Tüm alıştırma soruları

2933 soru

Soru 2741Soru →

A practical nurse (PN) is preparing to administer 8 units of regular insulin and 14 units of NPH insulin subcutaneously to a client with diabetes mellitus. In which order should the PN perform the following steps to prepare the medication? Arrange the actions in the correct sequence from first to last.

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Cevap

The correct sequence for mixing insulins is: roll the NPH vial, inject air into the NPH vial, inject air into the regular insulin vial, withdraw the regular insulin, and finally withdraw the NPH insulin.
To safely mix regular and NPH insulin, the nurse must follow the 'clear before cloudy' sequence to prevent contaminating the rapid-acting regular insulin with the longer-acting NPH insulin. The sequence involves preparing the suspension, pressurizing both vials (starting with NPH), and then withdrawing the insulins (starting with regular).

Adım Adım Çözüm

1
Roll the NPH insulin vial gently between the palms.
The suspension is evenly mixed without creating air bubbles.
NPH insulin settles when standing and must be resuspended to ensure an accurate dose.
2
Inject air equal to the prescribed dose into the NPH insulin vial.
The NPH vial is pressurized.
Injecting air prevents a vacuum. This is done first so the needle does not carry regular insulin into the NPH vial.
3
Inject air equal to the prescribed dose into the regular insulin vial.
The regular insulin vial is pressurized.
This prepares the vial for immediate withdrawal of the medication without creating a vacuum.
4
Withdraw the prescribed dose of regular insulin from its vial.
The regular insulin is drawn into the syringe.
Regular insulin (clear) is drawn first to prevent it from being contaminated by the NPH insulin (cloudy).
5
Withdraw the prescribed dose of NPH insulin from its vial.
Both insulins are accurately mixed in the syringe.
NPH is drawn last because any excess cannot be injected back into the vial without contaminating it with regular insulin.

Anahtar Kavram

Safe medication preparation: mixing clear (regular) and cloudy (NPH) insulins in a single syringe.
Soru 2742Soru →

A practical nurse is caring for a client who returned to the surgical unit 4 hours ago following a right-sided modified radical mastectomy with axillary lymph node dissection. Which actions should the nurse include in the client's basic care and comfort plan? Select all that apply.

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Cevap: Elevate the client's right arm on a pillow to promote fluid drainage.; Maintain the head of the bed in a semi-Fowler's position.; Encourage the client to perform gentle finger and wrist exercises on the right side.

Cevap

The correct actions are elevating the right arm on a pillow, maintaining the head of the bed in a semi-Fowler's position, and encouraging gentle finger and wrist exercises on the affected side.
Basic care and comfort following a mastectomy with axillary node dissection focuses on preventing lymphedema, maintaining proper body alignment, and promoting safe circulation. Elevating the affected arm on a pillow utilizes gravity to promote lymphatic and venous drainage. A semi-Fowler's position improves respiratory excursion and general comfort while reducing tension on the chest wall incision. Additionally, guiding the client through gentle distal range-of-motion exercises (finger and wrist) enhances circulation and prevents joint stiffness without risking injury to the primary surgical site.

Adım Adım Çözüm

1
Analyze the client's specific surgical procedure and recovery needs.
The client had a right-sided mastectomy with axillary lymph node dissection, indicating a high risk for lymphedema and compromised circulation on the right side.
Understanding the anatomical impact of the surgery identifies the need for specialized positioning and mobility precautions.
2
Evaluate the positioning and mobility interventions for safety and comfort.
Elevating the right arm, raising the head of the bed, and performing distal hand exercises are appropriate basic care measures.
These actions promote venous return, reduce dependent edema, and maintain joint mobility without placing undue stress on the surgical incision.
3
Identify contraindicated or unsafe actions in the distractors.
Lying on the operative right side, giving fluids to a groggy supine patient, and using false reassurance are incorrect and potentially harmful.
These actions compromise local tissue circulation, threaten airway safety, and block therapeutic communication.

Anahtar Kavram

Post-Mastectomy Basic Care and Positioning
Soru 2743Soru →

A practical nurse (PN) is preparing to perform tracheostomy suctioning for a pediatric client diagnosed with Respiratory Syncytial Virus (RSV). The facility's infection control protocol requires full personal protective equipment (PPE) due to contact and droplet precautions, as well as the high risk of splashing respiratory secretions. Arrange the steps for donning the necessary PPE in the correct sequence according to the Centers for Disease Control and Prevention (CDC).

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Cevap

The correct sequence for donning PPE is: perform hand hygiene, put on the isolation gown, apply the surgical mask, place the goggles or face shield, and finally don the examination gloves.
According to the Centers for Disease Control and Prevention (CDC), the standard sequence for donning personal protective equipment (PPE) maintains the cleanliness of the equipment and ensures a continuous protective barrier. Hand hygiene must always be performed first. The gown is donned next as it covers the largest area. The mask is applied to protect the airway, followed by eye protection which often rests slightly over the top of the mask. Finally, gloves are donned last and must be pulled completely over the gown cuffs to ensure no skin is exposed at the wrists.

