Tüm alıştırma soruları

2933 soru

Soru 681Soru →

An LPN receives orders to mobilize an immobile bariatric client to a specialized cardiac chair for the first time post-admission. The facility protocol mandates the use of a ceiling-mounted mechanical lift with a full-body sling. Place the following steps in the correct chronological order to ensure both nurse ergonomics and client safety during this procedure. All steps must be used.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence prioritizes pre-procedure equipment safety verification, ergonomic environmental preparation, proper sling placement, secure attachment, an initial safety suspension check, and finally the transfer execution.
The correct chronological sequence ensures both patient safety and nurse ergonomics. Verifying equipment safety parameters must always precede patient contact. Next, the environment is secured and optimized ergonomically by adjusting the bed height. Patient positioning comes third, ensuring skin integrity. Fourth, the equipment is attached. Fifth, a critical test lift is performed slightly above the bed to confirm structural integrity before the final step of executing the full transfer to the chair.

Adım Adım Çözüm

1
Inspect the sling and verify the lift's weight capacity.
Equipment is confirmed safe for this specific bariatric client.
Using faulty equipment or exceeding weight limits can cause severe injury.
2
Lock the bed and adjust it to an ergonomic height.
The bed is stable and at a safe working level.
Proper bed height prevents back strain for the nurse during patient repositioning.
3
Turn the client and position the sling smoothly.
The sling is securely placed without wrinkles.
Wrinkles under a heavy client can cause shearing forces and pressure injuries.
4
Connect the sling loops to the overhead spreader bar.
The client is physically connected to the lifting device.
Proper attachment ensures the client will not slip out during the lift.
5
Lift the client slightly off the mattress to check attachments.
Tension is applied to verify secure connections.
An initial test lift ensures safety before the client is fully suspended away from the safety of the bed surface.
6
Guide the lift to the chair and lower the client.
The client is successfully and safely transferred.
Moving the client only after all safety checks prevents catastrophic falls.

Anahtar Kavram

Ergonomics and Safe Use of Equipment
Soru 682Soru →

A practical nurse is caring for a client with congestive heart failure who is scheduled to receive a morning dose of oral digoxin. The client's morning laboratory results show a serum potassium level of 3.0 mEq/L3.0\text{ mEq/L} (3.0 mmol/L3.0\text{ mmol/L}) and a serum digoxin level of 1.4 ng/mL1.4\text{ ng/mL} (1.8 nmol/L1.8\text{ nmol/L}). The client's apical pulse is 64 beats/min64\text{ beats/min}. During the morning assessment, the client reports new-onset severe nausea and seeing yellow halos around the lights in the room. Which action should the practical nurse take first?

Cevabı ve açıklamayı göster

Cevap: Withhold the digoxin dose and immediately report the client's symptoms and laboratory values to the supervising registered nurse.

Cevap

The practical nurse must withhold the digoxin dose and immediately report the client's symptoms and laboratory values to the supervising registered nurse.
The correct action is to withhold the dose and notify the RN. The client's potassium level of 3.0 mEq/L3.0\text{ mEq/L} indicates hypokalemia. Low potassium increases the heart's sensitivity to digoxin, significantly elevating the risk of toxicity even when the serum digoxin level (1.4 ng/mL1.4\text{ ng/mL}) falls within the normal therapeutic range (0.5−2.0 ng/mL0.5-2.0\text{ ng/mL}). Furthermore, the client's nausea and visual disturbances (yellow halos) are classic clinical indicators of digoxin toxicity. The practical nurse must hold the medication and escalate these critical findings.

Adım Adım Çözüm

1
Evaluate the client's laboratory results against normal reference ranges.
The serum potassium level is critically low (3.0 mEq/L3.0\text{ mEq/L}, normal is 3.5−5.0 mEq/L3.5-5.0\text{ mEq/L}), while the digoxin level is within the standard therapeutic range (0.5−2.0 ng/mL0.5-2.0\text{ ng/mL}).
Identifying abnormal laboratory values is essential before administering cardiovascular medications.
2
Correlate the client's physical symptoms and laboratory results with the prescribed medication.
Hypokalemia increases the myocardium's sensitivity to digoxin, leading to toxicity even at normal serum drug levels. Nausea and visual disturbances (yellow halos) are classic signs of digoxin toxicity.
Clinical presentation takes precedence over 'normal' therapeutic drug levels when predisposing factors like hypokalemia are present.
3
Determine the appropriate intervention within the practical nurse's scope of practice.
The nurse must withhold the medication to prevent further toxicity and immediately escalate the critical findings to the RN or provider.
Ensuring client safety by withholding a harmful medication and reporting to the RN aligns with the practical nursing scope of practice.

