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Soru 2761Soru →

A client who is 2 days postoperative following a left hip arthroplasty requires assistance to move from the bed to a bedside commode. A continuous intravenous (IV) fluid infusion is running via an electronic pump. Which actions should the practical nurse (PN) take to ensure proper body mechanics and safe equipment handling? Select all that apply.

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Cevabı ve açıklamayı göster

Cevap: Apply a gait belt securely around the client's waist prior to beginning the transfer.; Verify that the IV pump is securely attached to a stable pole to prevent tension on the catheter tubing.; Stand with a wide base of support and flex the knees when helping the client to a standing position.

Cevap

The correct actions are applying a gait belt securely, verifying the IV pump is securely attached to a pole, and standing with a wide base of support while flexing the knees.
Applying a gait belt provides a stable handhold for the nurse, improving control over the client's movements. Securing the IV pump to a mobile pole ensures the infusion tubing is not stretched or dislodged during the transfer. Using a wide base of support with flexed knees allows the nurse to rely on strong leg muscles rather than straining the back, demonstrating proper ergonomic principles.

Adım Adım Çözüm

1
Identify the goal and safety requirements of the clinical scenario.
The client needs to transfer to a commode while protecting a surgical hip and managing a continuous IV infusion.
Understanding the client's specific physical limitations and attached equipment dictates the safety measures needed.
2
Evaluate principles of safe body mechanics for the nurse.
The nurse must use a wide base of support and bend at the knees.
These ergonomic actions lower the center of gravity and rely on strong leg muscles, which prevents occupational back injury.
3
Determine safe equipment handling and transfer protocols.
A gait belt must be used for stability, the transfer should be toward the strong side, and the IV pump must be secured to a mobile pole.
Gait belts provide a safe center of control, pivoting toward the strong side protects the surgical hip, and securing devices prevents IV dislodgement.
4
Identify incorrect or unsafe practices among the options.
Transferring toward the operative side, delegating initial mobility assessments to an AP, and using sedatives inappropriately are unsafe.
These actions violate post-operative positioning rules, delegation scope, and restraint guidelines.

Anahtar Kavram

Ergonomics, Patient Handling, and Safe Use of Equipment
Soru 2762Soru →

A practical nurse (PN) is assigned to collect a sterile urine specimen for culture and sensitivity from a client who has a continuous indwelling urinary catheter. Arrange the following nursing actions in the correct chronological order to safely collect the specimen and minimize the risk of complications.

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Cevabı ve açıklamayı göster

Cevap

The correct sequence is to first clamp the tubing to collect fresh urine, then disinfect the port, aspirate the sample with a syringe, transfer it to a sterile container, and finally unclamp the tubing to prevent bladder distension.
Safe and effective collection of a sterile urine specimen requires a logical sequence that prioritizes both infection control and client safety. The tubing is clamped first to gather fresh urine. The port is then sanitized to maintain a sterile barrier. The sample is aspirated and secured in a sterile container. Finally, unclamping the tube immediately after the procedure is a critical risk-reduction step to prevent urinary retention and potential renal injury.

Adım Adım Çözüm

1
Clamp the drainage tubing below the port.
Fresh urine accumulates near the sampling port.
Urine in the drainage bag is stagnant and not suitable for an accurate culture. Clamping ensures fresh urine from the bladder is collected.
2
Disinfect the sampling port with an antiseptic wipe.
The surface of the port is free of microorganisms.
Maintaining the sterile integrity of the closed urinary system is essential to prevent a catheter-associated urinary tract infection (CAUTI).
3
Aspirate urine using a sterile syringe.
The necessary volume of uncontaminated urine is collected.
Using a sterile syringe prevents the introduction of bacteria while safely extracting the sample.
4
Transfer the specimen to a sterile cup.
The sample is safely housed for transport to the laboratory.
The inside of the cup and lid must remain sterile to ensure laboratory results reflect the client's actual flora rather than environmental contaminants.
5
Unclamp the catheter tubing.
Continuous urinary drainage is restored.
Leaving the catheter clamped is a major safety risk that can lead to acute urinary retention, bladder trauma, or kidney damage.

Anahtar Kavram

Sterile Specimen Collection and CAUTI Prevention
Tahmini Süre:1m 30s
Soru 2763Soru →

A practical nurse (PN) is assigned to care for a 78-year-old client who returned to the unit 4 hours ago following a percutaneous coronary intervention (PCI) accessed via the right femoral artery. Which of the following actions by the PN are appropriate to reduce the risk of potential complications? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Instruct the client to maintain the right leg in a straight position and avoid flexing the hip.; Assess the right pedal pulse, color, and temperature of the right foot at prescribed intervals.; Monitor the right groin dressing and surrounding tissue for localized swelling or frank bleeding.