Adım Adım Çözüm

1
Perform hand hygiene using an alcohol-based hand rub or antimicrobial soap.
Hands are clean and ready to handle clean PPE without transferring pathogens.
Hand hygiene removes surface microorganisms before touching clean equipment.
2
Put on the isolation gown and fasten the ties securely at the neck and back.
The torso and arms are protected with a barrier.
The gown is the largest piece of equipment and must be placed first so gloves can later overlap its cuffs.
3
Apply a surgical mask and fit the flexible band securely to the bridge of the nose.
The nose and mouth are protected from infectious droplets.
The mask must be secured directly to the face for a proper fit before eye protection is added.
4
Place goggles or a face shield comfortably over the eyes and face.
The mucous membranes of the eyes are protected from potential splashes.
Eye protection rests over the edges of the mask, so it must be applied after the mask.
5
Don clean examination gloves, ensuring they extend over the cuffs of the gown.
The hands are protected and a continuous barrier is formed at the wrists.
Gloves are donned last to keep them clean for client contact and must cover the gown cuffs to prevent skin exposure.

Anahtar Kavram

The Centers for Disease Control and Prevention (CDC) sequence for donning personal protective equipment is designed to ensure maximum protection and prevent contamination of the equipment before providing care.
Soru 2744Soru →

A practical nurse (PN) discovers a client with type 1 diabetes mellitus unresponsive in bed. The client is profusely diaphoretic, and a stat capillary blood glucose reading is 34 mg/dL34 \text{ mg/dL} (1.9 mmol/L1.9 \text{ mmol/L}). The client does not have established intravenous (IV) access. Arrange the following emergency interventions in the safest priority sequence from first to last.

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Cevap

The correct sequence is to first administer IM glucagon, immediately position the client on their side to protect the airway, recheck the glucose in 15 minutes, assess the gag reflex upon awakening, and finally provide an oral snack once safe swallowing is confirmed.
In severe hypoglycemia where the client is unresponsive and lacks IV access, the immediate priority is raising the blood glucose using IM glucagon. Because glucagon frequently causes nausea and vomiting, the client must be immediately turned to a lateral side-lying position to prevent aspiration while they remain unconscious. Once the airway is physically protected, the PN follows the 'rule of 15' by rechecking the capillary blood glucose 15 minutes post-intervention. As the client regains consciousness, the PN must assess their gag reflex and swallowing ability to ensure oral intake is physically safe. Finally, providing a complex carbohydrate and protein snack is necessary to replenish hepatic glycogen stores and prevent a subsequent drop in blood glucose, as glucagon's metabolic effects are short-lived.

Adım Adım Çözüm

1
Treat the immediate life-threatening physiological deficit.
Administer the prescribed IM glucagon.
The client is unresponsive without IV access, making oral glucose contraindicated and IV dextrose impossible. IM glucagon is the fastest available and safest treatment method.
2
Anticipate adverse effects and protect the airway.
Place the client in a lateral side-lying position.
A frequent and dangerous adverse effect of glucagon is emesis. The recovery position prevents aspiration if vomiting occurs while the client is still unresponsive.
3
Evaluate the clinical response to the intervention.
Recheck the capillary blood glucose level in 1515 minutes.
Standard hypoglycemia protocols require reassessment 15 minutes after treatment to ensure the blood glucose is trending upward toward a safe range.
4
Assess readiness for safe oral intake.
Verify the gag reflex and swallowing ability.
Before providing sustained nutritional support by mouth, the nurse must ensure the client is alert enough to eat and will not aspirate the intake.
5
Prevent rebound physiological instability.
Provide a complex carbohydrate and protein snack.
Glucagon has a short duration of action. A mixed macronutrient snack provides sustained glucose release to prevent a secondary hypoglycemic event.

Anahtar Kavram

Management of severe hypoglycemia with IM glucagon requires immediate airway protection due to the high risk of treatment-induced emesis, followed by strict protocol reassessment.
Soru 2745Soru →

A client weighing 198 lb198\text{ lb} is prescribed enoxaparin sodium 1 mg/kg1\text{ mg/kg} subcutaneously every 12 hours for the treatment of a deep vein thrombosis. The medication is supplied as a prefilled syringe containing 120 mg120\text{ mg} in 0.8 mL0.8\text{ mL}. How many milliliters (mL\text{mL}) should the practical nurse administer for a single dose?

(Record the answer to the nearest tenth. Do not include units in the answer.)

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Cevap: 0.6

Cevap

0.6
To determine the correct volume to administer, the nurse must first convert the client's weight to kilograms: 198 lb÷2.2=90 kg198\text{ lb} \div 2.2 = 90\text{ kg}. Next, the desired dose is calculated by multiplying the weight by the prescribed amount: 90 kg×1 mg/kg=90 mg90\text{ kg} \times 1\text{ mg/kg} = 90\text{ mg}. Finally, the volume is calculated using the formula (Desired / Have) ×\times Volume: (90 mg÷120 mg)×0.8 mL=0.6 mL(90\text{ mg} \div 120\text{ mg}) \times 0.8\text{ mL} = 0.6\text{ mL}.