Anahtar Kavram

Digoxin Toxicity and Hypokalemia
Soru 683Soru →

During morning rounds on a medical-surgical unit, a practical nurse (PN) interacts with a non-English-speaking older adult client from a Middle Eastern background. Several family members are gathered at the bedside. Which interventions should the PN implement to ensure culturally sensitive and safe care? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Request a facility-approved medical interpreter to explain the purpose of upcoming diagnostic tests.; Proactively ask the client if they require any specific cultural or religious dietary accommodations.; Coordinate to have a same-gender healthcare provider assist the client with bathing and toileting.

Cevap

The correct interventions are to request a facility-approved medical interpreter, proactively ask about cultural dietary accommodations, and coordinate a same-gender caregiver for personal care.
Culturally congruent care requires the PN to respect and accommodate the client's cultural needs. Using a professional interpreter ensures accurate communication and informed decision-making without violating privacy or adding burden to the family. In many Middle Eastern cultures, modesty is highly valued, making a same-gender caregiver essential for personal hygiene. Additionally, proactively assessing for dietary restrictions prevents nutritional deficits and respects religious practices.

Adım Adım Çözüm

1
Identify the client's cultural and communication needs based on the clinical scenario.
The client is non-English-speaking and from a Middle Eastern background, which requires both language assistance and sensitivity to cultural norms.
Recognizing specific cultural demographics is the first step in planning individualized, culturally congruent care.
2
Determine appropriate communication strategies and avoid non-therapeutic responses.
A professional medical interpreter must be utilized for medical discussions, and non-therapeutic blocks like false reassurance must be avoided.
Professional interpreters ensure medical accuracy and privacy, while therapeutic communication encourages trust and respects the family's concerns.
3
Evaluate physical and dietary care requirements specific to the client's cultural background.
Modesty is addressed by assigning same-gender caregivers, and dietary preferences are proactively assessed.
Many Middle Eastern cultures highly value modesty and have specific dietary laws; proactively addressing these prevents culturally insensitive incidents.

Anahtar Kavram

Cultural Awareness and Influences on Health
Soru 684Soru →

An interprofessional care team is managing a group of clients on a medical-surgical neurology unit. A licensed practical/vocational nurse (LPN/VN) must prioritize tasks, understand role boundaries, and recognize when to escalate care. Which action by the LPN/VN demonstrates adherence to the legal scope of practice and safe care principles?

Cevabı ve açıklamayı göster

Cevap: Administering a scheduled oral antiepileptic medication to a client with a history of seizures, while notifying the registered nurse (RN) to evaluate a different client exhibiting sudden, unilateral facial drooping.

Cevap

The action of administering a scheduled oral medication while escalating the assessment of a client with sudden facial drooping to the RN demonstrates correct scope of practice.
The licensed practical/vocational nurse (LPN/VN) correctly operates within their scope by administering routine oral medications to a stable client with a chronic condition. Concurrently, the LPN/VN demonstrates safe practice by recognizing that sudden, unilateral facial drooping is an unstable, potentially life-threatening sign (possible stroke) that requires immediate escalation to the registered nurse (RN) for a comprehensive clinical assessment.

Adım Adım Çözüm

1
Analyze the LPN/VN scope of practice regarding medication administration, client stability, and appropriate escalation of care.
LPNs/VNs can administer oral medications to stable clients but must escalate new, unstable clinical findings.
Scope of practice defines legal boundaries to ensure client safety.
2
Evaluate the clinical significance of sudden, unilateral facial drooping.
This is an acute, unstable neurological sign indicating a potential stroke.
Unstable conditions require immediate comprehensive assessment by a registered nurse (RN) or provider, which exceeds the LPN/VN scope.
3
Assess the distractors against safe practice guidelines and legal boundaries.
The distractors involve performing IV push administration, explaining surgical risks, and ignoring respiratory alarms.
These actions violate the LPN/VN scope of practice, informed consent laws, and ABC prioritization frameworks.

Anahtar Kavram

Delegation, Scope of Practice, and Interprofessional Boundaries
Soru 685Soru →

While collecting morning data on a 78-year-old client three days post-hip arthroplasty, the practical nurse (PN) is approached by the client's adult child. The child states, 'I know memory problems are a normal part of getting older, but my parent suddenly doesn't know what year it is and was trying to pull out their IV line earlier. I guess dementia is finally setting in.' Which understanding regarding older adult transitions should guide the PN's response?

Cevabı ve açıklamayı göster

Cevap: An acute, sudden change in mentation is abnormal for any developmental stage and suggests an underlying physiological complication like delirium.

Cevap

An acute, sudden change in mentation is abnormal for any developmental stage and suggests an underlying physiological complication like delirium.
Sudden, acute changes in cognition, such as disorientation and agitation, are not part of the normal aging process or a typical developmental transition. They are classic indicators of delirium, which is an acute medical emergency often triggered by infections, hypoxia, or medication side effects in the older adult.