Cevap

The correct actions are instructing the client to keep the leg straight, assessing the pedal pulse and neurovascular status, and monitoring the groin dressing for bleeding.
Maintaining the affected leg in a straight position prevents the dislodgment of the clot at the femoral insertion site. Frequent neurovascular checks of the distal extremity ensure that arterial blood flow is not compromised by a thrombosis. Monitoring the groin dressing directly assesses for external bleeding or subcutaneous hematoma formation, allowing for prompt intervention.

Adım Adım Çözüm

1
Identify the primary risks associated with a femoral artery puncture.
Risks include hemorrhage, retroperitoneal hematoma, and distal arterial occlusion.
Understanding the specific procedural risks guides the selection of appropriate nursing interventions.
2
Evaluate the nursing actions that mitigate these specific risks.
Keeping the leg straight prevents clot disruption, while neurovascular checks and site monitoring detect complications early.
These actions directly address the physiologic risks of the PCI procedure and fall within the PN scope of practice.
3
Analyze the remaining options for safety and scope of practice violations.
Administering IV push medications is out of scope. Ignoring borderline vitals or acute confusion compromises patient safety.
Distractors in NCLEX style questions often test the nurse's ability to recognize limits of practice and early warning signs of deterioration.

Anahtar Kavram

Postoperative nursing care following a femoral access procedure involves strict site immobilization, frequent neurovascular monitoring, and prompt escalation of subtle signs of shock or delirium, while operating strictly within the PN scope of practice.
Soru 2764Soru →

An LPN/VN is preparing to transfer a client who recently underwent an exploratory laparotomy from the bed to a resting chair. To promote comfort and safety, in what order should the nurse execute these steps?

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Cevabı ve açıklamayı göster

Cevap

The correct sequence prioritizes positional adjustment, incisional support, hemodynamic stability, mechanical safety, and finally the physical transfer.
When transferring a postoperative abdominal surgery client, the nurse must first elevate the bed to reduce the effort of moving. Next, splinting the incision is required to protect the wound during the exertion of sitting up. Once supported, the client sits on the edge of the bed to allow their blood pressure to stabilize (preventing orthostatic hypotension). After stability is confirmed, the nurse applies the gait belt for a secure grip before finally assisting the client to stand and pivot into the chair.

Adım Adım Çözüm

1
Elevate the head of the bed.
The client is moved into an upright position.
Decreases the physical work of moving against gravity from a flat position.
2
Have the client splint the incision.
The abdominal wound is supported.
Prevents wound dehiscence and manages pain before the core is stressed.
3
Assist to sit and dangle legs.
The client sits safely on the edge of the bed.
Prevents orthostatic hypotension after periods of bed rest.
4
Apply the transfer gait belt.
Safety equipment is in place.
Provides a secure hold for the nurse once the client is upright and stable.
5
Stand, pivot, and sit in the chair.
The transfer is completed safely.
Moves the client to the destination while minimizing fall risk.

Anahtar Kavram

Safe postoperative mobility transfers and incisional care
Soru 2765Soru →

While conducting afternoon rounds on a medical unit, a nurse observes a 68-year-old client who was previously fully oriented now suddenly attempting to climb over the bed rails and forcefully tugging at an indwelling urinary catheter. An assistive personnel in the room offers to quickly apply soft wrist restraints to prevent immediate self-injury. What is the most appropriate priority action for the nurse to take?

Cevabı ve açıklamayı göster

Cevap: Conduct a rapid physical assessment including vital signs to identify a physiological cause for the sudden agitation.

Cevap

Conduct a rapid physical assessment including vital signs to identify a physiological cause for the sudden agitation.
The correct action prioritizes the nursing process by emphasizing assessment before intervention. Sudden onset of confusion and agitation in an older adult is a hallmark sign of delirium, often caused by a physiological issue such as hypoxia, a urinary tract infection, or medication effects. The nurse must first gather data to identify and treat the underlying cause using the least restrictive approach. Implementing restraints without an assessment increases the risk of client injury and fails to resolve the root cause.

Adım Adım Çözüm

1
Recognize the sudden onset of confusion and agitation as a potential sign of acute delirium rather than normal aging.
Identifies the immediate need to investigate underlying physiological causes.
Sudden behavioral changes in older adults are often triggered by acute medical issues such as hypoxia, infection, or electrolyte imbalances.
2
Evaluate the assistive personnel's suggestion to use restraints.
Determines that applying restraints is inappropriate at this stage.
Restraints are a measure of last resort and must only be used after all other less restrictive alternatives have been exhausted, as they can exacerbate agitation and lead to further injury.
3
Prioritize the initial nursing intervention based on the nursing process.
Selects physical assessment as the priority action over immediate intervention or delegation.
Data collection must precede intervention. Identifying a reversible cause allows for targeted treatment without the use of restrictive devices or unsafe practices.

