted via large respiratory droplets, requiring Droplet Precautions.
Accurate identification of the isolation category dictates the required infection control measures.
2
Determine the standardized protocol for transporting a client on Droplet Precautions outside their room.
The standard protocol requires the client to wear a medical (surgical) mask to contain infectious respiratory secretions.
Containing the source of the infection prevents the spread of droplets to the environment and other individuals during transit.
3
Evaluate the remaining options against safety standards and the practical nurse's scope of practice.
Negative pressure and N95s apply to Airborne Precautions. Delegating respiratory evaluation to a UAP violates the scope of practice.
Ensures the selected action is both clinically appropriate for the specific pathogen and legally sound.

Anahtar Kavram

Droplet Precautions and Transport Protocols
Soru 2502Soru →

An 82-year-old client receiving treatment for pyelonephritis suddenly exhibits severe combativeness and repeatedly attempts to dislodge their peripheral intravenous (IV) catheter. After less restrictive interventions are unsuccessful, the healthcare provider prescribes bilateral soft wrist restraints. The registered nurse applies the restraints and assigns ongoing monitoring to the practical nurse (PN). Which actions should the PN include in the client's care? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Evaluate the radial pulses, capillary refill, and skin temperature of both upper extremities at least every 2 hours.; Release the restraints one at a time every 2 hours to inspect the skin and assist with range-of-motion exercises.; Secure the restraint ties directly to the movable portion of the bed frame utilizing a quick-release knot.

Cevap

The correct actions include evaluating the client's circulation regularly, releasing the restraints one at a time every 2 hours for skin care and range of motion, and securing the ties to the movable part of the bed frame with a quick-release knot.
Safe restraint management requires the nurse to continuously monitor the client's physiological status and prevent complications. This includes evaluating neurovascular integrity (pulses, capillary refill, temperature) and releasing the restraints one at a time at least every 2 hours to provide essential skin care and range-of-motion exercises. Furthermore, securing the straps to the movable portion of the bed frame with a quick-release knot ensures the restraints will not constrict the client's limbs if the bed is repositioned and allows for immediate removal during an emergency.

Adım Adım Çözüm

1
Analyze the clinical scenario to identify the primary nursing responsibility.
The client is an older adult with acute confusion requiring soft wrist restraints, demanding strict adherence to safety, monitoring, and legal guidelines.
Restraints pose significant risks for injury, nerve damage, and reduced circulation, necessitating careful procedural compliance.
2
Evaluate each option against safe restraint application mechanics and monitoring standards.
Assessing pulses, releasing restraints every 2 hours, and using a quick-release knot on the movable bed frame align with evidence-based safety standards.
These actions directly prevent the complications associated with restraint use, such as skin breakdown, joint contractures, and impaired perfusion.
3
Identify contraindicated actions based on the PN scope of practice and legal restraint requirements.
Delegating assessments, obtaining PRN restraint orders, and dismissing acute confusion as normal aging are incorrect.
These actions violate delegation rules, federal restraint regulations, and proper geriatric clinical judgment.

Anahtar Kavram

Safe Application and Monitoring of Physical Restraints
Soru 2503Soru →

An adult client enrolled in a clinical medication trial tells the practical nurse (PN), "I want to drop out of this study because the nausea is unbearable, but I am terrified the healthcare team will discharge me from the facility if I quit." In what order should the PN perform the following actions? Arrange the actions in the correct chronological sequence.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence is to first reassure the client of their rights, then collect data about the nausea, notify the healthcare provider, and finally document the event.
The correct sequence follows the standard nursing process and prioritization frameworks. The PN must first address the client's immediate psychological distress and advocate for their rights. Next, the PN collects necessary clinical data about the adverse effects. Only after gathering this data should the PN notify the provider, followed by documenting all actions as the final step.

Adım Adım Çözüm

1
Address the client's immediate psychosocial concern and validate their rights.
The client is reassured that their standard medical treatment will continue regardless of trial participation.
According to the Patient's Bill of Rights, clients have the right to refuse treatment or withdraw from research at any time without negative consequences to their routine care.
2
Perform focused data collection.
The PN gathers specific details about the severity and duration of the nausea.
Accurate clinical data is required before contacting the provider to ensure a complete and actionable report (SBAR) can be given.
3
Report findings up the chain of command.
The primary healthcare provider and research coordinator are informed.
The provider must be notified so they can officially discontinue the experimental medication and prescribe alternative interventions for the nausea.
4
Complete nursing documentation.
The client's statements, the collected data, and the notifications are recorded in the chart.
Timely and accurate documentation serves as legal proof of the client's wishes and the advocacy actions taken by the nurse.

