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Soru 61Soru →

A practical nurse (PN) is preparing to measure orthostatic vital signs for an older adult client who reports experiencing dizziness when getting out of bed. Arrange the following steps in the correct sequence the PN should follow to safely and accurately assess for orthostatic hypotension.

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Cevap

The correct sequence is to first have the client lie supine for 5 to 10 minutes, measure the baseline vitals, assist the client to a standing position, wait 1 to 3 minutes, and finally re-measure the vitals in the standing position.
Measuring orthostatic vital signs accurately requires a strict protocol to detect orthostatic hypotension safely. The client must first rest supine to establish a true baseline. After taking these baseline measurements, the client is assisted to a standing position. Gravity causes blood to pool in the lower extremities, and the nurse must wait 1 to 3 minutes to see if the autonomic nervous system properly compensates. Finally, re-measuring the vitals will reveal if there is a significant, sustained drop in blood pressure or an abnormal increase in heart rate.

Adım Adım Çözüm

1
Ensure the client rests in a supine position for 5 to 10 minutes.
The cardiovascular system reaches a resting baseline state.
Accurate comparison requires a stable, resting baseline before initiating positional changes.
2
Measure and record the blood pressure and pulse rate.
Baseline vital signs are established.
These values serve as the control to determine if subsequent positional changes cause abnormal deviations.
3
Assist the client to a standing position.
Gravity causes a sudden fluid volume shift toward the lower extremities.
Standing triggers the baroreceptor reflex, which tests the autonomic nervous system's ability to compensate for the positional change.
4
Wait 1 to 3 minutes after the position change.
The body is given time to compensate for the fluid shift.
Taking vitals too quickly can yield false results, as the cardiovascular system needs a brief period to adjust to the gravitational pull.
5
Measure and record the standing blood pressure and pulse rate.
Standing vital signs are obtained.
Comparing these values to the baseline identifies orthostatic hypotension, which is typically defined as a drop in systolic blood pressure of 20 mm Hg or more, or diastolic blood pressure of 10 mm Hg or more.

Anahtar Kavram

Orthostatic Vital Signs Assessment Protocol
Tahmini Süre:1m 30s
Soru 62Soru →

A practical nurse (PN) is preparing to administer an intramuscular (IM) injection of iron dextran to an adult client using the Z-track method. Arrange the following steps for this procedure in the correct chronological order.

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Cevap

The correct sequence for a Z-track IM injection is: cleanse the site, displace the tissue laterally, insert the needle and inject, wait 10 seconds, and finally withdraw the needle while releasing the tissue.
The Z-track method is designed specifically to prevent highly irritating or staining medications (like iron dextran) from leaking into the subcutaneous tissue. Proper sequence is vital: site preparation must happen first. The skin is then displaced to shift the entry point. While maintaining displacement, the injection is given. Waiting 10 seconds allows the medication to disperse. Finally, withdrawing the needle and releasing the skin simultaneously 'locks' the track, sealing the medication deep inside the muscle.

Adım Adım Çözüm

1
Cleanse the injection site and allow it to dry.
Pathogens are removed from the skin surface.
Prevents the introduction of microorganisms deep into the muscle tissue upon needle insertion.
2
Displace the skin and subcutaneous tissue.
The superficial tissues are offset from the underlying muscle.
Creates a non-linear path (a 'Z' track) for the needle to follow, preparing the mechanical lock.
3
Insert the needle at 90 degrees and inject.
Medication is delivered directly into the deep muscle belly.
Ensures the medication reaches the highly vascular muscle tissue for proper absorption.
4
Wait 10 seconds before removing the needle.
Medication diffuses into the surrounding muscle fibers.
Prevents the fluid from being forced back up the needle track due to pressure in the tissue.
5
Withdraw the needle and release the tissue simultaneously.
The displaced tissue slides back over the injection site in the muscle.
Closes off the needle track, preventing irritating medications like iron dextran from leaking into the subcutaneous layer and causing severe staining or pain.

Anahtar Kavram

Safe Medication Administration: Z-Track Method
Soru 63Soru →

A client with a tracheostomy requires suctioning to clear audible, coarse secretions. Arrange the following actions in the correct sequence that the practical nurse (PN) should perform to minimize the risk of hypoxia and mucosal trauma.

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The correct sequence is: hyperoxygenate the client, advance the catheter without suction, pull the catheter back slightly after meeting resistance, apply intermittent suction while rotating upon withdrawal, and finally reassess the client's status.
Performing tracheostomy suctioning requires a strict sequence to clear secretions safely. Preoxygenation protects against hypoxemia. Advancing without suction and pulling back at the carina prevents mucosal injury. Suctioning only on withdrawal with a twisting motion effectively clears mucus while avoiding tissue damage. Post-procedure assessment evaluates the success of the intervention.