Anahtar Kavram

Prioritizing the nursing process (assessment first), utilizing least restrictive interventions, and recognizing signs of delirium to prevent client injury.
Soru 2766Soru →

A practical nurse (PN) is working at the central station of a medical-surgical unit. An off-duty nurse from the maternity ward approaches and says, "I heard my cousin was admitted to this unit last night. How is he doing?" Which response by the PN is the most appropriate?

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Cevap: "I cannot share any client information with personnel who are not directly involved in the client's care."

Cevap

The response stating that client information cannot be shared with personnel not directly involved in the client's care is the most appropriate action.
The correct response directly upholds the core principles of confidentiality. Under HIPAA regulations, nurses and other healthcare providers are legally and ethically obligated to protect client information. Disclosing any information—even to another hospital employee or a family member—is strictly prohibited unless that person is directly involved in the client's care or the client has provided explicit, documented authorization.

Adım Adım Çözüm

1
Identify the requester's relationship to the client and their role in the facility.
The requester is a relative (cousin) and an off-duty employee, but is not part of the client's active treatment team.
HIPAA and facility policies dictate that protected health information (PHI) can only be shared with staff on a strictly 'need-to-know' basis for treatment, payment, or healthcare operations.
2
Determine the appropriate legal boundary regarding the request.
The PN must refuse to disclose any information, including confirming or denying the client's status or presence.
Providing any clinical update, even basic or general information, constitutes an unauthorized disclosure of PHI.
3
Select the response that professionally enforces the confidentiality policy without utilizing non-therapeutic communication.
The correct action is to clearly and objectively state that information cannot be shared with uninvolved personnel.
This establishes a firm professional boundary, protects the client's privacy, and aligns with standard nursing practice and legal regulations.

Anahtar Kavram

Under the Health Insurance Portability and Accountability Act (HIPAA), healthcare personnel may only access or receive protected health information (PHI) if they are directly involved in the client's care. Being a hospital employee or a relative does not grant automatic access to a client's medical information.
Soru 2767Soru →

A practical nurse is caring for a client who underwent a diagnostic cardiac catheterization via the right femoral artery 2 hours ago. The client is on prescribed strict bed rest and reports intense lower back discomfort from lying completely flat. Which action should the practical nurse take to promote the client's comfort?

Cevabı ve açıklamayı göster

Cevap: Assist the client to turn onto their left side while maintaining the right leg in a straight, neutral position.

Cevap

The correct intervention is to assist the client to turn onto their left side while maintaining the right leg in a straight, neutral position.
Following a femoral cardiac catheterization, the affected extremity must remain completely straight to prevent disruption of the arterial clot and subsequent bleeding or hematoma formation. Turning the client onto the unaffected (left) side while keeping the affected (right) leg straight is an effective comfort measure that relieves pressure on the lumbar spine without compromising the insertion site.

Adım Adım Çözüm

1
Identify the critical post-procedure constraints for a femoral cardiac catheterization.
The client must remain on bed rest with the affected leg (right leg) completely straight and immobilized.
Arterial punctures are under high pressure, and flexing the hip can dislodge the clot, causing a hematoma or hemorrhage.
2
Evaluate the client's request for back pain relief against these safety constraints.
The client needs a position change that relieves lumbar pressure without flexing the right hip.
Lying completely flat causes muscle tension in the lower back, requiring a safe nursing intervention for comfort.
3
Determine the safest basic care positioning intervention.
Turning the client to the unaffected (left) side while keeping the right leg extended is the best approach.
This shifts body weight off the sacrum and lumbar spine while maintaining the required straight alignment of the femoral insertion site.

Anahtar Kavram

Safe positioning and comfort measures following femoral artery access
Soru 2768Soru →

An 80-year-old client is recovering on the surgical unit two days after a colon resection. During a routine check, the practical nurse (PN) notes the client is restless, repeatedly attempting to remove their intravenous (IV) line, and has difficulty focusing on questions. The client's current vital signs are: heart rate 114 bpm, blood pressure 104/62 mm Hg (baseline 138/76 mm Hg), and respiratory rate 22 breaths/minute. Which action should the PN take first?

Cevabı ve açıklamayı göster

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

Cevap

Notify the registered nurse (RN) immediately regarding the changes in vital signs and mental status.
The client is displaying a classic triad of early shock or physiological decompensation: altered mental status (restlessness/confusion), tachycardia, and hypotension relative to baseline. In the practical nursing scope of practice, the recognition of an acute, potentially life-threatening change in client condition requires immediate escalation to the registered nurse or healthcare provider to prevent further deterioration.