Anahtar Kavram

Client Rights and Advocacy: Right to Refuse Treatment and Withdraw from Research
Soru 2504Soru →

An LPN/VN is assigned to the care of a client who experienced a forceps-assisted vaginal birth 24 hours ago. The client suddenly reports excruciating, unrelenting perineal pain and significant rectal pressure that was not relieved by an oral analgesic. Data collection reveals a firm, midline uterine fundus located at the umbilicus and a scant amount of lochia rubra on the perineal pad. Which action should the practical nurse take first?

Cevabı ve açıklamayı göster

Cevap: Assist the client to a side-lying position and visually examine the perineal and rectal area.

Cevap

The practical nurse should first assist the client to a side-lying position and visually examine the perineal area to collect data regarding a potential hematoma.
The client's presentation of unrelenting perineal pain and rectal pressure following an operative vaginal delivery (forceps) is the classic hallmark of a perineal hematoma. Because the fundus is firm and midline with minimal visible bleeding, uterine atony is ruled out. The practical nurse's priority is to utilize their data collection skills to visually inspect the perineum for swelling, tension, and bluish discoloration before immediately reporting the findings to the registered nurse.

Adım Adım Çözüm

1
Evaluate the client's subjective symptoms against the objective data.
The client reports severe pain and rectal pressure, but objective data shows a firm, midline fundus and scant lochia.
This differentiation rules out uterine atony and points toward a concealed hemorrhage, such as a perineal or vaginal hematoma, which is common after a forceps-assisted delivery.
2
Determine the most appropriate immediate action within the practical nursing scope of practice.
The nurse must visually inspect the perineum to confirm swelling, bluish discoloration, or extreme tenderness.
Direct data collection is a necessary independent nursing action before escalating the clinical findings to the registered nurse or healthcare provider.

Anahtar Kavram

Identifying complications of the postpartum period and prioritizing data collection within the PN scope of practice.
Tahmini Süre:1m 15s
Soru 2505Soru →

During a shift at a residential care facility, a resident with a baseline of mild cognitive impairment suddenly becomes highly agitated and attempts to climb over the dining tables. The resident is unsteady on their feet and at immediate risk for a fall. Which action should the practical nurse (PN) implement first to prevent injury?

Cevabı ve açıklamayı göster

Cevap: Escort the resident to a quiet, closely monitored environment away from the busy dining area.

Cevap

The correct action is to escort the resident to a quiet, closely monitored environment away from the busy dining area.
The correct action prioritizes immediate client safety using the least restrictive alternative available. Relocating the resident to a quiet, supervised area protects them from falling over the furniture while simultaneously removing them from the potentially overstimulating environment that may be triggering the acute agitation.

Adım Adım Çözüm

1
Assess the immediate environment and the client's risk for injury.
The resident is unsteady and actively attempting a dangerous maneuver (climbing tables), indicating a high, imminent fall risk.
Immediate physical safety is the highest priority in a behavioral crisis.
2
Determine the least restrictive intervention to ensure safety.
Removing the client from the overstimulating environment and providing close supervision addresses the behavior without using restraints.
Nursing standards mandate the use of least restrictive alternatives before considering physical or chemical restraints.
3
Plan for follow-up assessment.
Once the client is safe, the nurse must investigate the underlying cause of the sudden agitation (e.g., delirium, infection, or pain).
Sudden changes in cognition are acute medical events, not normal aging.

Anahtar Kavram

Least Restrictive Safety Interventions and Delirium Recognition
Soru 2506Soru →

A practical nurse is assigned to care for a client who is experiencing severe constipation and requires a large-volume cleansing enema. In what sequence should the nurse perform the following administration steps?

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence is: assist the client into the left lateral Sims' position, lubricate the tube, insert the tube while the client exhales, elevate the solution container, and finally release the tubing clamp.
Administering a cleansing enema requires a systematic approach to ensure both client safety and procedural efficacy. First, the client must be placed in the left lateral Sims' position because the descending colon is on the left side, allowing gravity to assist fluid flow. Next, the tube must be lubricated to prevent tissue trauma during entry. The tube is then gently inserted 3 to 4 inches past the internal sphincter. After the tube is safely in place, the container is elevated 12 to 18 inches above the anus to establish safe hydrostatic pressure (preventing fluid from entering too forcefully). Finally, the clamp is opened to allow the fluid to instill slowly and comfortably.

Adım Adım Çözüm

1
Assist the client into a left lateral Sims' position with the right knee flexed.
The client's descending colon is positioned downward.
Gravity will help the fluid flow naturally into the sigmoid and descending colon.
2
Lubricate the distal 2 to 3 inches (5 to 7.5 cm) of the rectal tube with a water-soluble lubricant.
The insertion tip is prepared for smooth entry.
Lubrication reduces friction and prevents traumatic injury to the sensitive rectal mucosa.
3
Instruct the client to exhale slowly while gently inserting the rectal tube 3 to 4 inches (7.5 to 10 cm) toward the umbilicus.
The tube passes safely through the anal sphincter into the rectum.
Exhaling relaxes the sphincter, and aiming toward the umbilicus follows the anatomical contour of the lower bowel.
4
Elevate the solution container 12 to 18 inches (30 to 45 cm) above the level of the client's anus.
Safe hydrostatic pressure is established.
Holding the bag too high causes rapid instillation and painful cramping, while holding it too low prevents adequate flow.
5
Release the tubing clamp to allow the warm solution to instill slowly into the colon.
The enema solution begins to enter the client's lower GI tract.
Administration can safely commence once proper positioning, insertion, and pressure height are confirmed.