Adım Adım Çözüm

1
Analyze the client's presentation described by the family member.
The client is experiencing a sudden, acute onset of disorientation and agitation (not knowing the year, pulling at IV lines).
Identifying the timeline and severity of cognitive changes is essential for differentiating chronic conditions from acute medical emergencies.
2
Compare the findings against expected developmental transitions for an older adult.
Normal aging may involve mild, gradual slowing of cognitive processing, but it does not cause sudden disorientation or combative behavior.
Understanding normal baseline expectations for older adults prevents the dangerous assumption that confusion is just 'old age'.
3
Determine the clinical significance of the acute changes.
The symptoms point to delirium, an acute and potentially reversible state of confusion often caused by physical stressors like infection, hypoxia, or medication effects.
Recognizing delirium prompts immediate physiological data collection and reporting to the provider to treat the underlying cause.

Anahtar Kavram

Differentiating Expected Aging Transitions from Acute Delirium
Tahmini Süre:1m 30s
Soru 686Soru →

A practical nurse is preparing to administer scheduled morning medications to a client diagnosed with hypothyroidism. The primary health care provider has prescribed levothyroxine 0.125 mg0.125\text{ mg} orally once daily. The pharmacy supplies levothyroxine as scored tablets containing 50 mcg50\text{ mcg} per tablet. How many tablets should the nurse administer?

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

Cevabı ve açıklamayı göster

Cevap: 2.5

Cevap

2.5
To safely administer the correct dose, the practical nurse must ensure the prescribed dose and the supplied dose are in the same unit of measurement. Converting the prescribed 0.125 mg0.125\text{ mg} to micrograms yields 125 mcg125\text{ mcg}. Dividing the desired dose (125 mcg125\text{ mcg}) by the available dose (50 mcg50\text{ mcg} per tablet) results in 2.5 tablets2.5\text{ tablets}. Because the tablets are scored, it is safe and appropriate to administer two and a half tablets to achieve the prescribed dose.

Adım Adım Çözüm

1
Convert the prescribed dose of levothyroxine from milligrams (mg) to micrograms (mcg) by multiplying by 1000.
0.125 mg×1000=125 mcg0.125\text{ mg} \times 1000 = 125\text{ mcg}
The prescribed dose and the supplied medication must be in the same unit of measurement before calculating the physical dosage.
2
Use the standard dosage calculation formula: Desired DoseAvailable Dose×Quantity\frac{\text{Desired Dose}}{\text{Available Dose}} \times \text{Quantity}.
125 mcg50 mcg×1 tablet=2.5 tablets\frac{125\text{ mcg}}{50\text{ mcg}} \times 1\text{ tablet} = 2.5\text{ tablets}
This calculation determines the exact physical quantity of the medication to administer based on the available pharmacy supply.

Anahtar Kavram

Dosage Calculation and Unit Conversion
Soru 687Soru →

A practical nurse (PN) is caring for a client who speaks limited English and is scheduled for an invasive diagnostic procedure. The healthcare provider arrives to explain the procedure and asks the PN to assist with obtaining informed consent. The client's adult child is at the bedside and offers to translate the medical information. Which action by the PN best demonstrates client advocacy and protects the client's rights?

Cevabı ve açıklamayı göster

Cevap: Intervene and request a facility-approved medical interpreter to translate the provider's explanation.

Cevap

Intervene and request a facility-approved medical interpreter to translate the provider's explanation.
The correct action prioritizes the client's right to receive accurate, unbiased medical information in their preferred language. Utilizing a facility-approved medical interpreter is the standard of care for ensuring that a client fully comprehends the risks, benefits, and alternatives of a procedure before giving informed consent.

Adım Adım Çözüm

1
Identify the communication barrier and the legal requirement for informed consent.
The client speaks limited English and requires a professional translation to fully understand the risks and benefits of the invasive procedure.
Informed consent is only valid if the client completely understands the information provided.
2
Evaluate the adult child's offer to translate the medical information.
Determine that family members should not serve as medical interpreters.
Family members may lack accurate medical vocabulary, introduce bias, or compromise the client's privacy.
3
Determine the appropriate advocacy action within the practical nurse's scope of practice.
The nurse must stop the process and secure a facility-approved medical interpreter.
This action protects the client's right to accurate information and ensures the legal standard for informed consent is met.

Anahtar Kavram

Client advocacy and the use of professional interpreters for informed consent
Soru 688Soru →

During morning rounds in the normal newborn nursery, a practical nurse evaluates a 6-hour-old term neonate delivered at 39 weeks of gestation. The infant's current axillary temperature is 97.2°F (36.2°C) and the respiratory rate is 68 breaths per minute. The nurse also notes the presence of mild expiratory grunting. Which of the following actions should the nurse take first?

Cevabı ve açıklamayı göster

Cevap: Report the vital signs and physical findings to the supervising registered nurse immediately.

Cevap

The practical nurse should immediately report the vital signs and physical findings to the supervising registered nurse.
The correct action is to promptly notify the supervising registered nurse because the neonate's vital signs and grunting indicate respiratory distress and cold stress. Recognizing these acute abnormalities and escalating the information ensures the infant receives appropriate, timely medical interventions, which perfectly aligns with the practical nurse's scope of practice.

