Examkin

Tüm alıştırma soruları

2933 soru

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Soru 861Soru →

A practical nurse is preparing to administer a prescribed liquid medication via a percutaneous endoscopic gastrostomy (PEG) tube to a client receiving continuous enteral feedings. The continuous feeding has been paused. Arrange the following steps for medication administration in the correct chronological order.

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Cevap

The correct sequence is: 1) Elevate the head of the bed, 2) Aspirate to check residual, 3) Flush with water, 4) Administer the medication, and 5) Flush again with water.
To safely administer a medication via a PEG tube, the practical nurse must prioritize airway protection by first elevating the head of the bed. Next, verifying the residual volume ensures the stomach is not dangerously full. Flushing with water then clears the tube and confirms patency before pouring the medication into the syringe barrel for gravity administration. Finally, a concluding flush ensures all the medication reaches the stomach and keeps the tube clear of residue.

Adım Adım Çözüm

1
Elevate the head of the bed.
The client is positioned safely.
Maintaining an upright position of at least 30 degrees minimizes the risk of aspiration during and after administration.
2
Aspirate stomach contents.
Gastric residual volume is measured.
Checking residual volume ensures the stomach is not overly distended, which could lead to vomiting or regurgitation.
3
Flush the tube with 30 mL of sterile water.
The tube is cleared of feeding formula.
Flushing establishes patency and prevents chemical interactions between the feeding formula and the medication.
4
Administer the liquid medication.
The medication enters the stomach via gravity.
Gravity administration prevents excessive pressure that could damage the tube or cause discomfort.
5
Flush the tube again with 15 to 30 mL of sterile water.
The tube is completely cleared of the medication.
The final flush delivers the remaining medication in the tube into the stomach and prevents future occlusions.

Anahtar Kavram

Safe enteral medication administration requires verifying placement, ensuring patency, preventing formula-drug interactions, and minimizing aspiration risk.
Soru 862Soru →

An 82-year-old client was admitted to the medical unit two days ago for treatment of a severe urinary tract infection. The client, who had been completely alert and oriented since admission, is suddenly restless, unable to state their current location, and attempting to pull out their intravenous (IV) catheter. The client's baseline blood pressure on admission was 142/84 mm Hg. Current data collection reveals a blood pressure of 100/60 mm Hg, heart rate of 112 beats/min, respiratory rate of 24 breaths/min, and a temperature of 97.2°F (36.2°C). Which action is the priority for the practical nurse?

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Cevap: Notify the registered nurse immediately regarding the acute change in mental status and vital sign trends.

Cevap

Notify the registered nurse immediately regarding the acute change in mental status and vital sign trends.
The correct action is to immediately notify the registered nurse. The client is demonstrating classic signs of early septic shock: a significant decrease in blood pressure from their baseline, tachycardia, tachypnea, and a sudden alteration in mental status. In older adults, sudden restlessness or confusion is frequently the first presenting sign of a severe physiological complication like systemic infection or hypoxia. The practical nurse must prioritize recognizing these subtle but critical cues and escalating care to prevent complete hemodynamic collapse.

Adım Adım Çözüm

1
Analyze the client's current mental status against their baseline.
The client has transitioned from alert and oriented to confused and restless.
Sudden changes in level of consciousness in older adults are critical early indicators of systemic issues like hypoxia, infection, or decreased cerebral perfusion.
2
Compare the current vital signs to the admission baseline data.
The blood pressure has dropped significantly (systolic down 42 points), heart rate is elevated (112), and respiratory rate is elevated (24). Temperature is slightly subnormal, which can occur in sepsis.
Recognizing relative hypotension (a drop from the client's specific baseline) is essential, rather than relying solely on standard reference ranges.
3
Synthesize the data to determine the underlying physiological process.
The combination of the UTI history, altered mental status, relative hypotension, tachycardia, and tachypnea strongly suggests the client is entering early septic shock.
Identifying the pattern of impending shock determines the urgency of the required response.
4
Determine the priority nursing intervention within the practical nurse scope of practice.
The situation requires immediate escalation to the registered nurse or rapid response team.
Hemodynamic instability requires rapid assessment, fluid resuscitation, and potential medication administration that falls under RN and provider responsibilities.

Anahtar Kavram

Recognition of Early Septic Shock and Borderline Vitals in Older Adults
Soru 863Soru →

A practical nurse is preparing to administer a prescribed bolus enteral feeding via a gastrostomy tube to an adult client. Arrange the following actions in the correct chronological sequence.