Adım Adım Çözüm

1
Analyze the client's vital signs and compare them to the baseline.
The heart rate is elevated (114 bpm) and the blood pressure is notably decreased (104/62 mm Hg) compared to the client's baseline (138/76 mm Hg), indicating potential circulatory compromise or shock.
Identifying trends and deviations from baseline is critical for recognizing early physiological deterioration.
2
Evaluate the new-onset behavioral changes in the context of the physical assessment.
The restlessness, pulling at lines, and inability to focus, when combined with the abnormal vital signs, suggest decreased cerebral perfusion (hypoxia or shock), not just typical delirium.
Altered mental status is often the earliest sign of impaired oxygenation or circulation in older adults.
3
Determine the priority action within the practical nurse (PN) scope of practice.
The PN must recognize the acute physiological instability and immediately escalate the findings to the RN.
When a client exhibits signs of acute decompensation, the immediate priority is to collaborate with the RN/provider to initiate life-saving interventions.

Anahtar Kavram

Recognizing Early Signs of Shock and Acute Deterioration
Soru 2769Soru →

An ambulatory care client has just been transferred to the short-stay surgical unit following a right eye cataract extraction. As the practical nurse assists the client into bed for the recovery period, which of the following positions is most appropriate to promote comfort and prevent postoperative complications?

Cevabı ve açıklamayı göster

Cevap: Positioned on the left side with the head of the bed elevated 30 degrees

Cevap

Positioned on the left side with the head of the bed elevated 30 degrees
The most appropriate position following cataract surgery is to have the head of the bed elevated (Semi-Fowler's position) and the client resting on the non-operative side or back. Elevating the head to 30 degrees promotes venous drainage from the head, thereby reducing intraocular pressure. Placing the client on the left side protects the right eye (the operative side) from direct pressure and accidental injury.

Adım Adım Çözüm

1
Identify the surgical procedure and the operative side from the scenario.
The client underwent a cataract extraction on the right eye.
Knowing the operative side is crucial for determining safe postoperative positioning.
2
Recall the principles of positioning after cataract surgery.
The goal is to decrease intraocular pressure (IOP) and protect the surgical site. This is achieved by elevating the head of the bed and avoiding pressure on the operative eye.
Increased IOP can cause severe complications, including hemorrhage or suture rupture.
3
Evaluate the given positions against these safety principles.
Positioning on the unoperated (left) side with the head elevated is the only option that minimizes IOP and avoids direct pressure on the right eye.
Other positions either place pressure on the operative side or fail to use gravity to reduce ocular pressure.

Anahtar Kavram

Postoperative Positioning for Cataract Surgery
Soru 2770Soru →

A practical nurse (PN) is assisting in the preoperative staging area. A client scheduled for an elective cholecystectomy has already signed the surgical consent form. While the PN is taking vital signs, the client states, 'I cannot do this. I have decided to cancel the surgery.' Arrange the following actions in the chronological order the PN should perform them.

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Cevap

The correct sequence is to first assess and clarify the client's intent, then halt the preoperative preparation, subsequently notify the surgeon and RN, and finally document the event in the medical record.
When a client revokes consent, the practical nurse must follow the nursing process. Assessment comes first to clarify the client's statement and ensure they mean to cancel. Next, implementation ensures immediate safety by stopping all preparations and holding sedatives. Then, communication ensures the provider is aware, as the surgeon must speak with the client. Finally, accurate documentation provides a permanent legal record of the client's decision.

Adım Adım Çözüm

1
Clarify the client's intent using open-ended questions.
The nurse confirms whether the client is formally withdrawing consent or simply expressing anxiety.
Assessment is always the foundational first step in the nursing process before any intervention occurs.
2
Halt preparation and withhold preoperative sedatives.
The client's safety and autonomy are maintained.
Administering a preoperative sedative to a client who has stated they do not want the surgery violates their right to refuse treatment.
3
Notify the surgeon and the supervising RN.
The chain of command and the responsible healthcare provider are informed.
The surgeon owns the informed consent process and is legally responsible for discussing the risks of refusing the procedure with the client.
4
Document the event in the medical record.
A chronological, legal record is established.
Objective documentation protects the client's rights and the facility from liability by proving that the refusal was properly handled.

Anahtar Kavram

A competent client has the right to revoke informed consent at any time; the nurse must assess the refusal, ensure client safety, notify the provider, and document the event.
Soru 2771Soru →

A practical nurse (PN) is assigned to care for a client who had a total knee arthroplasty 2424 hours ago and is receiving subcutaneous enoxaparin. While reviewing morning data and preparing for care, which of the following findings should the PN prioritize and report immediately to the registered nurse (RN)?