Adım Adım Çözüm

1
Analyze the neonate's vital signs and physical assessment data.
The temperature of 97.2°F (36.2°C) is abnormally low, and the respiratory rate of 68 breaths/minute with grunting indicates respiratory distress.
Normal newborn temperature ranges from 97.7°F to 99.5°F (36.5°C to 37.5°C), and normal respiratory rate is 30 to 60 breaths/minute.
2
Determine the priority of care based on the Airway, Breathing, Circulation (ABC) framework.
The abnormal respiratory findings take immediate priority over routine care or solely addressing the hypothermia.
Respiratory distress in a neonate can quickly lead to hypoxia and further physical deterioration.
3
Identify the appropriate action within the practical nurse's scope of practice.
The nurse must escalate the critical findings to the registered nurse for advanced assessment and collaborative intervention.
Practical nurses are responsible for gathering data, recognizing abnormal findings, and reporting them to the supervising RN or provider for timely medical management.

Anahtar Kavram

Recognizing signs of neonatal respiratory distress and adhering to the practical nurse's scope of practice by reporting abnormal findings.
Soru 689Soru →

A client in a medical-surgical unit is scheduled for a laparoscopic cholecystectomy. The surgeon visited earlier in the morning to discuss the procedure, potential risks, and expected benefits. A registered nurse (RN) delegates the task of obtaining the client's signature on the surgical consent form to the practical nurse (PN). Upon bringing the form to the bedside, the client states, "The doctor explained everything, but I still do not really understand what they are going to do inside my body." Which action by the PN is legally required?

Cevabı ve açıklamayı göster

Cevap: Notify the surgeon or the supervising RN that the client requires further clarification before signing the consent form.

Cevap

Notify the surgeon or the supervising RN that the client requires further clarification before signing the consent form.
For a surgical consent form to be legally valid, the client must fully comprehend the procedure. The nurse's role in informed consent is to act as a client advocate and witness the signature, not to provide the primary medical explanation. Because the client expressed confusion, the legally required action is to pause the consent process and notify the surgeon or the supervising RN so the provider can return to clarify the procedure.

Adım Adım Çözüm

1
Evaluate the client's statement regarding their understanding of the surgical procedure.
The client explicitly states they do not understand what will happen during the surgery, indicating a knowledge deficit.
Informed consent requires the client to have a clear, voluntary understanding of the procedure, risks, and benefits before signing any legal documents.
2
Determine the PN's legal role and scope of practice within the informed consent process.
The PN acts only as an advocate and a witness to the voluntary signature. The PN cannot provide the primary medical explanation.
Explaining the medical procedure is the sole legal responsibility of the healthcare provider who will perform the surgery.
3
Take appropriate action to protect the client's legal rights and ensure safe practice.
The PN must withhold the consent form and notify the appropriate personnel (surgeon or RN).
The provider must return to the bedside to clarify the procedure and answer questions before the client can legally give informed consent.

Anahtar Kavram

Informed Consent Witnessing and Scope of Practice
Soru 690Soru →

A practical nurse (PN) is caring for an older adult client who is experiencing acute confusion and repeatedly attempting to pull out their intravenous (IV) line. The client's spouse is visibly distressed and demands that the PN immediately apply wrist restraints to prevent the client from disrupting the treatment. Which action should the PN take first to advocate for the client's right to a safe and least restrictive environment?

Cevabı ve açıklamayı göster

Cevap: Conceal the IV insertion site using a tubular bandage and provide the client with a safe item to hold for distraction.

Cevap

The correct action is to conceal the IV insertion site and provide a safe item for the client to hold as a distraction.
The correct answer demonstrates advocacy by protecting the client's right to a least restrictive environment. By hiding the IV site and giving the client something else to occupy their hands, the practical nurse effectively addresses the safety concern (maintaining IV access) without resorting to physical restraints.

Adım Adım Çözüm

1
Identify the primary clinical and ethical conflict.
The client requires IV therapy but is confused and pulling at the line. The spouse is demanding restraints, which infringes on the client's rights.
Recognizing the conflict between safety and client rights is essential for determining the correct nursing intervention.
2
Recall the legal and ethical guidelines regarding restraint use.
Clients have the right to be free from physical or chemical restraints imposed for purposes of discipline or convenience. Restraints are a last resort.
Nurses must act as advocates to protect clients from unnecessary restriction of movement.
3
Select the intervention that prioritizes the least restrictive alternative.
Concealing the IV line (out of sight, out of mind) and providing a distraction item (such as a washcloth to fold) safely addresses the behavior without using physical restraints.
This approach satisfies both the need for client safety (maintaining IV access) and the ethical mandate to uphold the client's rights.

Anahtar Kavram

Client Rights: Least Restrictive Environment and Restraint Alternatives
Soru 691Soru →

An older adult client with no prior cognitive deficits is admitted to the medical unit for treatment of a severe infection. On the second day of admission, the client suddenly develops acute confusion, becomes highly agitated, and repeatedly attempts to climb over the bed rails. After multiple non-pharmacological interventions prove ineffective, the provider prescribes bilateral soft wrist restraints. Which action by the practical nurse (PN) demonstrates safe and legally compliant management of the client's restraints?