Adım Adım Çözüm

1
Convert the client's weight from pounds to kilograms
90 kg
The medication is prescribed based on the client's weight in kilograms.
2
Calculate the total required dose per administration
90 mg
Multiply the client's weight in kilograms by the prescribed dosage of 1 mg/kg.
3
Determine the liquid volume to administer
0.6 mL
Divide the desired dose (90 mg) by the available concentration (120 mg), then multiply by the supplied volume (0.8 mL).

Anahtar Kavram

Weight-based parenteral medication dosage calculation
Soru 2746Soru →

A practical nurse (PN) is collecting data on an 82-year-old client who is 24 hours postoperative following an open cholecystectomy. Which of the following assessment findings should the PN report to the registered nurse (RN) immediately? (Select all that apply.)

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Cevap: The client suddenly does not recognize family members and attempts to pull out the intravenous (IV) line.; Heart rate of 114 beats/min with a blood pressure of 98/64 mm Hg.; Urine output of 45 mL collected in the indwelling catheter bag over the past 2 hours.

Cevap

The correct findings to report immediately are sudden confusion, a heart rate of 114 beats/min with blood pressure of 98/64 mm Hg, and a urine output of 45 mL over 2 hours.
The correct options represent acute, life-threatening changes indicating physiological decompensation. Sudden confusion in an older adult is frequently an early sign of hypoxia or systemic infection. A heart rate of 114 beats/min with a blood pressure of 98/64 mm Hg represents borderline vital signs that are early compensatory mechanisms for hypovolemic shock or internal bleeding. A urine output of 45 mL over 2 hours (averaging less than 30 mL/hr) indicates severely compromised organ perfusion. These findings require immediate RN notification to prevent further clinical deterioration.

Adım Adım Çözüm

1
Analyze the clinical context and the client's risk factors.
The client is an 82-year-old adult, 24 hours post-abdominal surgery, placing them at high risk for complications like hemorrhage, fluid volume deficit, and hypoxia.
Establishing the postoperative timeframe and age-related risks helps differentiate expected recovery signs from acute decompensation.
2
Evaluate each assessment finding using the Airway, Breathing, Circulation (ABC) prioritization framework.
Sudden confusion (hypoxia indicator), tachycardia with borderline hypotension (shock indicator), and oliguria (poor perfusion) are all critical ABC threats.
Life-threatening physiological changes must be escalated to the RN immediately to prevent irreversible organ damage.
3
Identify and exclude expected or non-emergent findings.
Incisional pain, a small amount of dark surgical drainage, and discharge anxiety are expected or stable findings for this postoperative stage.
Expected findings require routine nursing care and documentation but do not require emergency escalation over active physiological deterioration.

Anahtar Kavram

Recognizing early signs of physiological decompensation and shock in postoperative older adults.
Soru 2747Soru →

An adult client has returned to the surgical unit after undergoing a lumbar laminectomy. The practical nurse is providing basic care and comfort measures. Which of the following actions should the nurse implement when turning and positioning this client? Select all that apply.

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Cevap: Logroll the client using a draw sheet and the assistance of another staff member.; Place a pillow between the client's legs prior to turning them onto their side.; Maintain the client's spine in a straight alignment at all times during position changes.

Cevap

The nurse should logroll the client with assistance, place a pillow between the client's legs before turning, and maintain the spine in a straight alignment at all times.
Following a lumbar laminectomy, the client's spine must be kept perfectly straight to heal correctly and prevent nerve damage. Logrolling with a draw sheet and another staff member ensures the shoulders and hips move as a single unit. Placing a pillow between the legs prevents spinal rotation when side-lying, and maintaining a straight alignment is the fundamental rule for this procedure.

Adım Adım Çözüm

1
Identify the surgical procedure and its implications for basic care.
The client had a lumbar laminectomy, which involves the lower spine.
Understanding the surgical site is crucial to determine safe mobility and positioning limits.
2
Evaluate each positioning option against the requirement to keep the spine perfectly aligned.
Logrolling, using a pillow between the legs, and keeping the spine straight support alignment. Twisting and sitting upright at 90 degrees compromise alignment.
Any twisting, bending, or excessive pressure on the lumbar spine can cause severe damage to the surgical area.

Anahtar Kavram

Postoperative positioning and mobility for spinal surgery (lumbar laminectomy) require strict maintenance of spinal alignment.
Soru 2748Soru →

A practical nurse (PN) has finished providing care for a client on Airborne and Contact precautions for disseminated herpes zoster. Arrange the following actions for removing personal protective equipment (PPE) in the correct chronological sequence to prevent self-contamination.

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Cevap

The correct sequence is to first remove the gown and gloves together, then remove the face shield, exit the isolation room, remove the N95 respirator in the hallway, and finally perform hand hygiene.
Proper removal (doffing) of PPE is critical to prevent self-contamination and the spread of pathogens. According to standard guidelines for combined Airborne and Contact precautions, the nurse must first remove the most highly contaminated items (the gown and gloves) inside the client's room by peeling them off and rolling them inside-out. Next, the face shield is removed by touching only the clean back straps. Crucially, because the client requires Airborne precautions, the nurse must keep the N95 respirator on until they have completely exited the negative-pressure room and closed the door. Once in the hallway or anteroom, the N95 respirator is removed by the elastic straps to avoid touching the contaminated front. Finally, hand hygiene is performed as the absolute last step to eradicate any residual pathogens picked up during the doffing process.