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Cevap

The correct sequence is to first elevate the head of the bed, then check the gastric residual, flush the tube, administer the feeding formula, and finally flush the tube again.
Safe administration of enteral feedings requires a strict sequence to prevent complications, primarily aspiration. The client must first be positioned upright. Next, the nurse must assess gastrointestinal tolerance by checking residual volume. Once tolerance is established, the tube is flushed to ensure patency. The feeding is then administered, followed immediately by a final flush to maintain tube patency and hygiene.

Adım Adım Çözüm

1
Elevate the head of the bed.
The client is placed in a semi-Fowler's or Fowler's position.
This utilizes gravity to keep gastric contents in the stomach, minimizing the risk of reflux and aspiration during the procedure.
2
Check gastric residual volume.
The nurse determines how much formula remains in the stomach from prior feedings.
This assesses gastrointestinal tolerance; a high residual indicates delayed emptying and a high risk for aspiration if more feeding is added.
3
Perform the initial flush.
The tube is cleared with water.
This verifies that the tube is patent and functioning properly before administering a thicker substance.
4
Administer the feeding formula.
The client receives the prescribed nutrition.
Gravity feeding allows for a controlled rate, reducing the risk of nausea, cramping, and diarrhea.
5
Perform the final flush.
The tube is cleared of formula residue.
Formula left in the tube can solidify, causing blockages, and provides a medium for bacterial proliferation.

Anahtar Kavram

Enteral Nutrition Administration and Aspiration Precautions
Soru 864Soru →

A client is transferred to the surgical unit after undergoing a right modified radical mastectomy with axillary lymph node dissection. When assisting the client into a resting position in bed, which action regarding the right arm is most appropriate?

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Cevap: Support the arm on pillows so it rests higher than the level of the heart.

Cevap

Support the arm on pillows so it rests higher than the level of the heart.
The correct action is to elevate the affected arm on pillows above the level of the heart. Because axillary lymph nodes have been removed, normal lymphatic drainage is severely compromised. Elevating the arm uses gravity to promote venous and lymphatic return, which prevents painful swelling (lymphedema) and enhances overall client comfort.

Adım Adım Çözüm

1
Identify the physiological impact of the surgical procedure.
An axillary lymph node dissection disrupts the normal lymphatic drainage pathways in the affected arm, predisposing the client to lymphedema.
Understanding the anatomical changes helps prioritize the correct preventative care measure.
2
Determine the basic care and comfort goal for this specific postoperative period.
The goal is to prevent fluid pooling, minimize swelling, and maintain joint mobility without causing strain.
Excessive swelling causes severe discomfort, compromises tissue healing, and can lead to long-term complications.
3
Select the positioning technique that best achieves this goal.
Elevating the arm above the level of the right atrium (heart) enlists gravity to assist the compromised lymphatic system in returning fluid to central circulation.
Gravity is the most effective passive mechanism to reduce peripheral edema when normal lymphatic pathways are absent or healing.

Anahtar Kavram

Post-Mastectomy Care and Lymphedema Prevention
Soru 865Soru →

A practical nurse (PN) is caring for a client with acute encephalitis who is severely confused and repeatedly attempts to remove an intravenous (IV) catheter. After alternative measures have failed to keep the client safe, the healthcare provider prescribes bilateral soft wrist restraints.

Which of the following actions should the PN take while the client is restrained? (Select all that apply)

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Cevap: Remove the restraints at least every 2 hours to assess the skin and perform range-of-motion exercises.; Attach the restraint straps to a part of the bed frame that moves when the head of the bed is adjusted.; Ensure that two fingers can comfortably fit between the restraint device and the client's wrist.

Cevap

The correct actions are removing the restraints every 2 hours for skin care, attaching the straps to a movable part of the bed frame, and ensuring two fingers fit between the restraint and the wrist.
Safe restraint application requires strict adherence to safety protocols: regular removal (every 2 hours) is essential to prevent skin breakdown and maintain joint mobility. Securing the straps to the movable part of the bed frame prevents hazardous tightening when the bed is adjusted. Allowing a two-finger gap ensures that arterial and venous circulation is maintained while keeping the restraint functional.

Adım Adım Çözüm

1
Evaluate the requirement for routine restraint release.
Identify that restraints must be removed at least every 2 hours.
This action prevents skin breakdown, contractures, and allows for thorough neurovascular assessment.
2
Determine the proper anatomical and structural location for securing the restraint.
Identify that straps must be tied to the movable part of the bed frame, not side rails.
Securing to side rails causes injury if the rails are dropped; securing to a movable frame ensures the restraint moves safely with the client's body position.
3
Verify the correct tightness of the applied restraint.
Identify that a two-finger gap is the required standard.
This specific measurement ensures the restraint is tight enough to prevent escape but loose enough to maintain peripheral perfusion.
4
Analyze the incorrect actions for legal and scope-of-practice violations.
Rule out delegating assessments, tying to side rails, and PRN prescriptions.
Assessments cannot be delegated, side rails are a severe safety hazard, and PRN orders for restraints are legally prohibited.