Adım Adım Çözüm

1
Hyperoxygenate the client with 100% oxygen.
The client's oxygen reserves are maximized.
Prevents severe hypoxemia when airflow is temporarily compromised by the suction catheter.
2
Advance the sterile suction catheter without applying suction.
The catheter is positioned deep into the trachea.
Applying suction during insertion damages the mucosal lining and unnecessarily depletes oxygen.
3
Pull the catheter back slightly (1 to 2 cm) after meeting resistance.
The catheter tip is positioned just above the carina.
Resting the suction tip directly on the sensitive carina causes severe coughing and tissue trauma.
4
Apply intermittent suction while rotating the catheter upon withdrawal.
Secretions are cleared from the airway.
Rotation prevents the catheter from adhering to one spot, and limiting suction minimizes airway collapse.
5
Reassess the client's oxygen saturation and lung sounds.
The effectiveness of the procedure is confirmed.
Ensures the airway is clear and oxygenation is stable before concluding care.

Anahtar Kavram

Airway Management and Complication Prevention
Soru 64Soru →

While conducting mid-morning rounds, a practical nurse observes that a conscious, alert client with type 1 diabetes mellitus is trembling, pale, and profusely diaphoretic. The client's point-of-care capillary blood glucose reading is 52 mg/dL (2.9 mmol/L). Place the following nursing actions in the correct chronological sequence to safely manage this situation.

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Cevap

The correct sequence is to first administer a fast-acting carbohydrate, then recheck the glucose in 15 minutes, followed by providing a complex carbohydrate and protein snack, and finally documenting the event.
For a conscious client experiencing acute hypoglycemia, the priority is to immediately raise the blood glucose level using 15 grams of a simple carbohydrate. After a 15-minute interval, the nurse must recheck the glucose to evaluate if it has risen above 70 mg/dL. If the level is stable, a complex carbohydrate and protein snack is provided to maintain the glucose level over time. Documentation is always completed as the final step after the client is physically stabilized and the immediate risk is resolved.

Adım Adım Çözüm

1
Administer 15 grams of a fast-acting carbohydrate.
Provides an immediate source of glucose to the bloodstream.
Rapidly reverses the hypoglycemic state, reducing the risk of central nervous system depression or seizures.
2
Reassess the capillary blood glucose level after 15 minutes.
Determines if the initial intervention was successful.
Ensures the blood glucose is rising appropriately, aiming for greater than 70 mg/dL, as dictated by standard hypoglycemia protocols.
3
Provide a complex carbohydrate and protein snack.
Supplies sustained energy over the next several hours.
Fast-acting carbohydrates metabolize quickly; a complex carbohydrate combined with protein prevents a rebound hypoglycemic episode before the next scheduled meal.
4
Document the hypoglycemic episode and interventions.
Creates a permanent record of the acute event.
Fulfills professional obligations by communicating the event to the broader healthcare team only after the client has been safely stabilized.

Anahtar Kavram

Reduction of Risk Potential: Emergency Protocol for Hypoglycemia Management
Soru 65Soru →

A practical nurse is gathering supplies to enter the isolation room of an infant diagnosed with respiratory syncytial virus (RSV). The facility protocol requires full personal protective equipment (PPE) for this assignment. Arrange the following actions for putting on the required PPE in the correct chronological sequence.

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Cevap

The correct sequence is to first perform hand hygiene, then put on the gown, followed by the mask, then the goggles or face shield, and finally the gloves.
According to standard CDC guidelines for infection control, the proper sequence for donning full personal protective equipment begins with hand hygiene to ensure cleanliness. The isolation gown is applied first to cover the torso and arms. Next, the mask is secured to protect the respiratory mucous membranes. Goggles or a face shield are applied over the mask to protect the eyes. Finally, gloves are donned last so they can be pulled securely over the wrist cuffs of the isolation gown, creating an unbroken barrier between the nurse and the client environment.

Adım Adım Çözüm

1
Determine the correct starting point before applying any protective gear.
Hand hygiene must be performed first.
Starting with clean hands prevents the transfer of environmental pathogens onto the clean PPE supplies.
2
Identify the first physical garment to be worn.
The isolation gown is put on next.
The gown provides broad body coverage and serves as the primary base layer of the barrier protocol.
3
Determine the order for facial and respiratory protection.
The mask is applied before the goggles or face shield.
Securing the mask first ensures it fits tightly against the face. Eye protection is then placed over the top edge of the mask.
4
Identify the final step in the sequence.
Gloves are put on last.
Donning gloves at the end allows the nurse to pull the glove openings directly over the gown's long sleeves, creating a continuous seal without exposed skin.

