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Tüm alıştırma soruları

2933 soru

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Soru 461Soru →

An 81-year-old client is recuperating on the surgical unit 48 hours after a pelvic fracture repair. The client's visiting family member alerts the nursing staff, stating the client is suddenly acting agitated and asking when the train is arriving. The client's current vital signs show a heart rate of 106 beats/min, a respiratory rate of 22 breaths/min, a blood pressure of 104/64 mmHg, and an oxygen saturation of 91% on room air. Which action should the practical nurse (PN) take first?

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Cevap: Elevate the head of the bed and initiate prescribed supplemental oxygen therapy.

Cevap

The priority action is to elevate the head of the bed and initiate prescribed supplemental oxygen therapy.
The correct action directly addresses the client's immediate physiological threat. Sudden confusion and agitation in an older adult, especially with an oxygen saturation of 91%, tachycardia, and tachypnea, strongly indicate hypoxia. By elevating the head of the bed and applying oxygen, the practical nurse supports the client's airway and breathing, adhering to the ABC priority framework.

Adım Adım Çözüm

1
Analyze the client's sudden change in mental status (agitation, confusion) alongside the vital signs.
The client has an oxygen saturation of 91%, a heart rate of 106 beats/min, and a respiratory rate of 22 breaths/min.
Identifying abnormal clinical data helps pinpoint the underlying physiological cause of the sudden confusion.
2
Apply the Airway, Breathing, Circulation (ABC) prioritization framework to the findings.
The findings point to an issue with 'Breathing' and oxygenation (hypoxia), which takes precedence over pain management or routine monitoring.
According to the ABC framework, life-threatening respiratory issues must be addressed before secondary symptoms like agitation.
3
Select the nursing intervention that directly treats the identified problem.
Elevating the head of the bed promotes lung expansion, and administering supplemental oxygen directly corrects the hypoxemia.
Immediate physiological adaptation interventions are necessary to stabilize the client and prevent further deterioration.

Anahtar Kavram

Prioritizing ABCs and Recognizing Acute Delirium from Hypoxia
Soru 462Soru →

A female client is transferred to the medical-surgical floor immediately after undergoing a percutaneous liver biopsy in the radiology department. As the practical nurse helps the client settle into bed for the mandatory recovery phase, which position is most appropriate to implement?

Cevabı ve açıklamayı göster

Cevap: Lying on the right side with a folded blanket under the biopsy site

Cevap

The correct position is lying on the right side with a folded blanket under the biopsy site.
After a percutaneous liver biopsy, the priority is preventing hemorrhage. Placing the client on their right side uses the body's own weight against the bed and a folded blanket to apply direct, continuous pressure to the liver capsule and puncture site, effectively promoting hemostasis.

Adım Adım Çözüm

1
Identify the specific procedure performed and its primary associated complication.
The client underwent a percutaneous liver biopsy, which carries a high risk of severe bleeding due to the liver's highly vascular nature.
Recognizing the most life-threatening complication dictates the priority basic care intervention.
2
Determine the anatomical location involved in the procedure.
The liver is situated in the right upper quadrant of the abdomen.
Understanding anatomy is necessary to apply targeted, site-specific interventions.
3
Select the client position that best mitigates the identified bleeding risk.
Positioning the client on the right side applies the body's own weight as direct external pressure to the biopsy site.
Continuous mechanical compression promotes hemostasis and prevents internal hemorrhage at the puncture site.

Anahtar Kavram

Post-procedure Hemostasis and Client Positioning
Tahmini Süre:1m 0s
Soru 463Soru →

A practical nurse is providing care for a client with hepatic cirrhosis who underwent a therapeutic paracentesis for severe ascites three hours prior. The nurse reviews the client's current clinical data compared to baseline:

ParameterPre-Procedure BaselineCurrent Assessment
Heart Rate82 beats/min118 beats/min
Blood Pressure134/78 mm Hg92/56 mm Hg
Hemoglobin11.4 g/dL8.8 g/dL

Based on these findings, which action is the priority for the nurse to perform?

Cevabı ve açıklamayı göster

Cevap: Directly communicate the downward trends in hemodynamics and laboratory values to the charge nurse.

Cevap

The priority action is to directly communicate the downward trends in hemodynamics and laboratory values to the charge nurse.
The correct action involves immediately reporting the findings. The combination of marked tachycardia, hypotension, and a dropping hemoglobin level following an invasive procedure strongly indicates active internal bleeding or hypovolemic shock. This requires urgent medical intervention beyond the practical nurse's independent scope of practice.