Anahtar Kavram

Safe application, monitoring, and legal parameters of physical restraints.
Tahmini Süre:2m 0s
Soru 866Soru →

A practical nurse (PN) is providing home health care to a client who requires complex wound management and intravenous (IV) therapy. During the visit, several of the client's family members are present in the home. Which actions by the PN demonstrate adherence to legal and ethical practice standards? Select all that apply.

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Cevap: Respecting the client's decision to refuse the wound dressing change and documenting the refusal in the medical record.; Immediately contacting the nursing supervisor after witnessing a family member forcefully grab the client's arm.; Asking the client for explicit permission before exposing the wound while family members are in the room.

Cevap

The correct actions are respecting the client's treatment refusal, immediately reporting the witnessed physical altercation, and asking for permission before exposing the client's wound in front of family.
The practical nurse legally and ethically complies with standards by respecting a competent client's right to refuse treatment, honoring their privacy by asking permission before exposing their body to others, and fulfilling the legal duty to immediately report suspected physical abuse.

Adım Adım Çözüm

1
Evaluate the actions related to the PN's scope of practice and clinical delegation.
Identified that administering initial IV push medications is beyond the recognized scope for a practical nurse.
Scope of practice defines the legal boundaries of nursing interventions based on licensure.
2
Analyze the actions concerning client confidentiality and physical privacy.
Determined that leaving clinical documents visible violates HIPAA, whereas obtaining permission before exposing a wound appropriately protects client privacy.
Nurses are legally obligated to protect protected health information (PHI) and maintain client dignity.
3
Assess the responses to suspected client abuse.
Recognized that reporting forceful grabbing immediately is legally required, while delaying the report until receiving a verbal confirmation violates mandated reporting laws.
Mandated reporters must act on reasonable suspicion to protect vulnerable populations from immediate harm.
4
Review the action regarding the client's refusal of care.
Concluded that respecting and documenting a competent client's refusal of wound care upholds their right to autonomy.
The Patient Self-Determination Act protects a competent adult's right to accept or refuse medical interventions.

Anahtar Kavram

The practical nurse must operate strictly within their legal scope of practice while upholding core ethical principles, including mandatory abuse reporting, client confidentiality (HIPAA), and the right to autonomy.
Soru 867Soru →

An attending surgeon hands a surgical consent form to the practical nurse (PN) and states, "I am needed in the emergency department right now. Please explain the risks of the bowel resection to the client and get their signature." A friend is currently visiting in the client's room. Which of the following actions should the PN take to protect the client's rights and maintain safe practice? Select all that apply.

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Cevap: Inform the surgeon that the provider who performs the procedure must be the one to explain the surgical risks.; Ask the visiting friend to step out of the room before initiating any clinical discussions with the client.

Cevap

The correct actions are to inform the surgeon that explaining surgical risks is the provider's responsibility, and to ask the visiting friend to step out of the room before having any clinical discussions.
The correct actions uphold the practical nurse's scope of practice and protect the client's right to privacy. The healthcare provider performing the procedure is legally responsible for explaining the risks, benefits, and alternatives. The nurse's role is strictly to witness the signature. Additionally, asking the visitor to step out ensures the client's medical information is kept confidential, upholding HIPAA regulations.

Adım Adım Çözüm

1
Analyze the provider's request against the practical nurse's scope of practice.
The PN identifies that explaining surgical risks is solely the provider's responsibility.
The nurse's role in informed consent is limited to witnessing the client's signature only after the provider has fully educated the client.
2
Evaluate the environment for potential privacy violations.
The presence of a friend in the room poses a risk to client confidentiality.
HIPAA and client rights regulations require medical information to be discussed in private unless the client explicitly consents to others hearing it.
3
Select the interventions that uphold both scope of practice and confidentiality.
The PN declines the out-of-scope task and secures the room's privacy.
Client advocacy requires protecting both the client's legal right to proper informed consent and their right to privacy.

Anahtar Kavram

Informed Consent and Confidentiality
Soru 868Soru →

A practical/vocational nurse (LPN/VN) receives the shift handoff on a surgical orthopedics unit. While organizing the daily workflow, the nurse identifies several pending client interventions. Which of the following tasks must the LPN/VN recognize as being outside their legal scope of practice and requiring reassignment to a registered nurse (RN)? Select all that apply.