Anahtar Kavram

Centers for Disease Control and Prevention (CDC) standardized sequence for donning personal protective equipment (PPE).
Soru 66Soru →

A practical nurse and an assistive personnel (AP) are preparing to move a postoperative client who has limited mobility up in bed using a draw sheet. In what order should the nurse perform the following actions? Arrange the steps in the correct sequence.

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1. Lower the head of the bed. 2. Place the pillow against the headboard. 3. Have the client fold arms and bend knees. 4. Roll the draw sheet tightly. 5. Slide the client upward on the count of three.
Moving a client up in bed requires careful sequencing to ensure the safety of both the client and the nursing staff. The procedure must begin by minimizing gravitational resistance, which is achieved by laying the bed flat. Next, the client's head must be protected by placing the pillow against the headboard. Preparing the client's body by crossing their arms and bending their knees reduces friction and allows the client to assist in the move. Finally, establishing a firm grip on the draw sheet close to the client's body allows for a safe, coordinated slide on the count of three, preventing shearing injuries and staff back strain.

Adım Adım Çözüm

1
Lower the head of the bed to a completely flat position.
The bed is horizontal, removing the incline.
Moving a client up an incline increases the physical strain on staff and the friction on the client's skin. A flat bed uses gravity properly.
2
Remove the pillow from under the client's head and place it against the headboard.
The headboard is padded by the pillow.
This crucial safety step prevents head trauma if the client is pulled too far upward during the maneuver.
3
Ask the client to fold their arms across their chest and bend their knees.
The client is in a compact position.
Crossing arms prevents injury and reduces surface area friction. Bending knees allows the client to use their leg muscles to help push.
4
Roll the edges of the draw sheet tightly against the sides of the client's body.
The draw sheet is prepared for grasping.
Holding the draw sheet close to the client's center of gravity improves biomechanics and reduces the risk of dropping or rolling the client.
5
Coordinate with the AP to shift weight and slide the client upward on the count of three.
The client is repositioned appropriately in the bed.
Coordinated action ensures a smooth transfer, reducing shearing forces on the client's skin and minimizing musculoskeletal strain on the staff.

Anahtar Kavram

Proper body mechanics and client safety during mobility assistance
Soru 67Soru →

A practical nurse (PN) is assisting a client who is 2 days postoperative following an abdominal surgery. The client coughs forcefully and reports a sudden "popping" sensation. The PN observes that the surgical wound has completely separated and loops of bowel are protruding. In what order should the PN perform the following actions? Arrange the actions from first priority to last.

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The correct sequence for managing a wound evisceration is to first stay with the client and call for help, then position the client in low Fowler's with knees flexed, followed by covering the wound with sterile saline-soaked dressings, measuring vital signs, and finally documenting the event.
Wound evisceration is a medical emergency requiring rapid, sequential intervention. The absolute first priority is client safety, meaning the nurse must stay at the bedside and call for help to get the RN, surgeon, and necessary supplies (Step 1). To prevent further protrusion of the bowel, the nurse immediately positions the client in a low Fowler's position with the knees flexed to relax the abdominal muscles (Step 2). Once supplies arrive, the exposed organs must be covered with sterile, normal saline-soaked dressings to prevent tissue drying and necrosis (Step 3). After the organs are protected, the nurse obtains vital signs to monitor for impending shock (Step 4). Finally, once the client is fully stabilized and prepared for return to the operating room, the nurse documents the event (Step 5).

Adım Adım Çözüm

1
Identify the immediate safety priority when an evisceration occurs.
The nurse stays with the client and calls for assistance.
The client is experiencing a surgical emergency and requires immediate advanced support and supplies, but leaving the client alone could compromise their safety.
2
Determine the physical action to prevent worsening of the condition.
The nurse places the client in a low Fowler's position with flexed knees.
This position reduces intra-abdominal pressure and tension on the suture line, preventing more bowel from protruding.
3
Identify the intervention to protect the exposed tissue.
The nurse covers the bowel with sterile, saline-moistened dressings.
Exposed internal organs can quickly dry out and become necrotic or infected; a moist, sterile environment preserves the tissue until surgery.
4
Determine the necessary clinical assessment.
The nurse obtains the client's vital signs.
Evisceration causes fluid shifts and immense physical stress, putting the client at high risk for shock. Monitoring vital signs detects this early.
5
Identify the final administrative responsibility.
The nurse documents the entire event.
Accurate charting is required for the medical record, but it must wait until the client's physiological safety is secured.