Adım Adım Çözüm

1
Analyze the client's clinical data in the context of the recent paracentesis procedure.
The client exhibits significant tachycardia (118 beats/min), hypotension (92/56 mm Hg), and a sharp drop in hemoglobin (11.4 to 8.8 g/dL).
Identifying deviations from expected post-procedure baselines is the first step in risk reduction.
2
Synthesize the findings to determine the underlying physiological risk.
The combined findings strongly suggest active internal bleeding resulting in hypovolemic shock, a life-threatening complication of the procedure.
Recognizing the clinical pattern of shock is essential for determining the urgency of the situation.
3
Determine the appropriate nursing action within the practical nurse scope of practice.
The priority is to escalate these critical findings immediately so life-saving medical interventions can be initiated.
Practical nurses must promptly report life-threatening changes to the registered nurse or healthcare provider to ensure patient safety.

Anahtar Kavram

Early recognition and escalation of post-procedural hypovolemic shock
Soru 464Soru →

A practical nurse (PN) is caring for an adult client with a history of a seizure disorder. The client has no known allergies and their morning vital signs are stable. The provider's prescription states: "phenytoin 300300 mg, PO, every 1212 hours." The pharmacy supplies the medication in a liquid suspension labeled "phenytoin 250250 mg / 55 mL." Which of the following actions should the PN take to safely administer this medication?

Cevabı ve açıklamayı göster

Cevap: Verify the client's identity using their full name and date of birth, then administer 66 mL of the suspension.

Cevap

The practical nurse should verify the client's identity using their full name and date of birth, then administer 66 mL of the suspension.
Safe medication administration requires fulfilling all the 'rights' of medication administration. First, the practical nurse must calculate the correct dosage. Using the formula DesiredHave×Quantity\frac{\text{Desired}}{\text{Have}} \times \text{Quantity}, the calculation is 300 mg250 mg×5 mL=6 mL\frac{300 \text{ mg}}{250 \text{ mg}} \times 5 \text{ mL} = 6 \text{ mL}. Second, the nurse must verify the 'right client' using at least two distinct, acceptable identifiers. The client's full name and date of birth are standard, safe identifiers. Therefore, the option that combines the accurate 66 mL dose with these valid identifiers is the only safe and correct action.

Adım Adım Çözüm

1
Determine the correct medication dosage using the standard calculation formula: DesiredHave×Quantity\frac{\text{Desired}}{\text{Have}} \times \text{Quantity}.
300 mg250 mg×5 mL=1.2×5 mL=6 mL\frac{300 \text{ mg}}{250 \text{ mg}} \times 5 \text{ mL} = 1.2 \times 5 \text{ mL} = 6 \text{ mL}.
Accurate dose calculation is a critical component of the 'right dose' principle in medication administration.
2
Identify the proper method for verifying the right client before administration.
Select two acceptable patient identifiers, such as the client's full name, date of birth, or medical record number.
National patient safety standards strictly prohibit the use of room numbers or bed assignments to identify a client.

Anahtar Kavram

Safe medication administration involves both precise dosage calculation and strict adherence to the rights of medication administration, including proper client identification.
Soru 465Soru →

A practical nurse (PN) is assessing a client who is 12 hours postoperative following an open cholecystectomy. Which of the following assessment findings should the PN recognize as expected at this stage of recovery? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Hypoactive bowel sounds auscultated in all four abdominal quadrants; Serosanguineous drainage on the surgical dressing that has not increased in size since the previous shift; A temperature reading of 99.5°F (37.5°C)

Cevap

The expected postoperative findings for this client include hypoactive bowel sounds, stable serosanguineous drainage on the surgical dressing, and a low-grade temperature of 99.5°F (37.5°C).
Expected findings at 12 hours post-abdominal surgery include hypoactive bowel sounds (due to anesthesia and bowel manipulation), stable serosanguineous drainage (normal early wound healing), and a low-grade fever up to 100.4°F (38°C) resulting from the body's inflammatory response to surgical trauma. These require routine monitoring but no immediate escalation.

Adım Adım Çözüm

1
Evaluate the vital signs for indicators of shock or respiratory compromise.
The elevated heart rate with low blood pressure and the critically low oxygen saturation are identified as abnormal, emergent findings.
Early identification of ABC (Airway, Breathing, Circulation) compromise prevents life-threatening postoperative complications like hemorrhage or hypoxia.
2
Analyze the laboratory values against normal therapeutic ranges.
The potassium level of 2.9 mEq/L is identified as critically low.
Hypokalemia must be escalated immediately because it can precipitate fatal cardiac arrhythmias.
3
Identify the expected physiological responses to abdominal surgery and anesthesia.
Hypoactive bowel sounds, a mild temperature elevation, and stable serosanguineous wound drainage are recognized as normal recovery milestones.
Surgical trauma and anesthesia predictably cause temporary bowel sluggishness, mild systemic inflammation, and initial wound weeping.