Adım Adım Çözüm

1
Remove the gown and gloves.
The most contaminated outer layers of PPE are safely discarded inside the room.
Gloves and gowns carry the highest bioburden; rolling them inside-out together contains the pathogens and protects the nurse's uniform.
2
Remove the face shield.
Eye protection is removed without touching the contaminated front.
Handling only the back straps prevents direct transmission of pathogens to the nurse's bare hands.
3
Exit the isolation room.
The nurse leaves the airborne-contaminated environment while still wearing respiratory protection.
The N95 respirator must remain sealed to the face until outside the negative-pressure room to prevent inhalation of suspended infectious particles.
4
Remove the N95 respirator.
The respirator is discarded in a safe area outside the room.
Removing the mask by its straps in the hallway prevents exposure to the airborne pathogen.
5
Perform hand hygiene.
Any residual pathogens on the hands are destroyed.
This is the universal final step to ensure safety and prevent cross-contamination to other clients, staff, or the environment.

Anahtar Kavram

The correct doffing sequence for Airborne and Contact precautions requires removing the most contaminated items (gown, gloves, face shield) inside the room, while retaining the N95 respirator until safely outside the negative-pressure environment.
Soru 2749Soru →

A practical nurse (PN) is caring for a client who is 4 hours post-operative following a partial bowel resection. The client's preoperative blood pressure was 122/76 mm Hg with a heart rate of 74 bpm. Current vital signs are: blood pressure 94/58 mm Hg, heart rate 114 bpm, respiratory rate 20 breaths/min, and temperature 98.8°F (37.1°C). The client reports mild nausea and incisional pain rated as 3 on a 0 to 10 scale. Which action should the PN take first?

Cevabı ve açıklamayı göster

Cevap: Notify the registered nurse (RN) immediately about the changes in the client's vital signs

Cevap

Notify the registered nurse (RN) immediately about the changes in the client's vital signs
The correct answer is to notify the registered nurse immediately because the client is exhibiting classic early signs of hypovolemic shock or internal bleeding (tachycardia and a significant decrease in blood pressure from baseline) just 4 hours after a major abdominal surgery. The PN must prioritize client safety by recognizing these risk factors and escalating the situation to ensure timely medical intervention.

Adım Adım Çözüm

1
Compare current vital signs to the preoperative baseline.
Identified a significant drop in blood pressure and a notable increase in heart rate.
To detect early physiological changes that may indicate a developing postoperative complication.
2
Analyze the findings within the clinical context of a recent bowel resection.
Recognized that new-onset tachycardia and relative hypotension are early indicators of fluid volume deficit, hemorrhage, or shock.
To determine the clinical significance and urgency of the vital sign changes.
3
Determine the priority PN action based on scope of practice and client safety.
Decided to immediately escalate the findings to the supervising RN.
Because managing a potentially hemodynamically unstable client requires RN-level assessment and collaborative intervention to reduce the risk of severe complications.

Anahtar Kavram

Early recognition and escalation of postoperative complications (shock/hemorrhage) within the PN scope of practice.
Soru 2750Soru →

A practical nurse is preparing to transfer a non-weight-bearing client from a bed to a bedside chair using a full-body mechanical lift. As the sling is positioned and the lift is slightly elevated, the client becomes acutely confused, thrashing their arms and attempting to remove the sling loops. Which action should the nurse take?

Cevabı ve açıklamayı göster

Cevap: Lower the lift to return the client's weight to the bed and request additional staff assistance.

Cevap

The correct action is to lower the lift to return the client's weight to the bed and request additional staff assistance.
Safe equipment operation protocols for full-body mechanical lifts dictate that the client must be calm enough to maintain a stable center of gravity. If a client becomes acutely agitated and thrashes while suspended, there is an immediate risk of the sling unhooking or the patient falling out. The absolute priority is patient safety, which requires the nurse to immediately lower the client back onto the stable surface of the bed before taking any further action or attempting to de-escalate the confusion.

Adım Adım Çözüm

1
Identify the immediate equipment safety hazard.
The client is thrashing while suspended in a mechanical lift, which severely alters their center of gravity and creates a high risk of a catastrophic fall or equipment tipping.
Mechanical lifts require the client to be relatively still and cooperative to maintain balance and ensure the sling loops remain securely attached to the lifting hooks.
2
Determine the safest immediate ergonomic intervention.
The nurse must immediately reverse the elevation of the lift.
Lowering the client back onto the bed places them on a stable, secure surface where they cannot fall, neutralizing the immediate physical hazard.
3
Evaluate alternative actions to ensure they do not violate safety protocols.
Proceeding with the lift, delegating operation during an emergency, or applying unauthorized restraints are all ruled out as unsafe.
These actions ignore the acute physical instability of the suspended client and violate safe equipment operation protocols.