Anahtar Kavram

Cleansing Enema Administration Sequence
Soru 2507Soru →

A practical nurse is initiating a 24-hour urine collection for a client to evaluate renal function. To ensure the accuracy of the diagnostic test and reduce the risk of sample invalidation, in what order should the nurse implement the following steps?

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence is to first prepare the client with equipment and instructions, then have them empty their bladder and discard the initial urine, followed by documenting this exact start time. Afterward, all subsequent urine is collected and stored on ice, ending with one final void at exactly the 24-hour mark.
For a 24-hour urine collection, the procedure begins by ensuring client understanding and readiness. The actual collection period must start with an empty bladder, so the first void is discarded and that specific time is noted as the start. All subsequent urine is kept chilled to preserve the sample. Exactly 24 hours later, a final void is obtained and added to the container to capture all urine produced during the time frame.

Adım Adım Çözüm

1
Provide equipment and explain the procedure.
The client is prepared to participate correctly.
Ensures compliance and proper technique from the beginning of the test.
2
Have the client empty their bladder and discard the urine.
The bladder is empty.
The 24-hour period must start with an empty bladder so only newly formed urine is measured.
3
Document the start time.
The 24-hour clock officially begins.
Accurate timing is critical for the diagnostic validity of a timed urine test.
4
Collect all subsequent urine and keep it on ice.
Urine is safely preserved.
Cold storage prevents specimen degradation and bacterial overgrowth.
5
Collect a final void exactly 24 hours later.
The collection is complete.
Captures the very last urine produced within the precise 24-hour window.

Anahtar Kavram

Proper chronological technique for a 24-hour urine collection ensures the diagnostic validity of the specimen and reduces the risk of having to restart the test.
Tahmini Süre:1m 0s
Soru 2508Soru →

A practical nurse (PN) employed on an orthopedic rehabilitation unit is organizing their daily tasks following the morning handover. Which planned action indicates that the PN is practicing safely within their legal scope and adhering to professional standards?

Cevabı ve açıklamayı göster

Cevap: Reinforcing weight-bearing restrictions and administering scheduled oral analgesics to a client recovering from a total hip arthroplasty.

Cevap

The correct action is reinforcing weight-bearing restrictions and administering scheduled oral analgesics to a client recovering from a total hip arthroplasty.
The correct answer demonstrates appropriate application of the PN scope of practice. Administering scheduled oral medications to a stable client and reinforcing education that was initially provided by a Registered Nurse (RN) or physical therapist are fundamental tasks within the legal scope of the practical nurse. This action ensures safe, effective, and collaborative client care without overstepping professional boundaries.

Adım Adım Çözüm

1
Analyze the PN scope of practice regarding client care tasks and teaching.
PNs can administer routine medications and reinforce prior teaching, but cannot perform initial comprehensive assessments.
NCSBN standards reserve comprehensive assessment and initial care planning exclusively for the RN.
2
Evaluate the role of the PN in the informed consent process.
The PN can witness a signature but cannot explain procedural risks, benefits, or alternatives.
Explaining the procedure is the legal responsibility of the healthcare provider.
3
Assess the environmental context for sharing client clinical data.
Discussing client status in a public elevator is a clear HIPAA violation.
Confidential client data must only be discussed in private, secure clinical areas to protect privacy.
4
Select the action that aligns with safe, legal PN practice.
The option involving reinforcing restrictions and giving oral analgesics is the correct choice.
These are established, routine tasks firmly within the PN scope of practice.

Anahtar Kavram

Practical Nurse (PN) Scope of Practice and Professional Standards
Soru 2509Soru →

Prior to transferring a client with bilateral lower extremity weakness from a bed to a bedside chair, it is determined that a powered sit-to-stand mechanical lift is indicated. Place the following steps for operating this equipment in the correct sequence to maximize ergonomic safety and prevent injury.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence requires prioritizing client assessment, followed by environmental safety, application of the sling, positioning the client on the device, securing the straps to the lift, and finally executing the transfer.
Safe use of mechanical transfer equipment dictates a logical progression to prevent musculoskeletal injury to both the client and the nurse. The sequence must move from assessment (suitability for the specific equipment) to environmental safety (locking brakes), to applying the wearable component (sling), to positioning the client onto the stationary base of the machine, to connecting the lifting mechanism, and finally, executing the mechanical lift. Any deviation exposes the client to a risk of falls or joint strain.