Anahtar Kavram

Prioritization of Wound Evisceration Management
Soru 68Soru →

A practical nurse is preparing to administer a morning dose of 10 units of regular insulin and 20 units of NPH insulin subcutaneously to a client with type 2 diabetes mellitus. Arrange the following steps for preparing and mixing these insulins in the correct chronological order.

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The correct sequence is to roll the NPH vial, inject air into the NPH vial, inject air into the regular vial, withdraw the regular insulin, and finally withdraw the NPH insulin.
The standard 'clear before cloudy' procedure ensures that the shorter-acting, clear regular insulin is not contaminated by the longer-acting, cloudy NPH insulin. Rolling the NPH gently prevents bubble formation while ensuring the suspension is properly mixed. Injecting air into both vials prevents a vacuum from forming, which ensures accurate dosing.

Adım Adım Çözüm

1
Roll the NPH insulin vial between the palms.
The cloudy insulin suspension is evenly mixed without forming bubbles.
Shaking the vial can cause bubbles, which leads to inaccurate dosing.
2
Inject 20 units of air into the NPH vial and remove the syringe.
Pressure is equalized in the NPH vial.
Air must be injected to prevent a vacuum, but withdrawing medication now would contaminate the needle before it enters the regular insulin vial.
3
Inject 10 units of air into the regular insulin vial.
Pressure is equalized in the regular insulin vial.
This prepares the regular insulin vial for immediate medication withdrawal.
4
Withdraw 10 units of regular insulin.
The short-acting (clear) insulin is drawn into the syringe first.
Drawing the clear insulin first prevents it from being contaminated by the longer-acting NPH insulin.
5
Withdraw 20 units of NPH insulin.
The syringe now contains a total of 30 units of mixed insulin.
Drawing the cloudy insulin last completes the mixture safely without risking contamination of the regular insulin vial.

Anahtar Kavram

Safe preparation and mixing of short-acting (clear) and intermediate-acting (cloudy) insulins.
Soru 69Soru →

A client recovering from an ischemic stroke is receiving a continuous enteral tube feeding. The client suddenly develops a forceful cough, perioral cyanosis, and audible wheezing. In what order should the practical nurse (PN) perform the following actions? (Arrange the items in the correct chronological sequence from first to last.)

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The correct sequence of actions is to first stop the enteral feeding, then elevate the head of the bed, obtain vital signs and oxygen saturation, auscultate lung sounds, and finally notify the RN.
In an acute respiratory emergency involving enteral feedings, the practical nurse must follow the ABCs (Airway, Breathing, Circulation) framework and the nursing process. The immediate threat is ongoing aspiration, so the feeding must be stopped first to secure the airway. Next, positioning the client upright supports breathing and ventilation. Only after these immediate interventions should the nurse gather assessment data (vital signs followed by focused auscultation) to prepare a complete clinical report. Finally, the nurse escalates the situation by notifying the RN with the collected data.

Adım Adım Çözüm

1
Stop the continuous enteral feeding pump.
Prevents further formula from entering the client's lungs.
Addresses the immediate root cause threatening the client's airway (Airway priority).
2
Position the client in a high-Fowler's position.
Maximizes lung expansion and utilizes gravity.
Supports effective breathing and oxygenation (Breathing priority).
3
Obtain the client's oxygen saturation and vital signs.
Provides immediate objective hemodynamic and respiratory data.
Quantifies the severity of the client's physiological distress to establish a baseline.
4
Auscultate the client's anterior and posterior lung sounds.
Identifies specific adventitious breath sounds such as wheezing or crackles.
Provides focused clinical assessment data necessary for formulating an accurate clinical picture.
5
Notify the registered nurse (RN) about the change in condition.
Escalates the client's care to the appropriate clinical leader.
Ensures the client receives necessary advanced medical interventions based on the gathered assessment data.

Anahtar Kavram

When a client experiences sudden respiratory distress during an enteral feeding, the practical nurse must prioritize interventions using the airway, breathing, and circulation (ABC) framework: first stop the feeding (airway), optimize positioning (breathing), gather physiological data, and then escalate care.
Soru 70Soru →

A practical nurse has finished providing care for a client on Contact and Droplet precautions. The nurse is currently wearing gloves, an isolation gown, a face shield, and a surgical mask. In what order should the nurse safely remove the personal protective equipment (PPE)? Arrange the steps in the correct sequence from first to last.