Anahtar Kavram

Ergonomics and Safe Use of Equipment
Soru 2751Soru →

During early morning rounds, the practical nurse encounters an older adult client who recently underwent a right femoral-popliteal arterial bypass. The client appears highly agitated, is trying to climb over the raised side rails, and incorrectly believes they are at a train station. The nurse observes that the client's right knee is sharply flexed against the side rail. Which initial action should the nurse prioritize to maintain proper body alignment and ensure client safety?

Cevabı ve açıklamayı göster

Cevap: Carefully reposition the client to the center of the mattress with the right leg fully extended, and remain at the bedside to provide verbal reorientation.

Cevap

Carefully reposition the client to the center of the mattress with the right leg fully extended, and remain at the bedside to provide verbal reorientation.
The correct action addresses two immediate priorities: correcting a body position that threatens the surgical graft and managing acute confusion safely. Following a femoral-popliteal bypass, sharp flexion of the knee or hip is contraindicated because it can compress and occlude the newly placed arterial graft. Extending the leg restores proper body alignment and preserves vital blood flow. Additionally, remaining at the bedside to reorient the client serves as the least restrictive, nonpharmacological intervention for agitation and effectively prevents a potential fall.

Adım Adım Çözüm

1
Analyze the client's surgical history and current physical position.
The client had an arterial bypass. The right knee is sharply flexed, which can restrict arterial blood flow and cause graft failure.
Maintaining proper body alignment and avoiding sharp flexion at the hip or knee is a critical basic care standard for vascular surgery patients.
2
Evaluate the client's psychosocial status and environmental safety.
The client is experiencing acute confusion (delirium) and is at an immediate risk for falls by attempting to climb out of bed.
Sudden disorientation requires immediate nonpharmacological comfort and safety measures, such as constant presence and reorientation.
3
Determine the most appropriate and least restrictive initial intervention.
Repositioning the leg to an extended position protects the graft, while remaining at the bedside provides safety without the use of physical restraints.
Nursing standards require implementing the least restrictive interventions first and avoiding actions that compromise arterial circulation.

Anahtar Kavram

Proper postoperative body alignment and implementation of least restrictive safety measures for acute delirium.
Soru 2752Soru →

A practical nurse is managing the care of a client who has a fractured left ankle and is learning to safely ambulate using axillary crutches. Which of the following observations or actions demonstrate the correct application of ergonomic principles, safe equipment use, and appropriate clinical practice? (Select all that apply)

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: The client maintains a gap of two to three finger widths between the crutch pads and the axillae.; The client supports their body weight entirely on the hand grips rather than resting on the underarms.; The client positions the crutch tips slightly forward and lateral to their feet to create a wide base of support.

Cevap

The correct actions involve the client maintaining a two to three finger width gap below the axillae, supporting their full body weight on the hand grips, and positioning the crutches forward and laterally to establish a wide base of support.
Proper ergonomic use of axillary crutches requires the client to bear weight entirely on the hands and arms, not the axillae, to prevent brachial plexus nerve injury. A gap of two to three finger widths between the axilla and the crutch pad ensures the equipment is fitted safely. Placing the crutch tips slightly forward and to the sides establishes a wide base of support, maximizing stability and preventing falls.

Adım Adım Çözüm

1
Evaluate the client's physical use of the crutches for proper ergonomics and safety.
A gap under the axillae and weight-bearing on the hands prevent brachial plexus nerve damage. A wide base of support prevents falls.
These are fundamental principles of assistive device safety and body mechanics.
2
Analyze the nurse's delegation and communication strategies.
Delegating the initial fitting to an assistive personnel is out of scope. Telling the client not to worry is an example of false reassurance.
Initial assessments require clinical judgment, and non-therapeutic communication invalidates the client's feelings and anxiety regarding the new equipment.
3
Assess the physical positioning of the fractured limb during the activity.
Allowing the injured leg to hang in a dependent position is incorrect.
Dependent positioning increases swelling, pooling of blood, and pain in a recently fractured extremity.

Anahtar Kavram

Ergonomics and Safe Use of Assistive Devices
Tahmini Süre:1m 30s
Soru 2753Soru →

A client diagnosed with active pulmonary tuberculosis and a draining methicillin-resistant *Staphylococcus aureus* (MRSA) leg wound is isolated in a negative-pressure room. After completing a dressing change, the practical nurse must remove an N95 respirator, a face shield, a disposable gown, and gloves. Which action demonstrates the correct procedure to prevent environmental cross-contamination?

Cevabı ve açıklamayı göster

Cevap: Remove the gloves, face shield, and gown inside the isolation room, and remove the N95 respirator after exiting.

Cevap

Remove the gloves, face shield, and gown inside the isolation room, and remove the N95 respirator after exiting.
To prevent the spread of MRSA, the nurse must remove contact precaution PPE (gloves and gown) and standard precaution PPE (face shield) inside the client's room. To prevent exposure to airborne tuberculosis pathogens, the N95 respirator must remain securely in place until the nurse has completely exited the negative-pressure room and closed the door.