Anahtar Kavram

Discriminating between expected postoperative recovery milestones and emergent clinical complications.
Soru 466Soru →

A practical nurse (PN) is preparing to draw up a prescribed medication from a single-dose glass ampule for an intramuscular injection. Arrange the following actions in the correct chronological order to ensure safe medication preparation.

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Cevabı ve açıklamayı göster

Cevap

The correct sequence is to first tap the ampule to clear the top, wrap the neck with gauze, snap it away from the body, draw the medication using a filter needle, and finally replace the filter needle with an appropriate administration needle.
Safe preparation of medication from a glass ampule requires a specific sequence to prevent injury to the nurse and avoid injecting glass particles into the client. The fluid must first be moved to the lower chamber, the ampule safely broken away from the user with a protective barrier, the fluid drawn with a device that filters out glass, and the needle changed to ensure the client is safely injected.

Adım Adım Çözüm

1
Tap the top of the ampule lightly to clear medication from the uppermost portion.
Fluid is consolidated into the bottom chamber of the ampule.
This prevents wasting medication that might be trapped in the top when the ampule is broken.
2
Place a sterile gauze pad or a commercial ampule breaker around the scored neck.
The nurse's fingers are shielded.
This physical barrier protects the nurse from accidental cuts if the glass shatters unpredictably.
3
Snap the neck of the ampule quickly and firmly away from the body.
The ampule is opened safely.
Directing the breaking force away from the face and body ensures that any flying glass shards do not cause injury.
4
Attach a filter needle to the syringe and withdraw the prescribed volume of medication.
Medication is drawn into the syringe without glass contaminants.
Breaking the ampule introduces microscopic glass shards into the fluid; a filter needle catches these particles.
5
Remove the filter needle and attach a sterile administration needle of the appropriate size.
The syringe is ready for safe client administration.
The filter needle cannot be used for injection as it may harbor glass particles and is typically the wrong gauge/length for administration.

Anahtar Kavram

Safe Medication Preparation from an Ampule
Soru 467Soru →

A practical nurse is planning care for an adult client who underwent a right above-the-knee amputation two days ago. Which actions should the nurse implement to promote optimal healing and basic comfort? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Assist the client to lie on their abdomen for 30 minutes, three to four times a day.; Cleanse the intact skin surrounding the surgical site daily with mild soap and warm water.; Encourage active range-of-motion exercises for the unaffected extremities.

Cevap

The correct actions include assisting the client into a prone position several times daily, cleansing the intact skin with mild soap, and encouraging active range-of-motion exercises for unaffected extremities.
Appropriate basic care for a client 48 hours after an above-the-knee amputation focuses on preventing contractures via prone positioning, maintaining hygiene using mild soap and water on intact skin, and promoting general mobility through active range-of-motion exercises on unaffected limbs.

Adım Adım Çözüm

1
Identify the primary risks and care needs for a client 48 hours post-amputation.
The main risks are hip flexion contractures, immobility complications, and impaired skin integrity.
Understanding the postoperative timeline is critical; interventions change significantly after the first 24 hours.
2
Evaluate the positioning options against contracture risks.
Prone positioning is indicated to extend the hip; elevating on a pillow is contraindicated after 24 hours.
Prolonged elevation causes the hip flexor muscles to shorten, leading to permanent contractures.
3
Assess the nursing actions for scope of practice compliance.
IVP medication administration is excluded from the practical nurse scope of practice.
The practical nurse must recognize boundaries of their licensure regardless of the client's pain level.
4
Select interventions that safely promote hygiene and mobility.
Basic skin cleansing and active ROM for unaffected limbs are appropriate basic care measures.
These actions maintain physiological integrity and prepare the client for future rehabilitation without causing harm.

Anahtar Kavram

Post-Amputation Positioning and Basic Care
Tahmini Süre:1m 30s
Soru 468Soru →

A client recovering from a radical neck dissection has a newly established tracheostomy. The client exhibits restlessness, and coarse rhonchi are heard upon auscultation. The practical nurse prepares to suction the artificial airway. Arrange the following steps of the procedure in the correct chronological order from first to last.

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Cevabı ve açıklamayı göster

Cevap

The correct sequence is to first hyperoxygenate the client, then advance the catheter without suction, apply intermittent suction only during withdrawal, flush the catheter with saline, and finally reassess the client's lung sounds.
Airway clearance via tracheostomy suctioning must follow strict chronological steps to ensure safety and prevent hypoxia. The client must first be pre-oxygenated to build a respiratory reserve. The catheter is then advanced without suction to protect the mucosal lining from trauma. Once resistance is met or the desired depth is reached, intermittent suction is applied only during withdrawal for a maximum of 10 to 15 seconds to remove secretions while limiting oxygen deprivation. Afterward, the catheter is flushed to maintain patency, and the client's respiratory status is reassessed to evaluate the procedure's success.