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Cevap

The correct doffing sequence is: 1) Remove gloves, 2) Remove face shield, 3) Remove gown, 4) Remove surgical mask, 5) Perform hand hygiene.
The standard sequence for removing PPE is designed to minimize the risk of self-contamination. Gloves are the most contaminated and are removed first. The face shield is removed next, handling only the clean back strap. The gown is then unfastened and rolled inside out. The mask is removed last to protect the airway while other items are doffed. Finally, hand hygiene is mandatory to remove any residual pathogens.

Adım Adım Çözüm

1
Identify the most contaminated item to remove first.
Gloves are the most contaminated and are removed and discarded first.
To prevent transferring pathogens to other surfaces, clean areas of PPE, or the face.
2
Determine the next item to remove that protects the eyes.
The face shield is removed next by grasping the clean back strap.
The front is contaminated; handling only the back strap protects the hands.
3
Determine the sequence for the gown.
The gown is removed third.
Unfastening and peeling it off inside out prevents contact with the contaminated front and sleeves.
4
Determine the sequence for the mask.
The surgical mask is removed fourth.
It continues to protect the respiratory tract during the removal of the gown and face shield.
5
Identify the final required action.
Perform thorough hand hygiene.
To remove any residual pathogens that may have inadvertently contaminated the hands during the doffing process.

Anahtar Kavram

Personal Protective Equipment (PPE) Doffing Sequence
Soru 71Soru →

A practical nurse (PN) is observing a client who is receiving a transfusion of packed red blood cells. Ten minutes into the transfusion, the client reports sudden lower back pain, chills, and shortness of breath. In what order should the PN perform the following actions to minimize client risk?

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Cevap

The correct sequence is to first stop the transfusion, then maintain the IV line with new tubing and normal saline, assess the client's vital signs, notify the RN and provider, and finally prepare the blood equipment for laboratory return.
The correct sequence prioritizes immediate risk mitigation by stopping the source of harm (the blood). Next, venous access is secured with uncontaminated tubing to prevent flushing residual blood into the client. Only after the client is safe from further immediate harm are assessments performed and the RN/provider notified for advanced orders. Finally, administrative and diagnostic steps like saving the equipment are completed.

Adım Adım Çözüm

1
Stop the transfusion completely.
The administration of the offending blood product is halted.
This is the most critical first step to prevent further physiological harm during a suspected hemolytic or allergic reaction.
2
Disconnect the tubing and attach a new line with normal saline.
Venous access is maintained without administering more blood.
Flushing the existing tubing would push the remaining reactive blood in the line into the client's circulation, exacerbating the reaction.
3
Measure vital signs and oxygen saturation.
Baseline hemodynamic and respiratory data are collected.
Current physiological status must be evaluated to determine the severity of shock or respiratory distress.
4
Notify the RN and healthcare provider.
Higher-level care and emergency interventions are initiated.
The practical nurse must escalate life-threatening acute changes so the RN and provider can prescribe and administer emergency treatments.
5
Prepare the blood bag and tubing for return.
The physical evidence is ready for laboratory analysis.
The blood bank must test the product and tubing to identify the specific type of reaction once the client is safely stabilized.

Anahtar Kavram

Transfusion Reaction Emergency Management
Soru 72Soru →

A practical nurse (PN) is preparing to obtain a capillary blood glucose reading for a client with type 2 diabetes mellitus. To ensure an accurate result and reduce the risk of infection, in what order should the PN perform the following actions? (Arrange the steps in the correct sequence.)

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Cevap

The correct sequence is to identify the client, cleanse the finger, let it air dry, puncture the skin and wipe the first drop, then test the second drop.
Performing the steps in this specific order guarantees both client safety and the exact accuracy of the diagnostic lab value. Identifying the client is always the priority. Cleansing the site removes surface bacteria and residual sugars. Allowing the alcohol to naturally air dry ensures it does not alter the glucose result or cause a burning sensation upon puncture. Wiping away the first drop of blood is crucial because it contains serous tissue fluid that dilutes the sample. The second drop provides an accurate capillary specimen, which is vital for safe medication administration.

Adım Adım Çözüm

1
Verify identity and explain the procedure.
The correct client is confirmed and prepared.
Prevents medication and diagnostic errors by ensuring the right patient is being tested.
2
Cleanse the lateral aspect of the finger.
The puncture site is sanitized.
Reduces the risk of infection and removes any external glucose (e.g., from food) on the skin.
3
Allow the alcohol to air dry.
The site is dry and ready for puncture.
Wet alcohol can cause stinging during puncture and can hemolyze the red blood cells, leading to an inaccurate reading.
4
Puncture the skin and wipe away the first drop of blood.
Tissue fluid is removed from the sample site.
The initial drop of blood is heavily mixed with interstitial serous fluid, which can artificially dilute the blood glucose concentration.
5
Apply the second drop of blood to the test strip.
An accurate glucose reading is obtained.
The second drop consists of pure capillary blood, providing the most reliable value for potential insulin administration.