Adım Adım Çözüm

1
Identify the transmission-based precautions required for the client's diagnoses.
Airborne precautions (N95) are required for tuberculosis, and contact precautions (gown, gloves) are required for MRSA.
Determining the required precautions dictates the correct doffing procedure and appropriate locations for removal.
2
Determine where to safely remove the contact and standard precaution PPE (gloves, face shield, gown).
These items must be removed inside the client's room before opening the door.
Removing contaminated garments inside the room prevents spreading MRSA and other pathogens into the clean hallway environment.
3
Determine where to safely remove the airborne precaution PPE (N95 respirator).
The respirator must be removed only after exiting the room and closing the door.
The N95 respirator protects against suspended infectious airborne particles, which remain circulating in the negative-pressure room's air.

Anahtar Kavram

Doffing protocols for combined airborne and contact precautions
Soru 2754Soru →

A client is recovering on the telemetry unit four hours after a percutaneous coronary intervention performed through the right femoral artery. When the practical nurse enters the room, the client complains of a new, persistent dull ache in the lower back and right flank. Current vital signs include a heart rate of 106 beats/min and a blood pressure of 104/64 mm Hg, compared to a pre-procedure baseline of 78 beats/min and 126/78 mm Hg. The femoral insertion site dressing remains clean, dry, and intact. Which action should the nurse take first?

Cevabı ve açıklamayı göster

Cevap: Escalate the findings immediately to the registered nurse due to the risk of internal hemorrhage.

Cevap

The correct action is to escalate the findings immediately to the registered nurse due to the risk of internal hemorrhage.
The correct answer identifies the need for immediate escalation. A client who has undergone a femoral cardiac catheterization is at high risk for a retroperitoneal hemorrhage. Because the bleeding occurs internally into the retroperitoneal space, the external femoral dressing will often appear dry and intact. The classic signs of this severe complication are new-onset lower back or flank pain, accompanied by early signs of hypovolemic shock, such as an increasing heart rate and a decreasing blood pressure. The practical nurse must recognize this acute physiological deterioration and immediately escalate the findings to the registered nurse or provider for rapid intervention.

Adım Adım Çözüm

1
Analyze the client's history and current symptoms.
The client had a right femoral artery procedure and now has new right flank and back pain.
Identifying the procedure type helps anticipate specific complications, such as retroperitoneal bleeding.
2
Evaluate the vital sign trends against the baseline.
The heart rate has increased from 78 to 106 beats/min, and blood pressure has dropped from 126/78 to 104/64 mm Hg.
Comparing current vitals to baseline reveals early hemodynamic instability and signs of hypovolemic shock.
3
Correlate the physical findings to determine the clinical priority.
Despite a dry external dressing, the combination of flank pain, tachycardia, and hypotension points to internal retroperitoneal hemorrhage.
Internal bleeding is a life-threatening physiological complication that requires immediate medical intervention.
4
Select the nursing action that addresses the highest priority.
The nurse must immediately notify the registered nurse.
The practical nurse scope of practice requires escalating unstable clients and critical complications to the registered nurse for advanced assessment and intervention.

Anahtar Kavram

Recognition of Retroperitoneal Hemorrhage
Soru 2755Soru →

A practical nurse (PN) is caring for a client who suddenly develops acute respiratory distress. The PN prepares to contact the covering healthcare provider using the ISBAR (Identify, Situation, Background, Assessment, Recommendation) communication framework. Place the following statements in the correct order the PN should deliver them.

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Cevabı ve açıklamayı göster

Cevap

The correct sequence follows the ISBAR framework: Identify, Situation, Background, Assessment, and Recommendation.
Effective interprofessional collaboration requires standardized communication to ensure client safety and prevent errors. The ISBAR framework organizes critical information logically. The nurse first identifies themselves and the client. Next, the acute situation (chest pain and dyspnea) is reported to immediately establish urgency. This is followed by the relevant background (DVT and heparin) to provide context. Then, the nurse shares their assessment data (vital signs and clinical impression). Finally, the nurse makes a specific recommendation or request (immediate evaluation) to ensure the client receives timely medical intervention.

Adım Adım Çözüm

1
Identify the communication framework required by the scenario.
The scenario requires the ISBAR format.
ISBAR is the standard evidence-based tool for safe and effective interprofessional collaboration.
2
Select the 'Identify' statement.
The statement introducing the nurse and the client's location.
The receiver must first know who is calling and which client is being discussed to access the correct medical record.
3
Select the 'Situation' statement.
The statement describing the acute chest pain and shortness of breath.
The immediate reason for the call must be stated promptly to capture the receiver's attention and establish urgency.
4
Select the 'Background' statement.
The statement detailing the admission for deep vein thrombosis and current heparin therapy.
Contextual history provides essential information for interpreting the acute situation without providing unnecessary details.
5
Select the 'Assessment' statement.
The statement providing the oxygen saturation data and the suspicion of a pulmonary embolism.
Objective data and the nurse's clinical judgment help quantify the severity of the problem for the provider.
6
Select the 'Recommendation' statement.
The statement requesting an immediate evaluation and potential orders.
The communication must conclude with a clear request for action to ensure immediate client safety and care.