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Cevap: Creating the initial discharge education plan for a client who had a total hip arthroplasty.; Evaluating a client's respiratory status following an urgent nebulizer treatment for sudden-onset wheezing.; Administering an intravenous (IV) push dose of hydromorphone for breakthrough incisional pain.

Cevap

The tasks that exceed the LPN/VN scope and require RN reassignment are creating the initial discharge education plan, evaluating a client's response to an urgent breathing treatment, and administering an IV push dose of hydromorphone.
The tasks that exceed the practical nurse's scope of practice involve comprehensive assessment, initial education planning, evaluation of unstable clients, and administration of high-risk intravenous push medications. Formulating an initial discharge plan requires the registered nurse's clinical judgment. Evaluating a client with a sudden respiratory compromise involves complex, continuous assessment of an unstable condition. Finally, pushing intravenous narcotics is restricted to the RN scope due to the rapid onset and risk for severe respiratory depression.

Adım Adım Çözüm

1
Analyze each delegated task against the established legal boundaries of practical nursing.
Identify whether each task involves routine care on a stable client or complex assessment on an unstable client.
The LPN/VN is legally obligated to refuse or reassign tasks that exceed their scope of practice to ensure client safety.
2
Evaluate the task involving the initial discharge education plan.
Recognize this as outside the LPN/VN scope.
The RN is responsible for synthesizing data to initiate teaching plans; the LPN/VN may only reinforce established teaching.
3
Evaluate the task involving sudden-onset wheezing.
Recognize this as outside the LPN/VN scope.
A client with an acute, sudden respiratory change is unstable. Evaluating their response requires comprehensive RN assessment, not basic data collection.
4
Evaluate the administration of IV push hydromorphone.
Recognize this as outside the LPN/VN scope.
Due to the inherent risks and need for immediate clinical judgment regarding adverse reactions, IV push medications are generally restricted to RNs.
5
Verify the remaining tasks (subcutaneous injection, established sterile dressing, emptying drains).
Confirm these are within the LPN/VN scope.
These represent standard, predictable care procedures on stable clients and do not require complex RN-level clinical judgment.

Anahtar Kavram

LPN/VN Scope of Practice: Distinguishing Between Independent Tasks and Required RN Collaboration
Soru 869Soru →

A practical nurse is preparing to administer a scheduled dose of oral digoxin to an adult client. Prior to administration, the nurse auscultates the client's apical pulse and notes a rate of 5454 beats per minute. Which of the following actions should the practical nurse take?

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Cevap: Withhold the medication and report the heart rate to the registered nurse.

Cevap

Withhold the medication and report the heart rate to the registered nurse.
Digoxin is a cardiac glycoside that slows the heart rate. The standard nursing safety protocol is to withhold the medication and notify the supervising registered nurse or healthcare provider if an adult client's apical pulse is less than 6060 beats per minute, as administering it could cause severe, symptomatic bradycardia or indicate medication toxicity.

Adım Adım Çözüm

1
Analyze the client's pre-administration clinical data.
The client has an apical pulse of 5454 beats per minute.
Cardiac glycosides like digoxin require a current heart rate assessment before every dose.
2
Compare the assessment finding to standard safe administration parameters.
The heart rate of 5454 beats per minute is below the standard adult minimum threshold of 6060 beats per minute.
Digoxin exerts a negative chronotropic effect, meaning it further slows down the heart rate.
3
Identify the safest action within the practical nurse's scope of practice.
The nurse must safely withhold the medication and escalate the finding.
Administering the medication could cause harm, and altering the dose is outside the PN scope. The RN or provider must evaluate the client.

Anahtar Kavram

Pre-administration Assessment and Safe Medication Practices for Cardiac Glycosides
Soru 870Soru →

During morning rounds, the practical nurse evaluates a client who is 48 hours postpartum following an uncomplicated vaginal delivery. The nurse observes a moderate amount of dark red vaginal drainage with a fleshy odor on the perineal pad. What is the most appropriate action for the nurse to take based on this clinical finding?

Cevabı ve açıklamayı göster

Cevap: Document the finding as normal lochia rubra in the client's medical record.

Cevap

Document the finding as normal lochia rubra in the client's medical record.
At 48 hours postpartum, a moderate amount of dark red vaginal discharge with a fleshy odor is a completely normal and expected physiological finding known as lochia rubra. Lochia rubra typically lasts for the first 3 to 4 days after delivery. The practical nurse's correct and independent action is to accurately document this normal progression in the client's medical record.