Adım Adım Çözüm

1
Hyperoxygenate the client with 100% oxygen.
The client's oxygen reserves are maximized.
To prevent severe hypoxemia when oxygen is removed from the airway along with secretions.
2
Advance the sterile suction catheter into the airway without applying suction.
The catheter reaches the proper depth safely.
Applying negative pressure during insertion strips and traumatizes the tracheal mucosa, increasing the risk of bleeding.
3
Apply intermittent suction for no longer than 10 to 15 seconds during catheter withdrawal.
Secretions are cleared from the airway.
Intermittent suction clears the mucus, while the strict time limit minimizes oxygen deprivation and mucosal damage.
4
Flush the suction catheter and connecting tubing with sterile saline.
The catheter and tubing are cleared of thick secretions.
To maintain patency for subsequent passes or future use.
5
Auscultate bilateral lung sounds to evaluate the effectiveness of the intervention.
The client's respiratory status is documented.
To confirm whether the airway is clear or if the suctioning process needs to be repeated.

Anahtar Kavram

Airway Management: Tracheostomy Suctioning Sequence
Soru 469Soru →

A practical nurse is caring for a 6-year-old child who has just returned to the pediatric unit following a tonsillectomy. The child is currently sleeping but arouses easily to verbal stimuli. Which position is the safest and most appropriate for the nurse to place this client in?

Cevabı ve açıklamayı göster

Cevap: Partially prone or side-lying with the head turned to one side

Cevap

The safest and most appropriate position is partially prone or side-lying with the head turned to one side.
Following a tonsillectomy, clients who are not fully awake should be placed in a side-lying or partially prone position. This alignment uses gravity to naturally drain blood and oral secretions out of the mouth rather than down the throat, thereby maintaining a clear airway and preventing aspiration.

Adım Adım Çözüm

1
Identify the client's surgical procedure and current level of consciousness.
The client had a tonsillectomy and is currently drowsy and sleeping.
Postoperative tonsillectomy clients are at high risk for bleeding and aspiration of secretions, especially when not fully awake.
2
Determine the primary goal of positioning for this specific client.
The primary goal is to maintain a patent airway by allowing blood and oral secretions to drain out of the mouth.
Airway maintenance is always the highest priority in postoperative care (ABC prioritization).
3
Evaluate the positioning options against the primary goal.
A side-lying or partially prone position allows gravity to drain fluids from the mouth, whereas supine positions encourage fluids to pool in the back of the throat.
Gravity-assisted drainage minimizes the risk of choking and aspiration in a client who cannot independently clear their own airway.

Anahtar Kavram

Postoperative Airway Management and Positioning
Soru 470Soru →

A practical nurse (PN) is reviewing the morning laboratory results for an adult client who is scheduled to receive a dose of subcutaneous enoxaparin. The client's most recent platelet count is 45,000/mm345,000/\text{mm}^3 (normal reference range: 150,000 to 400,000/mm3150,000 \text{ to } 400,000/\text{mm}^3). Which of the following is the most appropriate action for the PN to take?

Cevabı ve açıklamayı göster

Cevap: Withhold the scheduled medication and immediately notify the supervising registered nurse (RN) or healthcare provider.

Cevap

The most appropriate action is to withhold the scheduled dose of enoxaparin and promptly report the abnormal laboratory result to the registered nurse (RN) or healthcare provider.
The correct answer involves withholding the medication and notifying the supervising RN or healthcare provider. Enoxaparin is a low-molecular-weight heparin used as an anticoagulant. The client's platelet count is 45,000/mm345,000/\text{mm}^3, which indicates severe thrombocytopenia (normal is 150,000 to 400,000/mm3150,000 \text{ to } 400,000/\text{mm}^3). Administering an anticoagulant to a client with critically low platelets creates a severe risk for hemorrhage. A key responsibility within the practical nurse's scope of practice is to evaluate relevant laboratory data prior to medication administration, withhold medications when safety parameters are not met, and immediately report these critical findings.