Cevabı ve açıklamayı göster

Cevap: A morning hemoglobin level of 7.4 g/dL7.4\text{ g/dL} (74 g/L74\text{ g/L}), a significant decrease from the previous day's result of 12.8 g/dL12.8\text{ g/dL} (128 g/L128\text{ g/L}).

Cevap

The significant decrease in the hemoglobin level must be reported immediately.
The correct answer identifies a severe drop in hemoglobin, which is a critical laboratory finding indicating potential internal hemorrhage. Because the client had major surgery and is on an anticoagulant, the practical nurse must immediately escalate this finding to the registered nurse so that the anticoagulant can be held and treatments (such as a blood transfusion) can be initiated.

Adım Adım Çözüm

1
Analyze the client's clinical scenario and associated risks.
The client recently underwent major orthopedic surgery and is receiving an anticoagulant (enoxaparin), placing them at a high risk for postoperative bleeding.
Identifying the client's primary physiological risks directs the nurse to look for specific complications.
2
Evaluate each assessment finding against expected baseline data and LPN scope of practice.
The vital signs are normal, the ID band issue is a routine safety hurdle, and the care plan modification is a non-urgent RN task. The hemoglobin drop is the only critical, life-threatening finding.
Prioritization requires distinguishing between stable/expected findings, procedural tasks, and acute physiological deterioration.

Anahtar Kavram

Prioritizing Critical Laboratory Values in Postoperative Care
Soru 2772Soru →

The unit coordinator is distributing client assignments to nursing staff on an acute medical-surgical floor. Which assigned client situation should prompt a practical nurse (PN) to immediately request an assignment change from the supervising registered nurse (RN)?

Cevabı ve açıklamayı göster

Cevap: A newly admitted client presenting with an acute asthma exacerbation who requires an initial comprehensive assessment and care plan development.

Cevap

The practical nurse must decline the assignment for the newly admitted client presenting with an acute asthma exacerbation who requires an initial comprehensive assessment.
The correct answer identifies a newly admitted client with an acute condition requiring a comprehensive assessment. The practical nursing scope of practice dictates that PNs care for stable clients with predictable outcomes. Initial comprehensive assessments and the development of initial care plans require the advanced clinical judgment of a registered nurse and cannot be delegated to a PN.

Adım Adım Çözüm

1
Analyze the practical nurse scope of practice regarding assessments, client stability, and care planning.
Practical nurses are legally permitted to care for stable clients with predictable outcomes and perform focused, ongoing data collection rather than comprehensive assessments.
To determine the legal and safety boundaries for accepting a client care assignment.
2
Evaluate each assigned client for complexity, stability, and required nursing interventions.
The newly admitted client is unstable and requires an initial comprehensive assessment, which must be performed by an RN. The other clients require routine tasks (witnessing a signature, reinforcing education, and administering oral medications) that are within the PN scope.
To identify which specific assignment exceeds the practical nurse's legal scope of practice and requires escalation.

Anahtar Kavram

Delegation and Scope of Practice for the Practical Nurse
Soru 2773Soru →

A practical nurse (PN) is caring for an older adult client who is receiving treatment for a urinary tract infection (UTI). Which assessment findings indicate a potential systemic complication that requires immediate reporting to the registered nurse (RN)? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Blood pressure decreasing from 134/82 mm Hg to 90/58 mm Hg; Heart rate increasing from 78 to 116 beats/minute; New onset of acute confusion and agitation

Cevap

The findings that require immediate reporting are a blood pressure drop to 90/58 mm Hg, a heart rate increase to 116 beats/minute, and a new onset of acute confusion.
A significant drop in blood pressure, an increasing heart rate, and new onset of confusion are clinical indicators of physiological decompensation, specifically systemic infection (sepsis) and poor tissue perfusion. These acute changes represent a direct threat to circulation and require immediate escalation to the registered nurse for emergency intervention.

Adım Adım Çözüm

1
Analyze the client's current diagnosis and baseline status.
The client has a UTI, which can progress to a severe systemic infection (sepsis) if it worsens or is left untreated.
Understanding the primary diagnosis helps the nurse anticipate potential complications.
2
Evaluate each assessment finding to distinguish between expected localized symptoms and unexpected systemic complications.
Burning during urination and cloudy urine are expected localized symptoms. The changes in vital signs and mental status are unexpected systemic changes.
Nurses must be able to differentiate normal disease manifestations from acute physiological deterioration.
3
Apply prioritization principles, specifically looking for airway, breathing, or circulation (ABC) threats.
The systemic changes (hypotension, tachycardia, altered mental status) threaten circulation and tissue perfusion, requiring immediate reporting.
Life-threatening circulatory issues always take precedence over localized, expected symptoms.