Adım Adım Çözüm

1
Analyze the client's postpartum timeframe.
The client is exactly 48 hours (2 days) postpartum.
Lochia stages are strictly determined by the amount of time elapsed since delivery.
2
Evaluate the characteristics of the observed vaginal drainage.
The drainage is described as a moderate amount of dark red fluid with a fleshy odor.
These specific characteristics define lochia rubra, which is the normal shedding of blood and decidua.
3
Determine the appropriate independent nursing intervention.
The practical nurse should accurately document the finding as expected lochia rubra.
Because the clinical presentation represents a normal, expected physiological process, it requires standard documentation rather than emergency interventions or escalation to the registered nurse.

Anahtar Kavram

Postpartum Lochia Progression
Soru 871Soru →

A practical nurse (PN) on a medical-surgical unit is caring for an older adult client with Alzheimer's disease who is hospitalized for dehydration. The client is confused, highly restless, and repeatedly tries to climb out of bed. Which action should the PN take to ensure the client's safety while utilizing the least restrictive intervention?

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Cevap: Lower the bed to its lowest position and place a high-impact fall mat on the floor beside it.

Cevap

The correct action is to lower the bed to its lowest setting and place a high-impact fall mat beside it.
Lowering the bed and placing a fall mat on the floor are evidence-based, non-restrictive interventions. These actions do not limit the client's freedom of movement—therefore they are not restraints—but they significantly reduce the distance of a potential fall and cushion the impact, directly preventing severe injury.

Adım Adım Çözüm

1
Analyze the client's behavior and associated risk factors.
The client is confused, restless, and at high risk for falls due to repeatedly attempting to climb out of bed.
Identifying the specific safety threat is the essential first step in clinical decision-making.
2
Evaluate the proposed interventions against the principle of least restrictive care.
Side rails, sedatives, and locked trays all act as physical or chemical restraints, which limit freedom of movement.
Nurses are legally and ethically mandated to exhaust all less restrictive alternatives before applying any form of restraint.
3
Select the intervention that promotes safety without functioning as a restraint.
Lowering the bed and using a fall mat prevents severe injury while maintaining the client's freedom of movement.
This approach aligns with evidence-based safety standards for managing restless clients with cognitive impairment.

Anahtar Kavram

Restraint Alternatives and Fall Injury Prevention
Tahmini Süre:1m 0s
Soru 872Soru →

A client with a confirmed diagnosis of active pulmonary tuberculosis needs to be transported to the radiology department for a prescribed imaging study. When preparing the client to leave their negative-pressure isolation room, which action should the practical nurse take?

Cevabı ve açıklamayı göster

Cevap: Apply a standard surgical mask over the client's nose and mouth prior to exiting the room.

Cevap

The correct action is to apply a standard surgical mask over the client's nose and mouth before they leave the isolation room.
When a client on airborne precautions (such as for active pulmonary tuberculosis) must be transported outside of their negative-pressure room, the priority is source control. Applying a standard surgical mask over the client's nose and mouth effectively traps infectious droplet nuclei before they enter the shared environment. The client does not wear an N95 respirator, as these are designed for healthcare personnel protection and require formal fit-testing.

Adım Adım Çözüm

1
Identify the pathogen and its mode of transmission.
Tuberculosis is transmitted via airborne droplet nuclei, requiring Airborne Precautions.
Understanding the transmission route is essential for selecting the correct infection control measures.
2
Determine the specific requirements for transporting a client on Airborne Precautions.
The primary goal is source control to prevent the client from expelling infectious droplets into the shared hospital environment.
Pathogens must be contained at the source when the client is moved outside of a controlled negative-pressure environment.
3
Select the appropriate personal protective equipment (PPE) for the client.
A standard surgical mask is chosen over an N95 respirator.
Surgical masks effectively contain respiratory secretions from the source, whereas N95s are designed for staff inhalation protection and require fit-testing.
4
Evaluate the need for staff PPE during transport.
Transporting staff do not need to wear full airborne PPE if the client is adequately masked.
Once the client is properly masked, the immediate risk of airborne transmission in the hallway is mitigated.

Anahtar Kavram

Airborne Precautions during Client Transport
Soru 873Soru →

A licensed practical/vocational nurse (LPN/VN) is providing care alongside a registered nurse (RN) and an assistive personnel (AP) for a client recovering from a total knee arthroplasty. Which action by the LPN/VN represents appropriate care assignment and collaboration?

Cevabı ve açıklamayı göster

Cevap: Administering a scheduled oral muscle relaxant before the AP assists the client with repositioning

Cevap

Administering a scheduled oral muscle relaxant before the AP assists the client with repositioning
The administration of scheduled oral medications is a standard, safe task within the LPN/VN scope of practice. Coordinating this intervention prior to the AP assisting with physical movement demonstrates excellent clinical judgment and interprofessional collaboration, as it proactively promotes client comfort and safety during mobility tasks.