Adım Adım Çözüm

1
Identify the normal reference range for a platelet count.
The normal platelet count is 150,000 to 400,000/mm3150,000 \text{ to } 400,000/\text{mm}^3.
Comparing the client's laboratory results to the expected normal range is necessary to identify potential abnormalities before administering medications.
2
Evaluate the client's specific laboratory value.
The client's platelet count of 45,000/mm345,000/\text{mm}^3 is critically low, a condition known as thrombocytopenia.
Recognizing a critical laboratory value determines whether the scheduled pharmacological therapy is safe to administer or if it poses a risk to the client.
3
Determine the appropriate nursing intervention based on safety and the PN scope of practice.
The medication should be withheld and the abnormal finding escalated to the supervising RN.
Enoxaparin is an anticoagulant that can cause severe bleeding in a client with existing thrombocytopenia. It is within the PN's scope to withhold a contraindicated medication and report the critical finding.

Anahtar Kavram

Pre-administration safety checks and escalating critical laboratory values
Soru 471Soru →

A practical nurse (PN) is monitoring an older adult client who is 12 hours post-operative following a total abdominal hysterectomy. The client suddenly becomes restless, appears mildly confused, and reports feeling 'out of breath.' Vital signs are heart rate 105 beats/minute, blood pressure 106/62 mm Hg, and respiratory rate 24 breaths/minute. Which action should the PN take first?

Cevabı ve açıklamayı göster

Cevap: Elevate the head of the bed and measure the client's oxygen saturation.

Cevap

Elevate the head of the bed and measure the client's oxygen saturation.
The client is exhibiting early signs of hypoxia (restlessness, confusion, tachypnea, tachycardia), which is a potential life-threatening complication such as a pulmonary embolism or acute respiratory distress. Prioritizing the ABCs (Airway, Breathing, Circulation) requires the nurse to first support breathing by elevating the head of the bed to maximize lung expansion and immediately obtaining an oxygen saturation reading to quantify the level of hypoxia.

Adım Adım Çözüm

1
Analyze the clinical cues
The client is displaying new-onset restlessness, confusion, tachypnea (respiratory rate of 24), and tachycardia (heart rate of 105) alongside subjective shortness of breath.
Identifying abnormal, acute findings is the first step in recognizing physiological deterioration.
2
Apply the ABC (Airway, Breathing, Circulation) prioritization framework
The client's symptoms point to a potential breathing compromise (hypoxia) as the most immediate threat.
The ABC framework dictates that airway and breathing issues must be addressed before circulation or neurological issues.
3
Determine the most appropriate initial nursing intervention
Elevating the head of the bed promotes immediate lung expansion, and obtaining a pulse oximetry reading provides objective data about oxygenation status.
These actions provide immediate relief and essential data without delaying care or acting outside the practical nurse's scope of practice.

Anahtar Kavram

Prioritizing interventions based on the ABC (Airway, Breathing, Circulation) framework during acute physiological decompensation.
Soru 472Soru →

A practical nurse in a long-term care facility is preparing to administer an intermittent enteral tube feeding via a nasogastric tube to a client who is recovering from a cerebrovascular accident (stroke). In what order should the nurse perform the following actions? Arrange the steps from first to last.

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Cevap

The correct sequence for administering an intermittent enteral feeding is to first elevate the head of the bed to prevent aspiration, then aspirate to verify placement and check residuals, return the residuals to the stomach, flush the tube to ensure patency, and finally administer the feeding formula.
The correct sequence prioritizes client safety by first ensuring proper positioning to prevent aspiration. Following positioning, verifying tube placement and assessing gastric residual volume are essential before introducing any fluids. Returning the residual prevents electrolyte loss, and flushing ensures the tube is patent before the formula is administered.

Adım Adım Çözüm

1
Elevate the head of the client's bed to at least 30 degrees.
The client is placed in a safe position for enteral intake.
Elevating the head of the bed utilizes gravity to help prevent gastric reflux and aspiration into the airway.
2
Aspirate gastric contents to verify tube placement and measure residual volume.
Tube location in the stomach is confirmed and delayed emptying is assessed.
Ensures the formula will enter the gastrointestinal tract safely and that the client is digesting previous feedings appropriately.
3
Return the aspirated gastric residual volume into the stomach.
Stomach contents are restored.
Prevents the loss of essential gastric electrolytes and fluids, which could lead to metabolic imbalances.
4
Flush the nasogastric tube with 30 mL of water.
The tube is cleared and patency is confirmed.
Flushing prevents tube occlusion and ensures there is no resistance before administering the thicker feeding formula.
5
Administer the prescribed intermittent enteral feeding formula.
The client receives the prescribed nutrition.
This is the final step once safety, placement, and patency have all been systematically verified.