Anahtar Kavram

Prioritization of systemic signs of infection and hypoperfusion over expected localized symptoms
Soru 2774Soru →

A client with a history of epilepsy is sitting in a chair at the bedside when they suddenly lose consciousness and begin experiencing generalized tonic-clonic muscle jerking. In what order should the practical nurse (PN) implement the following interventions? Arrange the actions in the correct sequential order.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence prioritizes immediate physical safety (moving to the floor), followed by airway management (turning to the side), breathing support (loosening clothing), continuous observation, and final reporting.
The correct order follows the foundational nursing principles of safety and the ABCs (Airway, Breathing, Circulation). When a client begins seizing in a chair, the most imminent threat is a traumatic fall; therefore, easing them to the floor and padding the head is the absolute first step. Once on the floor, the airway becomes the primary concern, requiring the nurse to turn the client to the side to prevent aspiration. Loosening tight clothing further supports breathing. After safety and ABCs are managed, the nurse observes the seizure's duration and characteristics. Finally, reporting and documentation occur after the acute phase has resolved.

Adım Adım Çözüm

1
Ease the client to the floor and place a soft pad under their head.
The client is protected from sustaining blunt force trauma or fractures from falling out of the chair.
Immediate physical safety is the primary concern when a client loses consciousness in an upright position.
2
Turn the client onto their side.
The airway is protected from obstruction by the tongue, and oral secretions can drain freely.
Following the ABCs (Airway, Breathing, Circulation), securing a patent airway prevents aspiration and hypoxia.
3
Loosen any restrictive clothing around the client's neck and chest.
Chest expansion is optimized, and venous return from the head is unhindered.
Removing mechanical restrictions supports the 'Breathing' and 'Circulation' components of emergency care.
4
Note the exact time the seizure began and observe the characteristics of the movements.
Accurate clinical data regarding the seizure is collected for later medical evaluation.
Careful observation dictates future pharmacological interventions, but it must not delay life-saving safety measures.
5
Document the seizure event and report the findings to the registered nurse (RN).
The healthcare team is informed, and the legal medical record is updated.
Reporting and charting are vital administrative and collaborative steps performed after the client is stabilized.

Anahtar Kavram

During a seizure, nursing priorities are strictly ordered: immediate physical safety (preventing falls/trauma), airway maintenance (side-lying position), breathing support (loosening clothing), continuous assessment, and post-event documentation.
Soru 2775Soru →

An adult client is receiving care on the orthopedic unit 48 hours after undergoing a right total hip arthroplasty. The client is prescribed prophylactic subcutaneous enoxaparin and scheduled oral analgesics. While the practical nurse (PN) collects morning data, several findings are noted. Which specific assessment finding indicates a life-threatening complication that requires the PN to immediately escalate care to the registered nurse?

Cevabı ve açıklamayı göster

Cevap: The client develops sudden-onset pleuritic chest pain, tachypnea, and an oxygen saturation of 88% on room air.

Cevap

The correct finding is the development of sudden-onset pleuritic chest pain, tachypnea, and an oxygen saturation of 88% on room air.
The finding of sudden-onset pleuritic chest pain, tachypnea (rapid breathing), and hypoxia (oxygen saturation of 88%) strongly indicates a pulmonary embolism. Clients recovering from total hip arthroplasty are at high risk for blood clots. A pulmonary embolism compromises pulmonary circulation and oxygenation, creating an immediate, life-threatening airway and breathing emergency that requires rapid escalation to the registered nurse and medical team for oxygen therapy and anticoagulation.

Adım Adım Çözüm

1
Analyze the client's clinical context and risk factors.
The client is 48 hours post-operative following a total hip arthroplasty.
Major lower extremity orthopedic surgeries place clients at a significantly elevated risk for venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE).
2
Evaluate each assessment finding using the ABC (Airway, Breathing, Circulation) prioritization framework.
The respiratory symptoms (hypoxia, tachypnea, chest pain) indicate an acute compromise of airway and breathing.
Physiological emergencies that threaten oxygenation must always be prioritized over routine post-operative findings or administrative safety protocols.
3
Differentiate between expected post-operative findings and critical complications.
Mild anemia (Hgb 10.6 g/dL) and low-grade inflammatory vitals (Temp 99.6°F) are expected 48 hours post-surgery. The missing ID band is a safety issue but not an immediate physiological threat.
Understanding normal post-operative physiological responses prevents the nurse from falsely escalating expected findings while missing a true life-threatening event.