Adım Adım Çözüm

1
Confirm the client has partial weight-bearing ability and can follow simple commands.
Validates the client is an appropriate candidate for a sit-to-stand lift.
Active mechanical lifts require patient participation; failing to assess this risks a severe fall.
2
Place the wheelchair adjacent to the bed and engage the wheel locks.
Establishes a safe destination for the transfer.
Securing the wheelchair prevents it from rolling away when the client is lowered.
3
Wrap the lift sling securely around the client's torso and fasten the support belt.
Prepares the client for connection to the lift.
Applying the sling first minimizes the time the bulky lifting machine needs to hover near the client's bed space.
4
Maneuver the lift device forward so the client's feet rest flat on the platform and knees touch the padded brace.
Aligns the client ergonomically with the lift's pivot points.
Proper bracing of the lower extremities prevents joint hyperextension and musculoskeletal strain during the lift.
5
Secure the sling attachments to the lifting mechanism and perform a visual check of all connections.
Safely couples the client to the lift.
Double-checking connections is a mandatory safety protocol to prevent equipment detachment.
6
Instruct the client to hold the safety handles while slowly activating the lift to an upright position.
Completes the transfer preparation and begins the elevation phase.
Lifting only occurs after all previous steps confirm maximum ergonomic alignment and safety.

Anahtar Kavram

The safe and ergonomic operation of a sit-to-stand mechanical lift requires a strict sequence: cognitive/physical assessment, environmental preparation, client preparation, precise anatomical alignment with the device, and secure attachment prior to activation.
Soru 2510Soru →

A practical nurse is preparing to administer scheduled morning medications, including oral digoxin and oral furosemide, to a client diagnosed with heart failure. Which of the following actions should the nurse perform? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Assess the client's apical pulse for 1 full minute prior to administering the digoxin.; Withhold the digoxin and notify the registered nurse if the client reports new-onset nausea and blurred vision.; Review the client's most recent serum potassium laboratory results before administering the furosemide.

Cevap

The nurse should assess the apical pulse for 1 full minute, withhold digoxin for signs of toxicity like nausea and blurred vision, and review serum potassium levels before administering furosemide.
The correct actions reflect essential safety protocols for a practical nurse administering high-risk medications. Digoxin requires checking the apical pulse for a full minute to ensure the heart rate is high enough to tolerate the medication. Because digoxin has a narrow therapeutic range, any signs of toxicity (like new-onset nausea or blurred vision) mandate withholding the drug and notifying the RN. Furthermore, because the client is taking furosemide (a potassium-depleting diuretic), the nurse must check the potassium level, as hypokalemia greatly increases the risk of digoxin toxicity.

Adım Adım Çözüm

1
Analyze the prescribed medications and their interactions.
Digoxin decreases heart rate and has a narrow therapeutic index. Furosemide causes potassium loss. Hypokalemia potentiates digoxin toxicity.
Understanding the pharmacology guides the necessary nursing assessments.
2
Identify the required pre-administration assessments for digoxin.
The apical pulse must be auscultated for a full minute, and the nurse must assess for signs of toxicity (GI and visual changes).
These assessments ensure it is safe to administer the cardiac glycoside.
3
Evaluate the practical nurse (PN) scope of practice regarding medication administration.
The PN can administer oral medications and monitor labs, but cannot administer IV push medications.
Adhering to the legal scope of practice prevents patient harm and professional liability.
4
Apply standard medication administration safety rights.
Two distinct identifiers (name, date of birth) must be used. Room numbers are invalid.
Proper identification prevents medication errors.

Anahtar Kavram

Safe administration of digoxin and furosemide requires meticulous monitoring of heart rate and potassium levels, recognizing signs of toxicity, and adhering to the practical nursing scope of practice.
Soru 2511Soru →

A practical nurse is preparing to administer phenytoin oral suspension to a client with a seizure disorder. The provider's prescription is for phenytoin 150 mg150\text{ mg} PO every 12 hours. The medication label indicates a concentration of 125 mg/5 mL125\text{ mg}/5\text{ mL}.

How many mL\text{mL} should the nurse administer for one dose? (Record the answer as a whole number. Do not include units in your answer.)

Cevabı ve açıklamayı göster

Cevap: 6

Cevap

6
To calculate the correct volume of medication to administer, the nurse uses the formula: Desired DoseDose on Hand×Quantity\frac{\text{Desired Dose}}{\text{Dose on Hand}} \times \text{Quantity}. Substituting the known values, the calculation is 150 mg125 mg×5 mL=1.2×5 mL=6 mL\frac{150\text{ mg}}{125\text{ mg}} \times 5\text{ mL} = 1.2 \times 5\text{ mL} = 6\text{ mL}. Therefore, the nurse should administer 6 mL6\text{ mL} per dose.