Cevabı ve açıklamayı göster

Cevap: Attaching the restraint ties to the movable section of the bed frame using a quick-release slip knot.

Cevap

The correct action is attaching the restraint ties to the movable section of the bed frame using a quick-release slip knot.
Securing restraints to the movable portion of the bed frame ensures that the straps move synchronously with the client when the head or foot of the bed is raised or lowered, preventing accidental tightening and injury. Utilizing a quick-release slip knot is a critical safety standard, allowing healthcare personnel to remove the restraints instantly in the event of a fire, seizure, or cardiac arrest.

Adım Adım Çözüm

1
Analyze the legal and safety requirements for applying and maintaining physical restraints in an inpatient setting.
Identifies that restraints must be secured in a way that prevents patient injury during bed movement and allows for immediate emergency removal.
Safety devices must not introduce new hazards, such as strangulation or restricted peripheral blood flow.
2
Evaluate the restraint prescription guidelines and the boundaries of nursing delegation.
Recognizes that PRN orders for restraints are universally illegal and that neurovascular assessments are beyond the UAP's scope of practice.
Regulatory standards mandate continuous evaluation for alternatives, and assessing physiological status requires a licensed nurse's clinical judgment.
3
Select the option that aligns with established safety protocols for restraint application.
Chooses the option detailing attachment to the movable bed frame with a slip knot.
This is the only intervention that correctly reflects safe, legally compliant restraint application principles.

Anahtar Kavram

Physical Restraint Safety, Legal Regulations, and Delegation Scope
Tahmini Süre:1m 30s
Soru 692Soru →

A practical nurse (PN) enters the room of a client who has a T4 spinal cord injury. The client reports a sudden, severe pounding headache and blurred vision. The PN observes profuse diaphoresis above the level of the spinal injury and measures a blood pressure of 210/110 mm Hg. In which order should the PN perform the following actions? (Arrange the actions from first to last)

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct order of actions is to first elevate the head of the bed, followed by inspecting the urinary catheter for blockages, notifying the supervising RN, administering prescribed antihypertensive medication, and finally documenting the event.
Autonomic dysreflexia is a life-threatening hypertensive emergency that occurs in clients with spinal cord injuries at or above the T6 level. The prioritization of care must focus on immediate physiological stabilization. The absolute first action is to elevate the head of the bed to a high-Fowler's position; this immediately helps lower the blood pressure through orthostasis and reduces the risk of cerebral hemorrhage. Next, the nurse must assess for and remove the most common triggering stimulus, which is bladder distention, by checking the catheter for kinks or blockages. If the stimulus cannot be resolved or blood pressure remains high, the nurse must immediately notify the RN to escalate care, followed by administering prescribed PRN antihypertensive medications as directed. Finally, once the crisis is managed and the client is stable, the nurse documents the event, the interventions performed, and the client's response.

Adım Adım Çözüm

1
Recognize the clinical presentation of autonomic dysreflexia.
Identify a life-threatening hypertensive emergency.
The client has a T4 injury (above T6), severe hypertension, headache, and diaphoresis, which are hallmark signs of autonomic dysreflexia.
2
Intervene immediately to lower blood pressure physically.
Elevate the head of the bed to 90 degrees.
This decreases venous return and utilizes orthostatic principles to lower blood pressure, reducing the immediate risk of a stroke.
3
Assess for and remove the noxious stimulus.
Inspect the urinary catheter tubing.
A distended bladder from a kinked or obstructed catheter is the most common cause of the massive sympathetic response.
4
Escalate care and provide pharmacological management.
Notify the RN and administer prescribed oral antihypertensives.
Collaboration with the RN is necessary, and medications are indicated if the physical stimulus cannot be immediately resolved.
5
Complete post-event responsibilities.
Document the findings and actions.
Accurate medical records must be maintained after the client is stable and out of immediate danger.

Anahtar Kavram

Autonomic Dysreflexia Emergency Management
Soru 693Soru →

An unlicensed assistive personnel (UAP) urgently calls the practical nurse (PN) to the room of an 81-year-old client who underwent a total knee arthroplasty the previous day. The UAP reports the client has become suddenly agitated, is speaking incoherently, and is trying to remove their intravenous (IV) line. The client was previously alert and oriented. Current vital signs are a heart rate of 112 bpm, blood pressure of 98/62 mm Hg, and a respiratory rate of 26 breaths/min. Which action is the priority for the PN to take?

Cevabı ve açıklamayı göster

Cevap: Obtain an oxygen saturation reading using a pulse oximeter.