Anahtar Kavram

Prioritization of Post-operative Complications and ABCs
Soru 2776Soru →

A practical nurse (PN) is providing care for an alert and oriented older adult client in a long-term care facility. The client's adult son approaches the PN in the hallway and requests an update on the client's recent diagnostic test results. The PN notes that the son is not listed as the designated healthcare proxy. Which of the following actions by the PN are appropriate to maintain confidentiality? (Select all that apply.)

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Review the client's medical record to determine if the son is listed on the authorized information release form; Approach the client privately to ask if they consent to sharing their diagnostic results with their son; Explain to the son politely that privacy regulations prohibit the sharing of medical information without the client's direct consent

Cevap

The appropriate actions are to review the medical record for an authorized release form, approach the client privately for consent to share the information, and politely explain privacy regulations to the son.
Maintaining client confidentiality requires the nurse to ensure that medical information is only shared with authorized individuals. Since the client is alert and oriented, the nurse must verify authorization in the chart, ask the client directly for consent, or politely inform the son of the privacy laws that prevent unauthorized disclosure.

Adım Adım Çözüm

1
Assess the client's mental status and the son's legal authority.
The client is alert and oriented, meaning they retain the right to direct their own healthcare information. The son is not a healthcare proxy.
To determine who legally has the right to access the client's diagnostic results.
2
Determine if prior authorization exists.
The PN must check the chart to see if the son is on the HIPAA release form before providing any information.
Clients often sign paperwork upon admission dictating which specific family members may receive updates.
3
Take action based on the absence of immediate authorization.
The PN must refuse the son's request politely by citing privacy laws and then ask the client privately if they wish to share the information.
This protects the client's legal right to privacy while maintaining a therapeutic relationship with the family.

Anahtar Kavram

Confidentiality and Information Security regarding Family Members
Tahmini Süre:1m 30s
Soru 2777Soru →

During morning rounds at an extended care facility, a resident with a history of hypertension and chronic kidney disease reports a new onset of muscle weakness and palpitations. The client's medication administration record includes scheduled oral doses of valsartan, hydrochlorothiazide, and a potassium chloride supplement. A basic metabolic panel drawn earlier this morning reveals a serum potassium level of 6.8 mEq/L6.8\text{ mEq/L} (6.8 mmol/L6.8\text{ mmol/L}). Based on the practical nurse's scope of practice, which action is the priority?

Cevabı ve açıklamayı göster

Cevap: Withhold the valsartan and potassium chloride, remain with the client, and immediately alert the registered nurse.

Cevap

Withhold the valsartan and potassium chloride, remain with the client, and immediately alert the registered nurse.
The client is exhibiting signs of severe hyperkalemia (potassium of 6.8 mEq/L), which can cause fatal cardiac dysrhythmias, manifested by the client's palpitations. Valsartan is an angiotensin II receptor blocker (ARB) that can increase serum potassium, and the potassium chloride supplement will further elevate the level. The practical nurse must recognize this critical laboratory value, withhold the contributing medications, stay with the unstable client, and immediately escalate the situation to the registered nurse for emergency intervention.

Adım Adım Çözüm

1
Analyze the client's laboratory results and presenting symptoms.
The serum potassium level of 6.8 mEq/L is critically high (normal 3.5-5.0 mEq/L), and palpitations indicate a potential cardiac dysrhythmia.
Identifying critical abnormalities is the first step in clinical decision-making.
2
Evaluate the scheduled medications for potential interactions with the laboratory findings.
Valsartan (an ARB) and potassium chloride supplements both increase serum potassium levels.
Administering these medications would exacerbate the severe hyperkalemia.
3
Determine the appropriate action based on the practical nurse's scope of practice.
The nurse must withhold the contraindicated medications and escalate to the registered nurse immediately.
A practical nurse cannot independently prescribe treatments or administer IV push medications for hyperkalemia, but is responsible for withholding harmful medications and reporting critical findings.

Anahtar Kavram

Recognizing critical laboratory values and medication contraindications within the practical nursing scope of practice.
Soru 2778Soru →

While working in a skilled nursing facility, a practical nurse observes the healthcare provider leaving a resident's room. The provider hands the nurse a consent form and states, "I have explained the bedside wound debridement. Please get the resident's signature." When the nurse presents the form, the resident asks, "I forgot to ask if they have to remove any healthy tissue along with the bad tissue. Do you know?" Which action should the nurse take?

Cevabı ve açıklamayı göster

Cevap: Defer witnessing the document and page the provider to clarify the surgical details with the resident.