Adım Adım Çözüm

1
Identify the known variables for the dosage calculation.
Desired (D) = 150 mg150\text{ mg}, Have (H) = 125 mg125\text{ mg}, Quantity (Q) = 5 mL5\text{ mL}.
Correctly identifying the prescription and medication label information is essential before performing any math.
2
Set up the dosage calculation formula.
150 mg125 mg×5 mL\frac{150\text{ mg}}{125\text{ mg}} \times 5\text{ mL}
Using the standard dimensional analysis or desired-over-have method ensures accurate dose calculation.
3
Perform the mathematical calculation.
1.2×5 mL=6 mL1.2 \times 5\text{ mL} = 6\text{ mL}
Solving the equation provides the final volume to be administered.

Anahtar Kavram

Oral Dosage Calculation
Tahmini Süre:1m 0s
Soru 2512Soru →

A 78-year-old client is admitted to the medical-surgical unit for a severe urinary tract infection and has been receiving oral ciprofloxacin for the past 48 hours. The practical nurse enters the room to administer the next scheduled dose. The client, who was alert and cooperative the previous evening, is now highly agitated, disoriented to place and time, and picking aimlessly at the bed linens. What is the most appropriate action for the practical nurse to take?

Cevabı ve açıklamayı göster

Cevap: Withhold the antibiotic dose and immediately notify the registered nurse of the client's altered mental status.

Cevap

The practical nurse should withhold the antibiotic dose and immediately notify the registered nurse of the client's altered mental status.
Acute confusion (delirium) in an older adult is a medical emergency that can indicate a severe adverse reaction to the medication, such as fluoroquinolone-induced central nervous system toxicity, or a life-threatening worsening of the underlying infection. The practical nurse must prioritize safety by withholding the scheduled drug and immediately escalating these acute neurological changes to the registered nurse for a comprehensive assessment.

Adım Adım Çözüm

1
Assess the client's current clinical presentation and compare it to their baseline status.
The client exhibits a sudden onset of extreme agitation and disorientation (acute confusion), which is a significant change from being alert and cooperative.
Identifying acute changes in mental status is critical for ensuring client safety and recognizing potential complications.
2
Correlate the assessment findings with potential pharmacological complications and the underlying disease process.
Acute confusion in an older adult receiving antibiotics may indicate drug toxicity (such as central nervous system adverse effects from fluoroquinolones) or a worsening of the underlying infection (such as the development of sepsis).
Recognizing severe adverse drug reactions or condition deterioration guides the decision regarding whether to proceed with medication administration.
3
Determine the appropriate action within the practical nurse scope of practice.
The nurse must withhold the ciprofloxacin and escalate the findings to the registered nurse.
The registered nurse or healthcare provider must evaluate the acute change in condition before any further doses of potentially contributing medications are administered.

Anahtar Kavram

Pre-administration Assessment and Withholding Criteria
Soru 2513Soru →

A practical nurse is caring for a client who is on strict bed rest and receiving continuous oxygen therapy via a nasal cannula for severe pneumonia. Which basic care and comfort interventions should the nurse implement? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Apply a water-soluble lubricant to the nares to relieve dryness and irritation.; Place protective padding on the oxygen tubing where it rests over the ears.; Encourage the client to perform active range-of-motion exercises in bed.

Cevap

The correct interventions are applying a water-soluble lubricant to the nares, placing protective padding on the oxygen tubing over the ears, and encouraging active range-of-motion exercises.
Providing a water-soluble nasal lubricant, padding the oxygen tubing, and encouraging active range-of-motion exercises are appropriate nursing actions that promote physical comfort, prevent medical device-related skin breakdown, and minimize the systemic risks associated with strict bed rest.

Adım Adım Çözüm

1
Analyze the client's condition and prescribed therapies.
The client has severe pneumonia, is on strict bed rest, and requires continuous oxygen via a nasal cannula.
Identifying the client's specific vulnerabilities (immobility, respiratory compromise, medical devices) dictates the appropriate basic care measures.
2
Evaluate each intervention for safety, efficacy, and relevance to comfort and basic care.
Lubricating the nares, padding the tubing, and performing range-of-motion exercises are safe and supportive measures.
These actions prevent skin breakdown, mucosal dryness, and complications of immobility without compromising the client's respiratory status.
3
Identify contraindicated actions that compromise client safety.
Positioning the client completely flat and removing the oxygen cannula for hygiene are unsafe.
A flat position impairs lung expansion, and removing oxygen during oral care ignores airway and breathing priorities.