Anahtar Kavram

ISBAR Communication Framework
Soru 2756Soru →

During a bedside assessment, a licensed practical nurse evaluates an adult client who underwent a right-sided thoracentesis earlier in the shift. The client suddenly reports a sharp, localized chest pain and exhibits a dry, hacking cough. Current vital signs reveal a respiratory rate of 26 breaths per minute, a heart rate of 114 beats per minute, and an oxygen saturation of 90% on room air. Which action should the nurse prioritize?

Cevabı ve açıklamayı göster

Cevap: Alert the supervising registered nurse immediately about the assessment findings.

Cevap

Alert the supervising registered nurse immediately about the assessment findings.
The correct action acknowledges that the client is displaying critical signs of a pneumothorax (hypoxia, tachypnea, tachycardia, sharp pain), a primary and severe complication following a thoracentesis. In the practical nurse's scope of practice, recognizing sudden respiratory deterioration and immediately escalating the findings to the registered nurse or healthcare provider is the essential action to reduce risk and ensure client safety.

Adım Adım Çözüm

1
Analyze the client's clinical presentation and vital signs.
Tachycardia, tachypnea, hypoxia, sharp chest pain, and a dry cough following a thoracentesis strongly suggest a developing pneumothorax.
Identifying patterns of symptoms is required to recognize severe procedural complications early.
2
Determine the priority framework.
Airway and Breathing are actively compromised, requiring immediate medical intervention.
ABC (Airway, Breathing, Circulation) principles dictate that acute respiratory compromise takes precedence over pain management or routine postoperative care.
3
Evaluate the practical nurse's scope of practice for the required intervention.
The practical nurse must escalate these emergent assessment findings to the RN or healthcare provider.
Practical nurses cannot independently prescribe medications or order diagnostic imaging, making prompt escalation the safest and most legally sound action.

Anahtar Kavram

Reduction of Risk Potential: Recognizing Complications of Diagnostic Procedures
Soru 2757Soru →

A practical nurse is assigned to care for a toddler who is newly admitted to the pediatric unit with suspected measles (rubeola). Which infection control interventions should the nurse implement? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Verify that the client is placed in a negative-pressure airborne infection isolation room.; Don a fit-tested N95 respirator before entering the client's room.; Place a standard surgical mask on the client if transport to another department is necessary.

Cevap

The correct interventions include verifying the client is in a negative-pressure isolation room, donning a fit-tested N95 respirator prior to entry, and placing a standard surgical mask on the client during necessary transport.
Measles requires Airborne Precautions. Essential interventions include placing the client in a negative-pressure airborne infection isolation room to prevent infectious air from circulating, wearing a fit-tested N95 respirator to filter out suspended droplet nuclei, and placing a standard surgical mask on the client during transport to contain their outgoing respiratory secretions.

Adım Adım Çözüm

1
Identify the pathogen and the required isolation precautions.
Measles (rubeola) is highly contagious and transmitted via the airborne route, requiring Airborne Precautions.
Airborne Precautions are designed to prevent the spread of infectious droplet nuclei that remain suspended in the air over long distances.
2
Determine the appropriate room assignment and personal protective equipment (PPE).
The client must be placed in a negative-pressure airborne infection isolation room. Staff must don an N95 respirator (or PAPR) before entering the room.
Negative pressure prevents contaminated air from escaping into surrounding areas. An N95 respirator filters out airborne infectious particles that a standard mask cannot block.
3
Identify safety protocols for transport and doffing of PPE.
The client must wear a standard surgical mask when transported outside the room. The nurse must remove the N95 respirator only after exiting the room and closing the door.
The client's mask contains their source respiratory secretions. Removing the N95 outside the isolation room protects the nurse from lingering airborne particles.
4
Differentiate the scope of practice for delegated tasks.
Evaluation of respiratory effort cannot be delegated to an unlicensed assistive personnel (UAP).
Evaluating a client's clinical status requires nursing knowledge and judgment, which strictly falls outside the UAP's scope of practice.

Anahtar Kavram

Airborne Precautions and Scope of Practice
Soru 2758Soru →

A practical nurse (PN) is preparing to administer scheduled medications on a medical-surgical unit. Which actions by the PN demonstrate safe medication administration and adherence to the scope of practice? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Verifying a client's allergy status in the medical record and on their identification band before giving a newly prescribed antibiotic.; Asking the client to state their full name and date of birth while comparing it to the medication administration record (MAR).; Scanning the barcode on the client's identification bracelet and the medication package immediately prior to administration.

Cevap

The correct actions are verifying the client's allergy status, checking the client's stated name and date of birth against the MAR, and scanning the barcode on the identification band and medication package.
Verifying allergies before administering a new antibiotic ensures client safety and prevents adverse reactions. Asking the client to state their name and date of birth provides two distinct, acceptable patient identifiers. Scanning the barcode on the identification band and medication package is a critical technological safeguard that verifies both the 'right patient' and 'right medication'.