Anahtar Kavram

Diagnostic Test Preparation and Specimen Collection
Soru 73Soru →

A practical nurse (PN) is preparing to administer an iron dextran intramuscular (IM) injection using the Z-track method to a client with severe iron deficiency anemia. The PN has already identified the client, donned gloves, cleansed the site, and prepared the syringe. In which order should the PN perform the following steps? (Arrange the actions from first to last)

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Cevap

The correct sequence for administering a Z-track IM injection is: pull the skin laterally, insert the needle at 90 degrees, inject the medication slowly, wait 10 seconds, and finally withdraw the needle before releasing the skin.
The Z-track method is designed to prevent irritating or staining medications (such as iron dextran) from leaking into the subcutaneous tissue. The correct sequence ensures the skin is displaced prior to needle insertion and remains displaced until after the needle is fully withdrawn. This creates a zig-zag path that permanently seals the medication within the muscle.

Adım Adım Çözüm

1
Pull the overlying skin and subcutaneous tissue laterally 1 to 1.5 inches.
The tissue is displaced from its normal alignment.
Displacing the tissue creates a staggered pathway that prevents medication leakage into the subcutaneous tissue.
2
Insert the needle at a 90-degree angle using a smooth, dart-like motion.
The needle enters the deep muscle.
A 90-degree angle ensures the medication reaches the vascular muscle layer rather than the subcutaneous fat.
3
Inject the medication slowly and steadily over several seconds.
The medication is delivered into the muscle.
Slow injection allows the medication to disperse evenly and minimizes tissue irritation.
4
Wait for 10 seconds while leaving the needle in place.
The medication begins to absorb.
Pausing prevents the medication from tracking back up the needle pathway immediately upon withdrawal.
5
Withdraw the needle smoothly and immediately release the retracted skin.
The needle track is sealed.
Releasing the skin after withdrawal restores the tissue alignment, sealing the track and locking the medication safely in the muscle.

Anahtar Kavram

Z-track method for intramuscular injections
Soru 74Soru →

A practical nurse is preparing to transfer a client with left-sided hemiparesis from the bed to a wheelchair. In what order should the nurse perform the following actions? Arrange the steps in the correct sequence.

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Cevap

The correct sequence is to first position and lock the wheelchair on the strong side, sit the client on the edge of the bed with proper footwear, apply a transfer belt, brace the weak leg, and finally instruct the client to stand, pivot, and reach for the armrests.
Safe transfer of a client with one-sided weakness (hemiparesis) requires prioritizing the use of the unaffected side and maintaining strict fall precautions. The environment must first be prepared by placing the locked wheelchair on the strong side. The client is then safely positioned at the edge of the bed with non-skid footwear. A transfer belt is applied for grip, and the nurse must brace the weak leg to prevent buckling before initiating the stand-and-pivot motion.

Adım Adım Çözüm

1
Place the wheelchair parallel to the bed on the client's strong side and lock the wheels.
The environment is secured for a safe transfer.
Transferring toward the strong side allows the client to use their unaffected limbs to support their body weight.
2
Assist the client to sit on the edge of the bed and ensure they are wearing non-skid footwear.
The client is positioned upright and feet are protected from slipping.
Sitting allows time to assess for dizziness (orthostatic hypotension), and proper footwear prevents falls on smooth floors.
3
Secure a transfer belt around the client's waist over their clothing.
The transfer belt is securely fastened.
The belt provides the nurse with a firm, safe grip to assist with weight-bearing without pulling on the client's arms.
4
Face the client, maintain a wide base of support, and brace the client's left knee and foot.
The client's weak side is physically supported by the nurse.
Hemiparesis causes muscle weakness; bracing prevents the affected leg from buckling under the client's weight.
5
Instruct the client to stand, pivot on the right leg, and reach back for the wheelchair armrests.
The client is safely seated in the wheelchair.
Pivoting on the strong leg maximizes client independence and safety while completing the transfer.

Anahtar Kavram

Safe client transfer techniques for hemiparesis
Soru 75Soru →

An outpatient clinic has requested a 24-hour urine collection for a client being evaluated for nephropathy. The client is currently staying in a short-term rehabilitation unit. How should the nurse sequence the steps to ensure an accurate specimen collection? Arrange the actions in the correct chronological order.