Anahtar Kavram

Basic care for clients on bed rest with oxygen therapy focuses on maintaining skin integrity, preventing immobility complications, and supporting respiratory function.
Soru 2514Soru →

A practical nurse is preparing to enter the room of a client who has seasonal influenza and a sacral wound infected with methicillin-resistant Staphylococcus aureus (MRSA). Arrange the following steps for donning the required personal protective equipment (PPE) in the correct sequence, from first to last.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence for donning full personal protective equipment is to first perform hand hygiene, then put on the isolation gown, followed by the surgical mask, then the face shield or goggles, and finally put on the gloves, extending them over the gown cuffs.
According to the Centers for Disease Control and Prevention (CDC) guidelines, the standard sequence for donning PPE begins with hand hygiene to prevent contaminating the clean equipment. The gown is applied next to cover the torso. The facial protection (mask followed by goggles/face shield) is then applied. Gloves are donned last because they must be pulled up and over the cuffs of the isolation gown to ensure a continuous, unbroken barrier against infectious agents.

Adım Adım Çözüm

1
Perform hand hygiene.
Hands are decontaminated.
Prevents the transfer of existing hand flora or environmental pathogens to the clean PPE being applied.
2
Don the isolation gown.
Torso and arms are covered.
Protects the nurse's uniform from contamination during client care and establishes the base layer for further PPE.
3
Don the surgical mask.
Mouth and nose are protected.
Provides a barrier against large respiratory droplets generated by the client with influenza.
4
Don the face shield or goggles.
Eyes are protected.
Shields the conjunctiva from potential splashes or infectious droplets.
5
Don gloves and extend over gown cuffs.
Hands and wrists are fully sealed.
Ensures no exposed skin remains at the wrist and provides contact protection against MRSA.

Anahtar Kavram

The correct sequence for donning personal protective equipment is essential to prevent self-contamination and ensure proper barrier placement.
Soru 2515Soru →

A practical nurse (PN) is working on a busy rehabilitation unit. Which of the following actions by the PN demonstrate appropriate maintenance of client confidentiality and information security? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Placing printed client assignment sheets into a designated shredding bin at the end of the shift.; Providing a client's condition update over the telephone to a caller who states the correct privacy passcode.; Pulling the privacy curtain and speaking in a lowered voice when discussing care with a client in a semi-private room.

Cevap

The correct actions are placing printed sheets in a shredding bin, providing updates to callers with a privacy passcode, and using lowered voices and privacy curtains in semi-private rooms.
To comply with privacy regulations, nurses must properly dispose of documents containing protected health information in secure shredding bins. Providing information over the telephone is permissible only if the caller can verify authorization, typically through a predetermined privacy passcode. Additionally, when verbalizing health information in areas where it might be overheard, such as semi-private rooms, nurses must take reasonable precautions like pulling curtains and lowering their voices to minimize incidental disclosures.

Adım Adım Çözüm

1
Evaluate each option against Health Insurance Portability and Accountability Act (HIPAA) standards for protected health information (PHI).
Identify actions that prevent unauthorized access to written, verbal, and electronic data.
Nurses must apply security measures across all forms of communication.
2
Analyze electronic security practices.
Determine that minimizing a screen is insufficient (must log out) and using a personal smartphone is a violation (must use encrypted facility devices).
Electronic PHI requires strict access controls to prevent data breaches.
3
Analyze physical and verbal security practices.
Determine that shredding documents, verifying callers with passcodes, and lowering voices in semi-private rooms are compliant, while talking in an elevator is a violation.
Nurses must take reasonable safeguards to avoid incidental disclosures in shared spaces.

Anahtar Kavram

Maintaining client confidentiality and securing health information across various communication methods (electronic, verbal, and written) is a fundamental nursing responsibility under HIPAA regulations.
Soru 2516Soru →

A practical nurse is preparing to administer a scheduled morning dose of digoxin to an adult client. The bedside vital sign monitor displays a heart rate of 54 beats/minute. Arrange the following nursing actions in the correct sequence to reduce the client's risk of potential complications.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence is to first verify the heart rate by auscultating the apical pulse manually, then withhold the digoxin, notify the RN or healthcare provider, and finally document the actions and findings.
When a practical nurse identifies a potentially abnormal vital sign reading from an automated device, the first priority is to assess the client and verify the finding manually. Once an apical pulse below 60 beats/minute is confirmed, the nurse must withhold the digoxin to reduce the risk of toxicity. Subsequently, the nurse escalates the finding by notifying the RN or provider. Finally, all assessments, interventions, and notifications must be thoroughly documented in the client's medical record.

Adım Adım Çözüm

1
Auscultate the apical pulse manually for one full minute.
The exact heart rate is accurately verified.
Automated monitors can be inaccurate, and digoxin requires a precise apical pulse measurement before administration.
2
Withhold the scheduled dose of digoxin.
The medication is not administered.
Administering digoxin to an adult with a heart rate below 60 beats/minute increases the risk of severe bradycardia and toxicity.
3
Notify the registered nurse (RN) or healthcare provider.
The healthcare team is made aware of the client's status.
Prompt communication ensures the client receives appropriate follow-up care or medication adjustments.
4
Document the vital signs and the withheld medication.
The client's medical record is updated.
Documentation provides a legal record of care and ensures all team members are aware that the dose was held.