Adım Adım Çözüm

1
Evaluate each option against the standard 'rights of medication administration' and LPN/LVN scope of practice.
Identify which actions actively promote client safety and comply with nursing regulations.
Safe pharmacological therapy requires strict adherence to established protocols and legal boundaries.
2
Identify the safe and correct actions.
Verifying allergies, using two distinct client identifiers, and utilizing barcode scanning are all standard, mandated safety practices.
These actions directly prevent medication errors and ensure the right client receives the right medication.
3
Identify the unsafe or incorrect actions.
Leaving medications unattended at the bedside, administering IV push medications, and prematurely rounding calculation steps are incorrect.
These actions violate medication safety rights, increase the risk of dosing errors, and exceed the practical nurse scope of practice.

Anahtar Kavram

Safe Medication Administration and Scope of Practice
Soru 2759Soru →

At the beginning of a shift on a subacute telemetry unit, a licensed practical nurse (LPN) receives a delegated task list from the coordinating registered nurse (RN). The LPN must evaluate each assignment for safety and legal compliance. Identify the task the LPN must decline to perform.

Cevabı ve açıklamayı göster

Cevap: Creating the initial discharge education plan for a client going home with a newly placed continuous positive airway pressure (CPAP) machine.

Cevap

Creating the initial discharge education plan for a client going home with a newly placed continuous positive airway pressure (CPAP) machine.
According to the National Council of State Boards of Nursing (NCSBN) guidelines and standard state practice acts, initiating client education and developing teaching plans are strictly the responsibility of the Registered Nurse (RN). The LPN may reinforce teaching that has already been initiated and documented by the RN, but cannot independently create the initial plan.

Adım Adım Çözüm

1
Analyze the scope of practice limitations for a Licensed Practical Nurse (LPN) regarding the nursing process.
LPNs cannot perform initial comprehensive assessments, develop care plans, or initiate initial client education.
These specific tasks require the comprehensive clinical judgment, synthesis of data, and evaluation skills that are exclusive to a Registered Nurse (RN).
2
Evaluate each delegated task against the established LPN scope boundaries.
Initial education planning is identified as an RN-only responsibility. Witnessing consent, performing sterile dressing changes, and collecting sterile specimens are within the standard LPN scope.
Identifying the task that falls outside the legal scope ensures safe delegation and protects both the client and the nurse's license.

Anahtar Kavram

Licensed Practical Nurse (LPN) Scope of Practice and Delegation Boundaries
Soru 2760Soru →

A practical nurse (PN) is evaluating clients on a medical-surgical unit prior to dispensing scheduled medications. Which of the following clinical scenarios require the PN to withhold the pharmacological therapy and immediately intervene by notifying the registered nurse (RN)? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: A client prescribed oral warfarin for atrial fibrillation who has a recent International Normalized Ratio (INR) of 4.84.8.; A client prescribed oral metoprolol for hypertension who has a heart rate of 105 beats/minute105 \text{ beats/minute} and a blood pressure of 88/54 mm Hg88/54 \text{ mm Hg}.; A provider order directing the PN to administer a one-time intravenous (IV) push dose of bumetanide for a client experiencing fluid volume overload.

Cevap

The correct scenarios requiring the PN to withhold therapy and notify the RN involve the client with a supratherapeutic INR of 4.8, the client with hypotension (blood pressure 88/54 mm Hg) prescribed a beta-blocker, and the order directing the PN to administer an IV push medication.
The PN must recognize situations that compromise client safety or fall outside their legal scope of practice. An INR of 4.8 is significantly elevated above the therapeutic target (typically 2.0-3.0), placing the client at high risk for spontaneous bleeding; the warfarin must be withheld. The client prescribed metoprolol is experiencing significant hypotension (88/54 mm Hg), and administering a beta-blocker could precipitate severe hemodynamic instability or shock. Finally, administering medications via the intravenous (IV) push route is universally outside the scope of practice for a PN, requiring the RN to take over the task.

Adım Adım Çözüm

1
Analyze the client prescribed warfarin.
An INR of 4.8 is supratherapeutic (normal therapeutic range is typically 2.0-3.0 for most indications). Administering warfarin increases the risk of severe hemorrhage.
The PN must withhold the dose and notify the RN to prevent a critical bleeding event.
2
Evaluate the client prescribed metoprolol.
The client has a blood pressure of 88/54 mm Hg, indicating hypotension and potential borderline shock.
Metoprolol is a beta-blocker that will further lower blood pressure and heart rate, so it must be withheld to prevent hemodynamic collapse.
3
Review the IV push bumetanide order.
Administering IV push medications requires RN-level assessment and intervention.
This task is outside the legal scope of practice for a PN, requiring immediate escalation to the RN.
4
Assess the remaining scenarios for safety.
A potassium level of 4.2 mEq/L is normal. Mild arm soreness is an expected vaccine reaction. Using a wristband and barcode for an aphasic client is a standard safe identification method.
These three scenarios represent safe, expected clinical situations where the PN should proceed with medication administration independently.

Anahtar Kavram

Pharmacological safety and PN scope of practice require recognizing critical laboratory values, identifying borderline vital signs indicating potential shock, and escalating tasks requiring RN-level intervention (such as IV push administration).
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