Adım Adım Çözüm

1
Analyze the role and authorized tasks of the LPN/VN.
The LPN/VN is authorized to administer routine oral medications, care for stable clients, and collaborate with the AP for basic care tasks.
Understanding the foundational boundaries of the LPN/VN scope of practice is required to identify the correct clinical action.
2
Evaluate the collaborative aspect of the correct task.
Providing pain or muscle spasm relief prior to physical manipulation by the AP ensures the client can tolerate the movement.
Effective interprofessional collaboration involves anticipating client needs and coordinating care timing between team members.
3
Rule out actions that violate legal boundaries or safety standards.
Initial education for informed consent, IV push administration for acute changes, and sharing information with unassigned staff are all violations of LPN/VN scope or ethical standards.
Delegation and task acceptance must strictly adhere to the NCSBN guidelines, state practice acts, and HIPAA regulations.

Anahtar Kavram

LPN/VN Scope of Practice and Interprofessional Collaboration
Soru 874Soru →

A practical nurse is preparing to initiate prescribed phototherapy for a 2-day-old newborn who has hyperbilirubinemia. In what order should the nurse perform the following actions? Arrange the steps from first to last.

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Cevap

The correct sequence is to first remove the newborn's clothing except the diaper, then apply opaque eye shields, place the newborn under the unit, and finally turn on the phototherapy lights.
The priority when initiating phototherapy is to ensure treatment efficacy while maintaining strict safety standards. The newborn must first be undressed down to the diaper to maximize skin exposure. Next, opaque eye shields are applied to protect the retinas before the infant is exposed to the light source. The infant is then safely positioned under the unit. Finally, the lights are turned on, and the start time is documented to initiate the prescribed therapy.

Adım Adım Çözüm

1
Remove the newborn's clothing except for the diaper.
The newborn's skin is maximally exposed.
Maximum skin exposure is required for the phototherapy lights to effectively convert bilirubin into a water-soluble form.
2
Apply opaque eye shields over the newborn's closed eyes.
The newborn's eyes are securely protected.
The intense lights can cause retinal damage, so eye protection must be secured before exposure to the light source.
3
Place the newborn in the bassinet or incubator under the phototherapy unit.
The newborn is positioned in the treatment area.
The infant must be safely placed in the appropriate environment designed for the therapy.
4
Turn on the phototherapy lights and document the therapy start time.
Phototherapy is initiated and recorded.
Activating the lights begins the treatment, and documentation ensures accurate tracking of therapy duration.

Anahtar Kavram

Phototherapy setup and newborn safety
Soru 875Soru →

A practical nurse is caring for a client who is 4 hours postpartum following a prolonged vaginal delivery. The client's baseline vital signs upon admission to the postpartum unit were blood pressure 118/76 mm Hg and heart rate 82 beats/min. The current vital signs are blood pressure 92/58 mm Hg and heart rate 118 beats/min. The client's fundus is firm, midline, and at the umbilicus, with moderate lochia rubra. Which action should the practical nurse take?

Cevabı ve açıklamayı göster

Cevap: Notify the registered nurse immediately regarding the vital sign changes

Cevap

Notify the registered nurse immediately regarding the vital sign changes
The correct answer involves notifying the registered nurse immediately. The client's significant tachycardia (118 beats/min) and hypotension (92/58 mm Hg) are early, critical signs of hypovolemic shock. Because the fundus is firm and lochia is moderate, this bleeding may be concealed (such as a vaginal or pelvic hematoma) or from a cervical laceration. The practical nurse must recognize these abnormal vital signs and promptly escalate the situation to the registered nurse for comprehensive assessment and rapid medical intervention.

Adım Adım Çözüm

1
Analyze the client's vital sign trends by comparing baseline to current readings.
The blood pressure has decreased significantly (hypotension) and the heart rate has increased significantly (tachycardia).
Identifying significant deviations from baseline vital signs helps detect potential physiological instability and complications.
2
Evaluate the current postpartum physical assessment findings in relation to the vital signs.
The fundus is firm and midline with moderate lochia, indicating that uterine atony is not the likely cause of the vital sign changes.
Ruling out a boggy uterus helps determine that the instability might be caused by an unobserved issue, such as a cervical laceration or internal hematoma.
3
Determine the safest and most appropriate intervention based on the practical nurse's scope of practice.
The practical nurse must alert the registered nurse immediately about the client's deteriorating status.
Practical nurses must recognize early signs of shock and escalate care, as independent management of unstable clients is outside their designated scope.