Cevap

Obtain an oxygen saturation reading using a pulse oximeter.
Sudden restlessness, agitation, and confusion in an older adult client, especially postoperatively, are cardinal early signs of hypoxia. Combined with borderline tachycardia (112 bpm) and tachypnea (26 breaths/min), the clinical picture strongly suggests an acute respiratory or hemodynamic compromise. According to the ABC (Airway, Breathing, Circulation) prioritization framework, the nurse must first assess the client's oxygenation status before implementing other interventions.

Adım Adım Çözüm

1
Analyze the clinical cues in the scenario.
The client is experiencing a sudden onset of agitation, confusion, tachycardia (112 bpm), and tachypnea (26 breaths/min).
Recognizing a sudden change from baseline is critical for identifying acute physiological decompensation.
2
Apply the Airway, Breathing, Circulation (ABC) prioritization framework.
The symptoms strongly suggest a Breathing or oxygenation issue (hypoxia) as the root cause of the acute confusion.
Hypoxia often manifests early as restlessness and altered mental status, especially in older adults.
3
Select the intervention that addresses the highest priority physiological need.
Assessing oxygen saturation provides immediate objective data regarding the client's respiratory status.
Data on oxygenation is required to confirm hypoxia and guide further emergent interventions before addressing secondary issues.

Anahtar Kavram

Prioritizing ABCs in Acute Decompensation
Soru 694Soru →

Which of the following clinical actions by a practical nurse (PN) represent adherence to legal and ethical practice standards? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Logging out of the electronic medical record on a hallway computer before entering a client's room.; Declining a charge nurse's directive to independently perform the comprehensive admission assessment for a newly admitted client.; Signing a surgical consent form strictly to verify that the client's signature was provided voluntarily.

Cevap

The correct actions are logging out of the electronic medical record before leaving a computer, declining to perform an initial comprehensive admission assessment, and witnessing a surgical consent form to verify a voluntary signature.
Adhering to legal and ethical standards requires the practical nurse to protect client privacy by securing health records, operate strictly within their scope of practice by refusing comprehensive admission assessments, and fulfill their legal role in informed consent by acting solely as a witness to a voluntary signature.

Adım Adım Çözüm

1
Analyze each option to determine if it aligns with the practical nurse's scope of practice, confidentiality laws, and ethical mandates.
Identified that logging out of unattended computers, refusing out-of-scope comprehensive assessments, and witnessing consent signatures are legally and ethically correct actions.
These actions uphold the Health Insurance Portability and Accountability Act (HIPAA) privacy rules and the legal limits of the Nurse Practice Act.
2
Evaluate the remaining options for potential legal or ethical violations.
Determined that delaying an abuse report, explaining surgical risks to a client, and discussing client information in public areas are direct violations of nursing standards.
Nurses must report suspected abuse immediately without waiting for proof, avoid acting outside their scope by explaining medical procedures, and protect client privacy at all times.

Anahtar Kavram

Legal and ethical nursing practice requires strict adherence to confidentiality regulations, mandatory reporting laws, and the defined practical nursing scope of practice.
Soru 695Soru →

During the morning shift, a nurse is assigned to a client undergoing treatment for active pulmonary tuberculosis who has newly developed frequent, watery stools. The healthcare provider suspects a Clostridioides difficile infection. Which infection control interventions must the nurse implement? (Select all that apply.)

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Don an N95 respirator, a fluid-resistant gown, and gloves prior to entering the client's negative-pressure room.; Ensure the client wears a standard surgical mask if transport outside the negative-pressure room is necessary.; Retain dedicated vital sign equipment, such as a stethoscope and thermometer, exclusively inside the client's room.

Cevap

The nurse must don an N95 respirator, gown, and gloves prior to entry; ensure the client wears a surgical mask during transport; and keep dedicated vital sign equipment in the room.
The combination of tuberculosis and suspected C. difficile necessitates both airborne and contact precautions. This means the nurse must don an N95 respirator, gown, and gloves before entry. Dedicated equipment must remain in the room to prevent contact transmission, and the client must wear a standard surgical mask during transport to prevent airborne transmission.

Adım Adım Çözüm

1
Identify the primary transmission routes for the two conditions.
Tuberculosis requires airborne precautions; Clostridioides difficile requires contact precautions.
Determining the required isolation categories dictates the necessary personal protective equipment (PPE) and environmental controls.
2
Determine the appropriate PPE for entering the room.
An N95 respirator is needed for airborne precautions, and a gown and gloves are needed for contact precautions.
All required PPE must be donned before crossing the threshold to prevent exposure.
3
Evaluate the hand hygiene requirements for the suspected pathogen.
Soap and water must be used.
C. difficile forms spores that are resistant to alcohol-based hand rubs and must be physically washed away.
4
Assess the sequence for PPE removal.
The N95 respirator must be removed after leaving the room.
Removing the respirator inside the room exposes the nurse to airborne droplets of Mycobacterium tuberculosis.
5
Review transport and equipment guidelines.
The client must wear a surgical mask during transport, and equipment must be dedicated to the room.
These measures prevent the spread of both airborne droplets and contact spores to the hospital environment.