Cevap

Defer witnessing the document and page the provider to clarify the surgical details with the resident.
The correct action is to defer witnessing the document and contact the provider. The practical nurse's role in informed consent is strictly limited to witnessing the signature and verifying that the client gave voluntary consent. Because the client has an unresolved question about the procedure itself, they are not fully informed. It is the sole responsibility of the provider performing the procedure to explain the risks, benefits, and procedural details.

Adım Adım Çözüm

1
Evaluate the resident's statement regarding the procedure.
The resident is asking a specific question about how the procedure is performed and what tissue will be removed.
To determine if the resident has a clear understanding of the procedure before giving consent.
2
Determine the scope of practice for a practical nurse regarding informed consent.
The nurse's role is strictly limited to witnessing the signature and ensuring the consent is voluntary. The nurse cannot explain the risks, benefits, or procedural steps.
To ensure compliance with legal and ethical standards of nursing practice.
3
Select the appropriate intervention.
The nurse must stop the consent process and contact the provider to return and answer the resident's medical question.
Only the healthcare provider performing the procedure is legally authorized to explain the procedure and answer specific questions about it.

Anahtar Kavram

The practical nurse's role in informed consent is limited to witnessing the signature, while the healthcare provider is solely responsible for explaining the procedure, risks, and alternatives.
Soru 2779Soru →

An older adult client is admitted to a respiratory isolation unit with suspected pulmonary tuberculosis. The client exhibits sudden disorientation and repeatedly attempts to remove their peripheral intravenous (IV) catheter. Which action by the practical nurse demonstrates the appropriate application of safety and error prevention principles?

Cevabı ve açıklamayı göster

Cevap: Cover the intravenous site with a tubular bandage and utilize a bed exit alarm.

Cevap

The correct action is to cover the intravenous site with a tubular bandage and utilize a bed exit alarm.
To prevent injury and maintain safety, practical nurses must implement the least restrictive interventions first. Using a tubular bandage (IV sleeve) acts as a visual barrier to protect the catheter, and a bed alarm alerts staff if the confused client attempts to get out of bed, ensuring safety without improperly restricting movement.

Adım Adım Çözüm

1
Identify the immediate risks to the client.
The client is at risk for self-injury by pulling out the IV catheter and is at high risk for falls due to sudden disorientation.
Recognizing safety hazards is the first step in error and injury prevention.
2
Evaluate the proposed interventions against safety guidelines and the hierarchy of restraints.
Standards of care dictate that the least restrictive measures must be used before applying chemical or physical restraints.
Restraints can cause further agitation, injury, or severe complications.
3
Select the intervention that mitigates the risk using the least restrictive method.
A tubular bandage hides the IV site from the confused client (reducing the urge to pull it), and a bed alarm provides immediate notification if the client attempts to wander.
This combination effectively prevents injury without inappropriately restricting the client's freedom of movement.

Anahtar Kavram

Accident, Error, and Injury Prevention (Least Restrictive Alternatives)
Soru 2780Soru →

A practical nurse (PN) is performing a follow-up assessment on a client who underwent a Roux-en-Y gastric bypass 14 hours ago. Which clinical finding represents an acute decompensation that the PN must immediately escalate to the registered nurse?

Cevabı ve açıklamayı göster

Cevap: A resting heart rate of 116 beats/min accompanied by new-onset restlessness.

Cevap

A resting heart rate of 116 beats/min accompanied by new-onset restlessness.
After major abdominal or bariatric surgery, an unexplained increase in heart rate (tachycardia) and acute neurological changes (restlessness, anxiety) are classic, early indicators of systemic compromise. These findings strongly suggest severe complications such as hemorrhage, an anastomotic leak, or developing peritonitis. Because this represents an acute threat to the client's circulation and tissue perfusion (ABCs), the PN must escalate this immediately to the RN for rapid medical intervention.

Adım Adım Çözüm

1
Analyze the client's postoperative timeframe and specific surgical risks.
The client is 14 hours post-Roux-en-Y gastric bypass, placing them at high risk for hemorrhage or an anastomotic leak.
Recognizing procedure-specific risks guides the prioritization of assessment data.
2
Evaluate the clinical findings in each option for life-threatening complications (ABCs).
A heart rate of 116 beats/min and new restlessness indicate inadequate tissue perfusion or systemic infection.
Tachycardia is often the earliest physiological adaptation to shock, hemorrhage, or peritonitis.
3
Compare the abnormal systemic findings against expected or stable postoperative symptoms.
Incisional pain (6/10), clearable lung crackles, and adequate urine output (~46 mL/hr) are expected or stable findings.
Expected clinical findings do not take priority over impending cardiovascular or respiratory collapse.

Anahtar Kavram

Prioritization of early shock indicators (tachycardia, restlessness) over expected postoperative findings.
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