Anahtar Kavram

Recognizing early signs of postpartum hypovolemic shock and adhering to practical nurse scope of practice
Soru 876Soru →

Prior to providing direct care for a newly admitted client with confirmed pulmonary tuberculosis and a secondary scabies infection, a practical nurse must apply multiple forms of personal protective equipment. The client requires airborne and contact precautions, along with eye protection due to a planned wound irrigation. In what order should the nurse don the necessary protective items?

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Cevap

The correct sequence for donning personal protective equipment is: Hand hygiene, followed by the isolation gown, the N95 respirator, eye protection, and finally, gloves.
According to the Centers for Disease Control and Prevention (CDC) guidelines, donning personal protective equipment must follow a specific sequence to optimize safety and barrier integrity. Hand hygiene is always the critical first step. The gown is applied next to cover the torso and arms. The N95 respirator follows, allowing it to seal directly against the face. Eye protection is then added without disrupting the respirator seal. Finally, gloves are donned and pulled completely over the gown cuffs to seal the wrists.

Adım Adım Çözüm

1
Identify the first action required to prevent contamination of clean supplies.
Perform hand hygiene.
Hands must be clean before touching any unused personal protective equipment from the isolation cart.
2
Determine the first physical barrier to apply to the body.
Apply the isolation gown.
The gown provides core body coverage and is easiest to tie securely before applying other equipment to the face.
3
Identify the primary respiratory protection needed for airborne precautions.
Don the N95 respirator.
The respirator must be fitted directly against the skin for a secure seal before placing any eyewear.
4
Determine the next facial protection needed for the wound irrigation.
Place the face shield or goggles.
Eye protection is placed over or alongside the respirator without breaking the mask's protective seal.
5
Identify the final step for contact protection.
Put on clean gloves.
Gloves go on last so they can be pulled up over the gown cuffs, ensuring no skin on the wrists is exposed to pathogens.

Anahtar Kavram

The standardized Centers for Disease Control and Prevention (CDC) sequence for donning personal protective equipment ensures maximum infection control by preventing self-contamination and creating continuous physical barriers.
Soru 877Soru →

A client in an outpatient clinic has a new prescription for amoxicillin oral suspension 400 mg400\text{ mg} twice daily. The clinic stock contains amoxicillin in a concentration of 250 mg/5 mL250\text{ mg} / 5\text{ mL}. How many mL will the practical nurse administer for a single dose? (Record the answer to the nearest whole number. Do not include units in the answer.)

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Cevap: 8

Cevap

8
The practical nurse uses the standard dosage calculation formula: Desired doseAvailable dose×Quantity\frac{\text{Desired dose}}{\text{Available dose}} \times \text{Quantity}. The prescribed dose is 400 mg400\text{ mg}, and the available concentration is 250 mg250\text{ mg} per 5 mL5\text{ mL}. Plugging these values into the formula gives 400250×5=1.6×5=8 mL\frac{400}{250} \times 5 = 1.6 \times 5 = 8\text{ mL}. The nurse should administer 8 mL8\text{ mL} for a single dose.

Adım Adım Çözüm

1
Identify the prescribed (desired) dose.
400 mg400\text{ mg}
This is the amount of medication the provider has ordered for one dose.
2
Identify the concentration of the medication on hand (have) and the volume it comes in (quantity).
250 mg250\text{ mg} per 5 mL5\text{ mL}
This determines the strength of the available liquid medication.
3
Apply the dosage calculation formula: DesiredHave×Quantity\frac{\text{Desired}}{\text{Have}} \times \text{Quantity}.
400250×5=8 mL\frac{400}{250} \times 5 = 8\text{ mL}
This calculation yields the exact volume needed to deliver the prescribed 400 mg400\text{ mg} dose.

Anahtar Kavram

Dosage calculation for oral liquid medications
Soru 878Soru →

A practical nurse is preparing to provide oral hygiene to a client who remains unconscious following a prolonged surgical procedure. Arrange the following actions in the chronological order they must be performed to maintain client safety. (Assume hand hygiene and donning of gloves are complete.)

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Cevap

The correct sequence prioritizes airway safety: position the client side-lying, place protective linens/basin, safely open the mouth with a tongue blade, perform the oral cleansing, and finally moisturize the lips.
When providing basic care to an unconscious client, the absolute priority is maintaining a patent airway and preventing aspiration. Placing the client in a side-lying position must occur before any other step. After safety is established, the nurse protects the bed and clothing, safely gains access to the mouth to avoid reflex injuries, performs the actual cleansing, and completes the procedure by applying moisturizer for comfort.