Anahtar Kavram

Synthesis of Airborne and Contact Precautions
Soru 696Soru →

During handoff at a subacute care facility, a practical nurse receives an assignment that includes a client recovering from disseminated herpes zoster. The client's medical record indicates a new, concurrent infection with *Clostridioides difficile*. Which of the following care interventions should the practical nurse implement? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Perform hand hygiene strictly with soap and water after removing personal protective equipment.; Don a fit-tested N95 respirator, gown, and clean gloves prior to entering the client's isolation room.; Apply a standard surgical mask over the client's mouth and nose when transport to another department is required.; Verify that all healthcare staff entering the room have documented immunity to the varicella-zoster virus.

Cevap

The correct interventions include washing hands strictly with soap and water, wearing an N95 respirator along with a gown and gloves to enter the room, applying a standard surgical mask to the client during transport, and ensuring all entering staff have documented varicella immunity.
The client's dual diagnosis necessitates the synthesis of Airborne and enteric Contact precautions. Therefore, the nurse must don an N95 respirator, gown, and gloves prior to entry. Because C. difficile spores resist alcohol, hand hygiene must exclusively be performed with soap and water. During transport, clients on Airborne precautions must wear a standard surgical mask to contain respiratory secretions. Furthermore, only healthcare workers with documented immunity to varicella should provide care to prevent viral transmission.

Adım Adım Çözüm

1
Analyze the transmission risks for both pathogens.
Disseminated herpes zoster requires Airborne and Contact precautions. Clostridioides difficile requires enteric Contact precautions.
Identifying the specific transmission routes determines the appropriate combination of PPE, environmental cleaning, and room assignment.
2
Determine the necessary personal protective equipment (PPE) for room entry.
Staff must wear an N95 respirator (for airborne particles) plus a gown and gloves (for contact transmission).
Airborne precautions dictate respiratory protection, while Contact precautions dictate barrier protection for clothing and skin.
3
Identify specific hygiene and environmental cleaning protocols for the concurrent infections.
Hand hygiene must be performed with soap and water, and environmental surfaces must be cleaned with a bleach-based solution.
C. difficile spores are highly resilient and are not destroyed by alcohol-based hand rubs or standard quaternary ammonium disinfectants.
4
Evaluate the protocols for client transport and staff assignment.
The client must wear a standard surgical mask during transport, and only staff with documented varicella immunity should provide care.
A surgical mask contains the client's respiratory secretions at the source. Immune staff are protected from contracting the varicella-zoster virus.

Anahtar Kavram

Synthesizing multiple transmission-based protocols requires integrating Airborne precautions (N95 for staff, standard mask for client transport, immune staff only) with enteric Contact precautions (gown, gloves, soap and water handwashing, bleach disinfection).
Soru 697Soru →

A practical nurse (PN) is employed at a community-based hospice and palliative care center. Which of the following actions by the PN demonstrate adherence to legal boundaries and ethical mandates? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Verifying the physical presence of a signed Do Not Resuscitate (DNR) order in the medical record prior to withholding cardiopulmonary resuscitation.; Contacting the nursing supervisor and protective services immediately after observing a caregiver aggressively handle a vulnerable client.

Cevap

The correct actions are verifying the physical presence of a signed DNR order before withholding resuscitation and immediately reporting suspected caregiver abuse to the supervisor and protective services.
Verifying the physical presence of a signed DNR order ensures the nurse is following legal documentation rather than verbal hearsay when withholding life-saving measures. Additionally, immediately reporting suspected abuse fulfills the legal obligation of a mandated reporter to protect vulnerable clients from harm.

Adım Adım Çözüm

1
Evaluate each option against the legal scope of practice for a practical nurse.
Identify that explaining surgical complications and performing comprehensive admission assessments exceed the PN scope of practice.
The provider must obtain informed consent, and the RN must perform initial comprehensive assessments.
2
Analyze each option for compliance with ethical and legal mandates such as HIPAA and mandatory reporting.
Recognize that accessing an unassigned client's chart is a HIPAA violation, and delaying a report of suspected abuse violates mandatory reporting laws.
Nurses must protect client privacy and report suspicions of abuse immediately without waiting for definitive proof.
3
Identify the remaining appropriate actions.
Verifying a DNR order before acting and immediately reporting suspected abuse are both legally and ethically correct actions.
These actions adhere strictly to legal protocols for advance directives and mandated reporting laws.

Anahtar Kavram

The practical nurse must operate within their defined scope of practice, maintain strict client confidentiality, act as a mandated reporter of abuse, and follow established protocols for advance directives.
Soru 698Soru →

A client with left-sided weakness is scheduled to sit in a chair for their morning meal. The client is currently lying in bed. In what order should the nurse complete the following actions to safely transfer the client to a wheelchair?