Anahtar Kavram

Basic Care and Comfort: Enteral Nutrition Administration Sequence
Soru 473Soru →

A practical nurse (PN) is collecting data on an older adult client who is 8 hours post-operative following a right femoral-popliteal bypass graft. Which of the following findings indicate that the client is physiologically stable and do NOT require immediate reporting to the registered nurse (RN)? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Capillary refill time of 2 seconds in the toes of the right foot; Incisional pain rated as 4 on a 0 to 10 pain scale that is reduced by repositioning; Oral temperature of 99.1°F (37.3°C) and a respiratory rate of 16 breaths/min

Cevap

The expected, stable findings are a capillary refill time of 2 seconds, incisional pain rated as 4 out of 10, and an oral temperature of 99.1°F with normal respirations.
Stable post-operative adaptation includes manageable pain, adequate peripheral perfusion (capillary refill less than 3 seconds), and a mild inflammatory response (temperature up to 100.4°F or 38.0°C in the first 48 hours). These findings show the client is recovering as expected.

Adım Adım Çözüm

1
Analyze the clinical scenario and the specific question being asked.
The client is 8 hours post-operative from a vascular bypass graft. The question asks to identify which findings are expected and stable, meaning they do NOT require immediate escalation.
Understanding the timeline helps differentiate normal post-operative physiological responses from acute complications.
2
Evaluate each option to distinguish normal post-operative data from signs of physiological decompensation.
Normal findings include manageable pain, rapid capillary refill, and a low-grade temperature. Abnormal findings include tachycardia with hypotension, low hemoglobin, and new-onset confusion.
Early recognition of shock, bleeding, or hypoxia is critical to preventing adverse outcomes.
3
Select the options that represent stable, expected outcomes.
The correct selections are the normal capillary refill, the moderate pain, and the mild temperature elevation.
These findings reflect expected post-operative adaptation without indicating acute risk to Airway, Breathing, or Circulation.

Anahtar Kavram

Differentiating expected post-operative physiological adaptations from early signs of acute decompensation
Soru 474Soru →

A licensed practical nurse (LPN) is assisting with the care of a client who had a laparoscopic cholecystectomy 4 hours ago. The client is currently agitated and repeatedly asking about their location. Current vital signs include a heart rate of 118 bpm, a respiratory rate of 24 breaths/min, and a blood pressure of 92/56 mm Hg. The client's admission blood pressure was 128/74 mm Hg. Which of the following is the priority action for the LPN?

Cevabı ve açıklamayı göster

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

Cevap

The priority action is to immediately notify the registered nurse (RN) regarding the assessment findings.
The correct action is to notify the RN immediately. The client's sudden agitation, increased heart rate, and decreased blood pressure compared to baseline are classic early signs of hypovolemic shock (potentially from internal bleeding). Within the LPN's scope of practice, recognizing acute physiological deterioration and rapidly escalating the information is the highest priority.

Adım Adım Çözüm

1
Analyze the client's current clinical presentation against their baseline.
The client has a new onset of agitation, tachycardia (118 bpm), tachypnea (24 breaths/min), and a significant drop in blood pressure (92/56 mm Hg from 128/74 mm Hg).
Comparing current data to baseline is essential to identify trends indicative of physiological deterioration.
2
Correlate the findings to potential postoperative complications.
The combination of altered mental status, tachycardia, and hypotension strongly suggests early hypovolemic shock, likely due to internal bleeding.
Recognizing early signs of shock is a critical component of physiological adaptation and patient safety.
3
Determine the most appropriate action within the LPN scope of practice.
The LPN must immediately communicate these unstable findings to the RN for further assessment and collaborative intervention.
Acute, life-threatening changes require immediate escalation to ensure timely medical management.

Anahtar Kavram

Early recognition of shock and acute decompensation
Soru 475Soru →

A client is recovering in the rehabilitation unit with right-sided hemiparesis and moderate dysphagia secondary to a recent cerebrovascular accident. Which interventions should the practical nurse implement to promote comfort and safe oral intake during meals? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Assist the client into a high-Fowler's position prior to providing food or liquids; Instruct the client to tuck their chin downward toward the chest while swallowing; Perform oral hygiene care for the client both before and following the meal

Cevap

The correct interventions are to position the client upright in a high-Fowler's position, instruct the client to use a chin-tuck maneuver when swallowing, and perform oral hygiene care before and after eating.
Positioning the client upright in a high-Fowler's position uses gravity to help food travel down the esophagus and significantly reduces the risk of it entering the airway. Furthermore, the chin-tuck maneuver narrows the airway opening and widens the esophageal opening, providing mechanical protection against choking. Providing oral hygiene before meals enhances taste and salivary flow, while post-meal oral care is critical to remove any food particles pocketed in the mouth, which could later be aspirated.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
The client has right-sided paralysis and difficulty swallowing (dysphagia).
Understanding the deficits is crucial to identifying interventions that protect the airway and ensure safe nutrition.
2
Determine proper positioning during and after meals.
A high-Fowler's position and the chin-tuck maneuver are identified as necessary safety measures.
These specific anatomical positions utilize gravity and narrowing of the trachea to prevent food and liquid from entering the airway.
3
Identify supportive basic care routines related to feeding.
Providing oral hygiene before and after meals is selected as a priority comfort and safety measure.
Pre-meal oral care improves the sensory experience of eating, while post-meal care removes leftover food that could be silently aspirated.