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Cevap

To properly execute a 24-hour urine collection, the nurse must first instruct the client to empty the bladder and discard that urine, document the start time immediately, collect all subsequent urine in a chilled container, obtain one final void exactly 24 hours later, and then promptly label and send the completed specimen to the laboratory.
A 24-hour urine collection requires precise timing and sequencing to accurately measure kidney function. The protocol must always begin with an empty bladder (by discarding the first void) so only newly produced urine is measured. The start time must be documented immediately. All subsequent urine is kept cold to preserve its chemical composition. Exactly 24 hours later, the client voids one last time to finalize the collection, after which the complete specimen is labeled and sent for analysis.

Adım Adım Çözüm

1
Have the client void and discard the urine.
The bladder is emptied of preexisting urine.
Ensures the 24-hour period starts with no older urine in the bladder, which would skew the volume and analyte calculations.
2
Record the time of the discarded void.
The exact start time is established.
Provides a definitive, documented timestamp to calculate the 24-hour completion mark accurately.
3
Collect all subsequent urine and store it on ice or in a refrigerator.
All urine produced during the testing window is safely stored.
Cold storage preserves the specimen's integrity and prevents the breakdown of substances being measured.
4
Instruct the client to void exactly 24 hours after the start time and add this to the collection.
The final amount of urine produced in the period is captured.
Completes the physiological 24-hour cycle of urine production.
5
Label and transport the container.
The specimen reaches the lab safely and promptly.
Maintains specimen viability and ensures accurate patient identification for diagnostics.

Anahtar Kavram

24-Hour Urine Specimen Collection Protocol
Soru 76Soru →

A practical nurse (PN) is assisting a client who has a right-sided chest tube to change positions in bed. Suddenly, the chest tube is completely pulled out of the client's chest wall. Arrange the following immediate nursing actions in the correct chronological order.

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Cevap

The correct sequence is to first instruct the client to exhale and bear down, cover the site with petroleum gauze, secure the tape on three sides, assess the respiratory status, and finally notify the healthcare team.
In any respiratory emergency where the pleural space is exposed to the atmosphere, the absolute first priority is to stop air entry (Airway/Breathing principle). Asking the client to exhale and bear down provides an immediate internal pressure block, allowing the nurse a few seconds to apply the physical petroleum gauze seal. Taping it on three sides is the standard of care to create a one-way flutter valve. Only after securing the airway and breathing mechanics should the nurse assess the physiological response and notify the team.

Adım Adım Çözüm

1
Instruct the client to forcefully exhale and bear down.
Intrathoracic pressure immediately increases.
This prevents atmospheric air from entering the pleural cavity through the newly opened wound, which would collapse the lung.
2
Cover the insertion site with a sterile petroleum gauze.
An airtight seal is created over the wound.
The petroleum gauze acts as an immediate physical barrier to stop further air exchange between the atmosphere and the pleural space.
3
Secure the occlusive dressing with tape on three sides.
A flutter valve (one-way valve) is established.
Taping only three sides allows any trapped air to escape during exhalation but prevents outside air from being drawn in during inhalation, drastically reducing the risk of a tension pneumothorax.
4
Assess the client's respiratory rate and oxygen saturation.
Baseline respiratory data is obtained.
The nurse must evaluate if the client is experiencing respiratory distress, hypoxia, or signs of a developing pneumothorax after the acute intervention is applied.
5
Notify the registered nurse and healthcare provider.
The medical team is alerted to the critical event.
The client will likely require emergency medical intervention, such as a chest X-ray and the insertion of a new chest tube.

Anahtar Kavram

Emergency Priority Management of an Accidentally Dislodged Chest Tube
Soru 77Soru →

A newly admitted client experiencing severe constipation is prescribed a warm tap water enema. The equipment has been gathered and the solution is prepared in the enema bag. Arrange the following steps in the correct chronological sequence to safely administer the enema.

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Cevap

The correct sequence begins with proper positioning, followed by tube preparation, safe insertion, fluid instillation, and finally, managing potential complications like cramping.
Administering an enema requires sequential steps that prioritize safety, anatomical alignment, and client comfort. Proper left-sided positioning must occur first so gravity can assist fluid travel into the descending colon. Lubrication must happen before insertion to prevent mucosal damage. The tube is then inserted following the natural curve of the bowel (toward the umbilicus). Only after proper insertion should the clamp be opened to begin instillation. Finally, if the client experiences cramping during the procedure, the nurse must intervene by lowering the bag to reduce flow pressure.