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct chronological order is to first position the wheelchair on the client's strong side, lock all equipment brakes, assist the client to a sitting position to dangle their legs, apply the gait belt for safety, and finally instruct the client to bear weight on their strong leg to pivot into the chair.
Safe patient transfer requires a systematic approach to prevent injury to both the client and the nurse. Equipment positioning and stabilization must occur first by placing the chair on the strong side and locking all brakes. Next, the client is prepared physiologically by sitting up and dangling the legs to prevent orthostatic hypotension. A gait belt is then applied for handling safety. Finally, the physical pivot transfer is executed, relying on the client's strong leg to safely complete the movement into the wheelchair.

Adım Adım Çözüm

1
Position the wheelchair
Equipment is correctly aligned on the strong side.
Allows the client to use their unaffected side for maximum support during the movement.
2
Lock all brakes
Bed and wheelchair are completely immobilized.
Prevents equipment from shifting during the transfer, ensuring environmental safety.
3
Dangle legs on the edge of the bed
Client accommodates to an upright position.
Minimizes the risk of dizziness or orthostatic hypotension upon standing up.
4
Apply the gait belt
Nurse has a secure grip point.
Ensures the nurse can stabilize the client's center of gravity during the physical move without grabbing the client's arms or clothing.
5
Pivot transfer
Client is safely seated in the wheelchair.
Completes the transfer using safe body mechanics and the client's remaining strength.

Anahtar Kavram

Safe Client Transfer and Mobility
Soru 699Soru →

A practical nurse (PN) is reviewing the electronic health record of a client receiving a continuous intravenous heparin infusion for a pulmonary embolism. Which finding poses the greatest physiological risk to the client and requires immediate notification to the registered nurse?

Cevabı ve açıklamayı göster

Cevap: A platelet count of 85,000/mm³ that has decreased from a baseline of 210,000/mm³.

Cevap

The platelet count of 85,000/mm³ that has decreased from a baseline of 210,000/mm³.
A significant decrease in platelets (specifically a drop greater than 50% from baseline or a drop below 150,000/mm³) in a client receiving heparin strongly indicates Heparin-Induced Thrombocytopenia (HIT). This is a severe, immune-mediated complication that causes paradoxical widespread clotting and requires immediate notification of the registered nurse and healthcare provider to stop the infusion and initiate alternative anticoagulation.

Adım Adım Çözüm

1
Identify the client's current treatment and its associated severe risks.
The client is on a continuous heparin infusion, which carries a risk of severe bleeding and Heparin-Induced Thrombocytopenia (HIT).
Understanding the specific risks of high-alert medications guides the nurse to look for hallmark complications in the assessment data.
2
Analyze the laboratory data for critical values related to the therapy.
The platelet count has dropped by more than 50% and is critically low, whereas the aPTT of 68 seconds is perfectly therapeutic.
Differentiating between therapeutic effects and adverse reactions is essential for risk reduction.
3
Compare the severity of the physiological findings against environmental or administrative safety issues.
The platelet drop indicates a life-threatening physiological emergency, which takes strict priority over stable vital signs and missing barcode labels.
Clinical prioritization requires addressing immediate, life-threatening physiological complications before system or procedural issues.

Anahtar Kavram

Reduction of Risk Potential: Complications of Anticoagulant Therapy
Soru 700Soru →

While assisting a postoperative client who underwent abdominal surgery earlier in the day, a practical nurse obtains the following vital signs: temperature 98.8°F (37.1°C), heart rate 116 beats/min, respiratory rate 20 breaths/min, and blood pressure 92/54 mm Hg. The client's admission baseline blood pressure was 128/74 mm Hg. Which action should the nurse prioritize?

Cevabı ve açıklamayı göster

Cevap: Report the assessment data to the supervising registered nurse.

Cevap

The priority is to report the assessment data to the supervising registered nurse to address the potential circulatory compromise.
The correct action is communicating the abnormal vital signs to the supervising registered nurse. Tachycardia combined with a significant drop in blood pressure are classic early signs of shock or internal hemorrhage. Identifying and reporting circulatory instability addresses the 'C' (Circulation) in the ABC prioritization framework and is the most critical safety action.

Adım Adım Çözüm

1
Analyze the obtained vital signs against the baseline data.
The heart rate is elevated (116 beats/min) and the blood pressure has dropped significantly (92/54 mm Hg) compared to the baseline (128/74 mm Hg).
Comparing current data to baseline helps identify acute physiological changes.
2
Identify the clinical significance of these vital sign changes.
Tachycardia and hypotension in a postoperative client are classic early indicators of decreased cardiac output, hypovolemia, or internal hemorrhage.
Recognizing signs of shock is essential for preventing rapid deterioration.
3
Determine the priority intervention within the practical nursing scope of practice.
The supervising RN must be informed immediately to facilitate rapid assessment and medical intervention.
The practical nurse must escalate care when unstable or critical physiological changes are detected.

Anahtar Kavram

Early recognition of hypovolemic shock and timely escalation of care
Tahmini Süre:1m 0s
ÖncekiSayfa 35 / 147Sonraki
Tüm alıştırma soruları — NCLEX-PN | Examkin