Anahtar Kavram

Dysphagia Management and Aspiration Precautions
Soru 476Soru →

Following a percutaneous liver biopsy, a client is resting on the medical-surgical unit. The client's pre-procedure baseline showed a blood pressure of 132/82 mm Hg and a heart rate of 72 beats/minute. During an assessment two hours later, the blood pressure measures 108/66 mm Hg with a heart rate of 98 beats/minute, and the client mentions mild aching on the right side. What is the most appropriate next action for the licensed practical nurse to take?

Cevabı ve açıklamayı göster

Cevap: Promptly communicate the changing hemodynamic parameters to the registered nurse.

Cevap

The correct action is to promptly communicate the changing hemodynamic parameters to the registered nurse to ensure rapid intervention for potential internal bleeding.
The client's shift in vital signs—a decreasing blood pressure and increasing heart rate—are early compensatory signs of hypovolemic shock. Because the liver is a highly vascular organ, a percutaneous biopsy carries a significant risk of internal bleeding. The nurse must recognize these subtle trends as a potential life-threatening complication and immediately alert the registered nurse for further evaluation and intervention.

Adım Adım Çözüm

1
Analyze the client's current vital signs by comparing them to the pre-procedure baseline.
The blood pressure dropped from 132/82 to 108/66 mm Hg, and the heart rate increased from 72 to 98 beats/minute.
Comparing current data to baseline is essential for identifying early physiological changes rather than just relying on standard adult normal ranges.
2
Correlate the vital sign trends with the specific procedural risks associated with a liver biopsy.
The trends indicate early compensatory shock, likely from internal bleeding due to the liver's high vascularity.
Understanding procedural risks helps differentiate expected post-procedure findings from dangerous complications.
3
Determine the appropriate nursing action based on the practical nurse scope of practice.
The nurse must escalate the findings immediately to the registered nurse.
Recognizing and reporting subtle signs of clinical deterioration reduces the risk of severe adverse outcomes.

Anahtar Kavram

Recognizing Early Signs of Hemorrhage and Hypovolemic Shock
Soru 477Soru →

While receiving a continuous enteral tube feeding, a client with a history of stroke suddenly begins to cough forcefully, gasp for air, and develop circumoral cyanosis. The practical nurse (PN) is present at the bedside. Arrange the following actions in the priority order the PN should perform them, from first to last.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence is to first turn off the feeding pump, position the client laterally, suction the airway, apply oxygen, and finally alert the RN.
The correct sequence follows the ABC prioritization framework and the principle of mitigating immediate harm. Stopping the feeding immediately halts further aspiration. Positioning the client laterally uses gravity to protect the airway from further fluid entry. Suctioning clears the existing obstruction to establish patency. Oxygenation treats the resulting hypoxia once the airway is clear. Finally, notifying the RN ensures the client receives advanced assessment and ongoing medical management after the immediate crisis is stabilized.

Adım Adım Çözüm

1
Identify the immediate life threat.
Recognize that the client is exhibiting signs of active aspiration and airway compromise.
Forceful coughing, gasping, and cyanosis during a tube feeding indicate that formula is entering the respiratory tract.
2
Apply the principle of removing harm.
Determine that stopping the feeding pump is the first action.
Halting the source of the aspiration is the most direct and immediate way to prevent further respiratory compromise.
3
Apply the ABC (Airway, Breathing, Circulation) priority framework to remaining actions.
Order the remaining actions: protect airway (position), clear airway (suction), support breathing (oxygen), and escalate (notify RN).
Airway management physically precedes breathing support. Oxygen is ineffective if the airway is blocked with fluid. Escalation occurs only after immediate bedside stabilization.

Anahtar Kavram

Prioritization of Airway Emergencies and Aspiration Precautions
Soru 478Soru →

During the morning shift on a medical-surgical unit, a practical nurse is assigned to care for several clients requiring pharmacological therapies. Which actions by the practical nurse represent safe practice and adhere to the scope of practice? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Scanning the client's identification band and the medication packaging barcode immediately prior to giving oral metoprolol.; Withholding a scheduled dose of oral warfarin and promptly notifying the registered nurse (RN) after observing a client's INR result of 5.2.; Instructing a client to remain in an upright sitting position for at least 30 minutes after taking oral alendronate.