Anahtar Kavram

Prioritization and risk reduction for clients receiving cardiac glycosides with borderline vital signs
Tahmini Süre:1m 0s
Soru 2517Soru →

An 81-year-old client was recently admitted for management of acute decompensated heart failure. During the evening shift, the client suddenly becomes extremely agitated, pulls off their continuous positive airway pressure (CPAP) mask, and attempts to climb over the bed rails. Which initial action should the practical nurse (PN) take?

Cevabı ve açıklamayı göster

Cevap: Remain with the client to provide direct supervision, implement verbal reorientation, and assess oxygen saturation levels.

Cevap

The priority action is to remain with the client to provide direct supervision, implement verbal reorientation, and assess for physiological causes of delirium, such as hypoxemia.
The correct action focuses on implementing the least restrictive safety measures first. Staying with the client provides immediate physical protection from a fall without restricting their freedom of movement. Furthermore, assessing oxygen saturation directly addresses a highly probable physiological cause of the sudden delirium, specifically hypoxemia resulting from the removal of the CPAP mask.

Adım Adım Çözüm

1
Analyze the client's clinical presentation and identify the immediate safety risk.
The client is experiencing sudden agitation and delirium, posing an immediate risk for falls and hypoxemia by removing the CPAP mask.
Recognizing the acuity of the behavioral change is essential for prioritizing interventions.
2
Evaluate the proposed interventions against the principle of least restrictive restraints and scope of practice.
Immediate supervision and physiological assessment are non-restrictive and within the PN scope. Restraints are highly restrictive, and delegating assessment is out of scope for an AP.
Standards of care require attempting less restrictive safety measures before resorting to physical restraints.
3
Select the action that provides immediate safety while adhering to practical nursing protocols.
Remaining with the client provides direct safety, prevents injury, and allows for the assessment of underlying causes like hypoxemia.
This approach stabilizes the immediate threat without prematurely applying physical restraints or inappropriately delegating tasks.

Anahtar Kavram

Least Restrictive Interventions and Delirium Assessment
Tahmini Süre:1m 0s
Soru 2518Soru →

A pediatric client weighing 44 lb44\text{ lb} is prescribed oral amoxicillin 300 mg300\text{ mg} every 8 hours8\text{ hours}. The established safe pediatric dosage range for amoxicillin is 20 to 40 mg/kg/day20\text{ to }40\text{ mg/kg/day} in divided doses. The pharmacy dispenses an oral suspension concentrated at 250 mg/5 mL250\text{ mg}/5\text{ mL}. Which action should the practical nurse take?

Cevabı ve açıklamayı göster

Cevap: Withhold the medication and notify the registered nurse that the daily dose exceeds the safe limit.

Cevap

Withhold the medication and notify the registered nurse that the daily dose exceeds the safe limit.
To ensure medication safety, the practical nurse must systematically verify pediatric orders. First, convert the weight: 44 lb÷2.2=20 kg44\text{ lb} \div 2.2 = 20\text{ kg}. Next, calculate the safe daily range: 20 kg×20 mg=400 mg/day20\text{ kg} \times 20\text{ mg} = 400\text{ mg/day}, and 20 kg×40 mg=800 mg/day20\text{ kg} \times 40\text{ mg} = 800\text{ mg/day}. The provider prescribed 300 mg300\text{ mg} every 8 hours8\text{ hours} (which means 33 doses per day). Total daily dose = 300 mg×3=900 mg/day300\text{ mg} \times 3 = 900\text{ mg/day}. Because 900 mg/day900\text{ mg/day} exceeds the absolute maximum safe limit of 800 mg/day800\text{ mg/day}, the nurse cannot safely administer the medication. The correct action is to withhold the dose and immediately notify the RN or prescribing provider.

Adım Adım Çözüm

1
Convert the client's weight from pounds to kilograms.
44 lb÷2.2 lb/kg=20 kg44\text{ lb} \div 2.2\text{ lb/kg} = 20\text{ kg}
Safe pediatric dosages are based on body weight in kilograms.
2
Calculate the safe daily dosage range for this client.
Minimum: 20 kg×20 mg/kg/day=400 mg/day20\text{ kg} \times 20\text{ mg/kg/day} = 400\text{ mg/day}. Maximum: 20 kg×40 mg/kg/day=800 mg/day20\text{ kg} \times 40\text{ mg/kg/day} = 800\text{ mg/day}.
This establishes the safe parameters to compare against the provider's prescription.
3
Calculate the total daily dose prescribed by the provider.
300 mg×3 doses/day(every8hours)=900 mg/day300\text{ mg} \times 3\text{ doses/day} (every 8 hours) = 900\text{ mg/day}.
The prescribed daily amount must be determined to verify safety.
4
Compare the prescribed dose to the safe range and determine the appropriate action.
900 mg/day900\text{ mg/day} is greater than the maximum safe limit of 800 mg/day800\text{ mg/day}. The medication must be withheld.
Administering a dose that exceeds established safe limits is outside the scope of practice and risks patient harm.