Adım Adım Çözüm

1
Ensure an open and safe airway.
The client is positioned on their side.
A side-lying position uses gravity to help oral secretions and cleaning fluids drain out of the mouth, significantly reducing the risk of aspiration into the lungs.
2
Protect the client and bedding.
A towel and emesis basin are placed in position.
Gathering and placing supplies keeps the client clean, dry, and comfortable during the procedure.
3
Gain safe access to the oral cavity.
A padded tongue blade is used to separate the upper and lower teeth.
An unconscious client may have a strong involuntary bite reflex. A padded tongue blade safely keeps the mouth open without risking injury to the nurse's fingers or the client's teeth.
4
Perform the hygiene procedure.
The oral cavity is cleansed.
Thorough cleaning removes plaque and bacteria, which prevents hospital-acquired infections like pneumonia.
5
Provide final skin care.
Water-soluble moisturizer is applied to the lips.
Unconscious clients often breathe through their mouths, leading to dry and cracked lips. A water-soluble product provides safe moisture.

Anahtar Kavram

Prioritization of Airway Protection During Basic Care
Tahmini Süre:1m 30s
Soru 879Soru →

A practical nurse (PN) is preparing to implement a new prescription for mechanical wrist restraints for a client who is severely agitated and attempting to remove their central venous catheter. Place the following nursing actions in the correct chronological order.

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Cevap

The correct sequence is to first confirm the provider's prescription, then discuss the rationale with the client, apply protective padding to the wrists, fasten the straps to the movable section of the bed frame using a quick-release knot, and finally evaluate the client's neurovascular status distal to the device.
The correct sequence follows the standard of care for restrictive device application. Verification of the legal order ensures authorization; communication respects client rights; padding prevents skin breakdown during application; securing to an articulating frame with a slip knot ensures physical safety; and immediate neurovascular assessment confirms the device is not overly restrictive.

Adım Adım Çözüm

1
Confirm the provider's written prescription and specific clinical indications.
Verification that a valid, current legal order exists for the restrictive device.
Restraints require a valid provider order outlining the specific type and duration; they cannot be applied on a PRN (as needed) basis.
2
Discuss the rationale for the safety device with the client.
The client is informed about why the intervention is necessary.
Providing education respects the client's rights, reduces fear, and may increase cooperation even if the client is agitated.
3
Place protective padding around the client's wrists.
The bony prominences of the wrists are cushioned.
Padding minimizes friction and pressure, which prevents skin breakdown and tissue injury during device use.
4
Fasten the device straps to the articulating section of the bed using a slip knot.
The device is securely anchored to a safe location with a quick-release mechanism.
Securing straps to an articulating (movable) section prevents injury when the bed position is adjusted, and a slip knot ensures rapid removal in an emergency. They must never be tied to side rails.
5
Evaluate distal perfusion, sensation, and motor function.
The neurovascular status of the extremity is documented immediately after application.
Immediate assessment ensures the device is not applied too tightly, which could severely compromise blood flow or cause nerve damage.

Anahtar Kavram

Safe application of physical restraints requires a systematic approach beginning with legal order verification, followed by client education, proper physical application techniques to prevent injury, and immediate post-application neurovascular assessment.
Soru 880Soru →

A practical nurse is preparing to provide direct care for a pediatric client who has been admitted with respiratory syncytial virus (RSV) and is placed on contact and droplet precautions. Arrange the steps for donning the required personal protective equipment (PPE) in the correct sequence from first to last.

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The correct sequence is: Perform hand hygiene, put on the gown, apply the surgical mask, position the face shield or goggles, and finally put on the gloves.
According to the Centers for Disease Control and Prevention (CDC) guidelines, the correct sequence for donning PPE is to perform hand hygiene first, followed by the gown. The mask or respirator is applied next, followed by eye protection (goggles or face shield). Gloves are always put on last so they can be extended to cover the wrist cuffs of the isolation gown, ensuring no skin is exposed.

Adım Adım Çözüm

1
Identify the required precautions for RSV.
The nurse determines that contact and droplet precautions require a gown, surgical mask, eye protection, and gloves.
Knowing the correct PPE items is essential before beginning the donning process.
2
Apply the CDC recommended sequence for donning PPE.
The nurse sequences the steps starting with hand hygiene, followed by the gown, mask, eye protection, and finally gloves.
Following the standardized sequence prevents contamination of clean equipment and ensures all barriers (like the glove-over-gown seal) are properly established.

Anahtar Kavram

Standard Sequence for Donning Personal Protective Equipment (PPE)
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Tüm alıştırma soruları — NCLEX-PN | Examkin