Cevap

The correct actions are scanning the identification band and barcode for metoprolol, withholding warfarin for an INR of 5.2, and ensuring an upright position after administering alendronate.
The correct actions demonstrate a comprehensive understanding of pharmacological safety and legal scope. Utilizing barcodes ensures accurate identification, withholding warfarin for a critically high INR (5.2) prevents severe hemorrhage, and keeping a client upright after alendronate prevents esophagitis. All of these actions fall safely within the practical nurse's scope of monitoring and administration.

Adım Adım Çözüm

1
Analyze each pharmacological action for adherence to the fundamental rights of medication administration.
Barcode scanning meets safety criteria; using room numbers does not.
Safe medication administration requires reliable and unique client identifiers to prevent medication errors.
2
Evaluate each intervention against the practical nurse's legal and ethical scope of practice.
Administering oral medications and holding medications for critical laboratory values are within scope; administering IV push medications is out of scope.
Intravenous push medications typically necessitate immediate RN-level assessment and intervention due to their rapid onset of action.
3
Review specific pharmacological safety protocols for the mentioned drug classes.
Warfarin requires withholding for an INR substantially over the therapeutic range; alendronate requires an upright position for 30 minutes.
Applying drug-specific knowledge is essential to prevent severe adverse effects such as hemorrhage or esophageal ulceration.

Anahtar Kavram

Safe pharmacological practice for the practical nurse involves adhering to the rights of medication administration, recognizing the boundaries of the practical nursing scope of practice, escalating critical laboratory values, and implementing drug-specific safety protocols.
Soru 479Soru →

An adolescent client is resting in a clinic observation room immediately following a diagnostic lumbar puncture. To minimize the risk of a post-procedure headache and promote comfort, which position should the nurse maintain the client in?

Cevabı ve açıklamayı göster

Cevap: Supine with the bed completely flat.

Cevap

Supine with the bed completely flat.
Following a lumbar puncture, maintaining the client in a flat, supine position for several hours is a standard standard nursing intervention. This flat alignment prevents a rapid decrease in cerebrospinal fluid pressure at the dural puncture site, thereby significantly reducing the likelihood that the client will develop a debilitating spinal headache.

Adım Adım Çözüm

1
Identify the specific procedure the client just underwent.
The client had a diagnostic lumbar puncture.
Different diagnostic procedures require specific postoperative positioning to prevent targeted complications.
2
Recall the most common and significant complication associated with this procedure.
A post-lumbar puncture headache (spinal headache) caused by the continued leakage of cerebrospinal fluid from the puncture site.
Understanding the potential complication directly dictates the prophylactic care required.
3
Determine the correct body position to minimize this specific risk.
A flat position keeps cerebrospinal fluid pressure evenly distributed, minimizing leakage.
Evidence-based practice requires keeping the client supine and flat for a prescribed period following the puncture.

Anahtar Kavram

Post-Procedure Positioning: Lumbar Puncture
Soru 480Soru →

An older adult client is receiving continuous intravenous heparin for a deep vein thrombosis. During hourly rounds, the client reports sudden, severe lower back pain and mild dizziness. The client appears restless and the skin is cool to the touch. Which action should the practical nurse take first?

Cevabı ve açıklamayı göster

Cevap: Measure the client's current blood pressure and heart rate.

Cevap

Measure the client's current blood pressure and heart rate.
The correct action is to measure the blood pressure and heart rate. A client on continuous heparin experiencing sudden back pain accompanied by dizziness, restlessness, and cool skin is exhibiting classic signs of a retroperitoneal hemorrhage and early hypovolemic shock. Assessing circulatory status by collecting vital signs is the immediate priority for the practical nurse to confirm the complication and promptly report the findings to the registered nurse.

Adım Adım Çözüm

1
Analyze the client's new symptoms in the context of their current therapy.
The client is on heparin (high bleeding risk). Sudden back pain, dizziness, restlessness, and cool skin are indicative of a retroperitoneal hemorrhage and early hypovolemic shock.
To identify potential life-threatening complications requiring immediate intervention.
2
Apply the ABC (Airway, Breathing, Circulation) priority framework to the clinical picture.
The symptoms point to a critical circulation issue, which takes precedence over comfort measures or routine documentation.
Airway, breathing, and circulation are always the highest priorities in acute care.
3
Determine the appropriate initial action within the practical nursing scope of practice.
Obtaining a current set of vital signs provides objective data about the client's hemodynamic status.
Current vital signs are necessary to confirm circulatory compromise and properly escalate the situation to the registered nurse or healthcare provider.

Anahtar Kavram

Prioritization of care and early recognition of hypovolemic shock in clients receiving anticoagulants.
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