Adım Adım Çözüm

1
Assist the client into the left lateral Sims' position.
The client's descending colon is positioned optimally.
Gravity aids the flow of solution into the sigmoid and descending colon when the client is on their left side.
2
Lubricate the distal end of the enema tubing.
The tube tip becomes slick and smooth.
Lubrication prevents friction, discomfort, and trauma to the rectal mucosa.
3
Insert the tubing gently into the rectum angled toward the umbilicus.
The tube safely enters the lower bowel.
Angling toward the umbilicus aligns the tube with the anatomical contour of the rectum, minimizing the risk of bowel perforation.
4
Unclamp the tubing and allow the fluid to instill slowly.
The enema solution begins to flow into the client.
Slow instillation minimizes sudden bowel distention, which can cause intense cramping.
5
Lower the enema container if the client reports abdominal cramping.
The flow rate of the solution decreases.
Lowering the bag reduces hydrostatic pressure, alleviating cramps without having to remove the tube entirely.

Anahtar Kavram

Bowel Elimination and Enema Administration
Tahmini Süre:1m 0s
Soru 78Soru →

A practical nurse (PN) is preparing to remove an indwelling urinary catheter from an adult female client. Arrange the following actions in the correct sequence to reduce the risk of trauma and potential complications.

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Cevap

The correct sequence is: position the client and place a pad, attach the syringe to the port, withdraw all fluid from the balloon, instruct the client to exhale while withdrawing the catheter, and finally inspect the catheter tip.
The correct sequence ensures client comfort, prevents environmental contamination, and minimizes the risk of urethral trauma or retained foreign bodies. Proper preparation, complete balloon deflation, and post-removal inspection are key risk reduction strategies.

Adım Adım Çözüm

1
Position the client supine with knees flexed and place a waterproof pad under the buttocks.
The client is appropriately positioned, and the environment is protected.
Optimal visualization of the meatus and protection of bed linens are necessary first steps.
2
Attach a designated syringe to the catheter's balloon inflation port.
The syringe is securely connected.
A secure connection is required to draw back the fluid anchoring the catheter.
3
Withdraw the entire volume of sterile water from the balloon.
The balloon is completely deflated.
Failing to remove all fluid before pulling will cause significant urethral trauma and pain.
4
Instruct the client to take a deep breath and exhale while smoothly withdrawing the catheter.
The catheter is safely removed from the urethra.
Exhaling relaxes the pelvic floor sphincter muscles, reducing resistance during removal.
5
Inspect the catheter tip to ensure it is completely intact.
The tip is verified to be whole.
A retained catheter fragment can lead to bladder infection, obstruction, or calculi formation.

Anahtar Kavram

Indwelling Urinary Catheter Removal Sequence
Soru 79Soru →

A practical nurse (PN) and an unlicensed assistive personnel (UAP) are preparing to move a partially dependent client up in bed using a draw sheet. In what order should the nurse direct these actions? Arrange the steps from first to last.

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Cevap

The correct sequence is: 1) Position the bed flat and raise the bed height, 2) Remove the pillow and place it against the headboard, 3) Instruct the client to fold their arms and bend their knees, 4) Grasp the draw sheet close to the client, and 5) Shift weight to move the client on the count of three.
To safely move a client up in bed, the nurse must first prioritize environmental safety and ergonomics by flattening and raising the bed. Next, the client's head is protected by placing the pillow against the headboard. The client is then positioned to minimize friction and assist with the move (arms folded, knees bent). Finally, the caregivers establish a secure, close grip on the draw sheet and use a coordinated weight-shifting technique to execute the movement safely.

Adım Adım Çözüm

1
Prepare the environment for safe ergonomics.
The bed is flattened and raised to waist level.
Minimizes the need for the caregivers to reach or bend at the waist, reducing back strain and preventing gravity from working against the movement.
2
Protect the client from potential injury.
The pillow is placed against the headboard.
Provides a soft barrier that prevents the client's head from striking the hard surface of the headboard during the upward motion.
3
Prepare the client for movement.
The client's arms are folded and knees are bent.
Folding the arms reduces friction against the bed linens. Bending the knees allows the client to push with their heels, actively assisting the caregivers and reducing lifting requirements.
4
Establish a secure grip for the transfer.
The draw sheet is rolled and grasped close to the client's body.
Holding the sheet close to the client keeps the weight close to the caregivers' center of gravity, which is essential for safe body mechanics.
5
Execute the movement synchronously.
Caregivers shift their weight and the client is moved up in bed.
Moving on a unified count ensures smooth motion, evenly distributes the workload, and prevents jerky movements that could cause pain or injury.

Anahtar Kavram

Proper body mechanics and safety principles during client positioning and bed transfers.
Tahmini Süre:1m 15s
Soru 80Soru →

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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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
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