Anahtar Kavram

Pediatric Dosage Verification and Medication Safety
Soru 2519Soru →

A practical nurse (PN) is assigned to care for an adult client on a medical-surgical unit who is scheduled for an elective procedure. The healthcare provider has already discussed the procedure with the client. Which actions are within the PN's scope of practice regarding the informed consent process? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Serving as a witness to confirm that the client voluntarily signed the consent document.; Notifying the healthcare provider if the client asks new questions regarding alternative treatments.; Ensuring the client has not received preoperative opioid analgesics prior to signing the document.

Cevap

The correct actions include serving as a witness to the signature, notifying the provider if the client has questions about alternatives, and ensuring the client has not received mind-altering medications before signing.
The PN scope of practice regarding informed consent is strictly limited to advocacy and witnessing. The PN ensures the client is in a competent state (free from sedating medications), verifies the signature is voluntary, and pauses the process to contact the provider if the client expresses any lack of understanding about the procedure, risks, or alternatives.

Adım Adım Çözüm

1
Analyze the role of the practical nurse (PN) in the informed consent process.
The PN acts as a witness and advocate, not the primary educator for the procedure.
The healthcare provider who performs the procedure is legally responsible for explaining the risks, benefits, and alternatives.
2
Evaluate the correct options based on the PN scope of practice.
Witnessing the signature, verifying the client is unmedicated with opioids, and notifying the provider of unresolved questions are appropriate nursing actions.
These actions ensure the client's safety and legal rights are protected without overstepping the PN's scope.
3
Identify the incorrect options that fall outside the PN scope of practice.
Explaining surgical risks, detailing anatomical steps, and evaluating legal competency are incorrect.
Explaining risks and procedures belongs to the provider, while formal assessment of competency requires RN or provider-level clinical judgment.

Anahtar Kavram

The practical nurse's role in informed consent is limited to witnessing the client's voluntary signature, ensuring the client is competent (e.g., unmedicated), and acting as an advocate by notifying the provider if the client lacks understanding.
Tahmini Süre:1m 30s
Soru 2520Soru →

A 65-year-old client is receiving inpatient care for the management of hypertension and angina. The medication administration record indicates a scheduled dose of oral diltiazem 60 mg60\text{ mg}. Prior to giving the medication, the practical nurse (PN) obtains a heart rate of 52 beats/min and a blood pressure of 94/56 mmHg94/56\text{ mmHg}. The client reports feeling lightheaded when attempting to sit on the edge of the bed. Which action is the priority for the PN?

Cevabı ve açıklamayı göster

Cevap: Withhold the scheduled diltiazem dose and immediately communicate the client's vital signs and symptoms to the registered nurse.

Cevap

The priority action is to withhold the scheduled dose of diltiazem and immediately notify the registered nurse of the client's vital signs and symptoms.
Diltiazem is a calcium channel blocker utilized to manage hypertension and angina by relaxing blood vessels and slowing the heart rate. Because the client is currently exhibiting symptomatic bradycardia (a heart rate of 52 beats/min) and hypotension (a blood pressure of 94/56 mmHg94/56\text{ mmHg} with lightheadedness), administering this medication could precipitate a dangerous cardiovascular collapse. The practical nurse's priority is to ensure client safety by withholding the dose and immediately escalating the assessment findings to the registered nurse for further clinical evaluation.

Adım Adım Çözüm

1
Evaluate the client's vital signs and reported symptoms prior to medication administration.
The client has a heart rate of 52 beats/min (bradycardia), a blood pressure of 94/56 mmHg94/56\text{ mmHg} (hypotension), and reports lightheadedness.
Diltiazem is a calcium channel blocker that therapeutically lowers heart rate and blood pressure, making pre-administration assessment essential.
2
Determine the appropriate clinical intervention based on the assessment findings.
The medication must be withheld.
Administering a calcium channel blocker to a client who is already hypotensive, bradycardic, and symptomatic can cause severe cardiovascular compromise.
3
Identify the proper chain of command and scope of practice for the practical nurse.
The findings must be immediately reported to the registered nurse.
The registered nurse must evaluate the client's deteriorating condition and coordinate advanced interventions, as treatments like intravenous push medications are outside the practical nurse's scope.

Anahtar Kavram

Recognizing adverse cardiovascular effects and pre-administration holding parameters for calcium channel blockers.
ÖncekiSayfa 126 / 147Sonraki
Tüm alıştırma soruları — NCLEX-PN | Examkin