Tüm alıştırma soruları

2933 soru

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A practical nurse is providing basic care for a client who is on prolonged bed rest following an abdominal surgery. Which nursing actions will best promote client comfort and maintain skin integrity? Select all that apply.

Geçerli olan tümünü seçin

Keep the bottom bed sheets tight and free of wrinkles.

Reposition the client from side to side at least every two hours.

Raise the knee gatch of the bed to prevent the client from sliding downward.

Place a pillow under the client's lower legs to suspend the heels off the mattress.

Maintain the client in a continuous flat, supine position to rest the spine.

Cevabı ve açıklamayı göster

Cevap: Keep the bottom bed sheets tight and free of wrinkles.; Reposition the client from side to side at least every two hours.; Place a pillow under the client's lower legs to suspend the heels off the mattress.

Cevap

The correct actions are keeping bed sheets tight and wrinkle-free, repositioning every two hours, and placing a pillow under the lower legs to suspend the heels.

Promoting client comfort and skin integrity involves minimizing pressure, friction, and shearing forces. Keeping bed linens tight and wrinkle-free eliminates physical irritants that can damage fragile skin. Turning and repositioning the client at least every two hours ensures that blood flow is restored to tissues overlying bony prominences. Placing a pillow under the calves effectively floats the heels, completely removing pressure from this highly vulnerable area.

Adım Adım Çözüm

Identify the goal of care based on the stem.

The goal is to promote comfort and maintain skin integrity for a bedbound postoperative client.

Understanding the primary objective helps filter out actions that might cause harm or are ineffective.

Evaluate each option against basic care principles for skin integrity and safety.

Wrinkle-free sheets, frequent turning, and heel suspension are established, safe methods for preventing pressure injuries.

Evidence-based practice dictates these standard interventions for immobile clients.

Identify contraindicated positioning techniques.

Raising the knee gatch and keeping the client completely flat are identified as harmful practices.

These positions compromise circulation and respiratory function, violating basic safety and comfort principles.

Anahtar Kavram

Basic Care and Comfort: Skin Integrity and Positioning

Soru 882Soru →

A client prescribed oral metoprolol for hypertension is resting in bed. Before giving the morning dose, the practical nurse obtains an apical pulse of $48 \text{ beats/minute}$ . What is the most appropriate action for the nurse to take?

Give the medication as ordered and reassess the heart rate in

30 \text{ minutes}

Administer half of the prescribed dose to prevent further lowering of the heart rate.

Withhold the scheduled dose and promptly notify the registered nurse.

Ask the client to ambulate in the hallway to raise their heart rate before administration.

Cevabı ve açıklamayı göster

Cevap: Withhold the scheduled dose and promptly notify the registered nurse.

Cevap

The practical nurse should withhold the metoprolol and notify the registered nurse because the client's heart rate is below the safe administration threshold.

Metoprolol is a beta-adrenergic blocking agent that decreases both blood pressure and heart rate. The standard of care requires withholding the medication if the apical pulse is less than

60 \text{ beats/minute}

and reporting the finding to the supervising registered nurse or healthcare provider so they can provide further clinical judgment.

Adım Adım Çözüm

Evaluate the client's current apical pulse against the expected parameters for the prescribed medication.

The pulse of

48 \text{ beats/minute}

is below the standard

60 \text{ beats/minute}

threshold for administering a beta-blocker.

Metoprolol decreases heart rate; giving it to a bradycardic client can cause severe hemodynamic compromise.

Determine the appropriate intervention based on the practical nurse's scope of practice.

The correct action is to withhold the dose and escalate the abnormal finding.

The practical nurse must recognize abnormal vital signs, withhold potentially harmful medications, and report to the supervising registered nurse or provider.

Anahtar Kavram

Pre-administration vital sign parameters for beta-blockers and practical nurse scope of practice.

Soru 883Soru →

A client with a suspected lower respiratory tract infection requires a sputum specimen for culture and sensitivity testing. To minimize the risk of sample contamination with oral flora, which sequence of steps should the practical nurse follow? Arrange the actions in the correct chronological order.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence begins with oral preparation (rinsing), followed by lung expansion (deep breathing), mobilization of secretions (coughing), collection (expectorating), and finally securing the specimen (sealing and labeling).

Following the chronological order of rinsing the mouth, performing deep breathing, coughing deeply, expectorating into the container, and immediately sealing it ensures the specimen is uncontaminated and accurately reflects the lower respiratory tract environment.

Adım Adım Çözüm

Instruct the client to rinse the mouth with plain water without swallowing.

Reduces oral flora in the mouth.

Decreases the risk of contaminating the specimen with normal mouth bacteria.

Ask the client to take several slow, deep breaths to expand the lungs.

Maximizes lung expansion.

Helps loosen secretions in the lower respiratory tract.

Direct the client to perform a deep, forceful cough to mobilize lower airway secretions.

Moves sputum upward.

Ensures the sample is from the lungs, not just saliva from the upper airway.

Have the client expectorate the mobilized secretions directly into the sterile container.

Captures the sterile specimen.

Avoids outside contamination by collecting directly into the sterile environment.

Secure the lid on the container immediately and apply the client's identification label.

Seals and identifies the sample.

Maintains specimen integrity and ensures correct client identification for laboratory processing.

Anahtar Kavram

To ensure diagnostic accuracy and reduce the risk of misdiagnosis due to sample contamination, a sputum specimen must be collected from the lower respiratory tract using a sterile technique and proper client preparation.

Soru 884Soru →

A practical nurse (PN) is assisting a healthcare provider with a bedside thoracentesis for a client who has a large pleural effusion. To ensure client safety and reduce the risk of procedural complications, in what order should the PN perform the following actions? (Arrange the steps from first to last.)

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence is: 1) Obtain baseline vital signs and respiratory assessment, 2) Position the client upright and leaning forward, 3) Instruct the client to remain still and not cough, 4) Apply a sterile dressing to the puncture site, and 5) Auscultate bilateral breath sounds.

Safe assistance during a thoracentesis follows a strict logical flow to reduce risk: establishing a clinical baseline, physically preparing the client via positioning, preventing injury during the active procedure by teaching the client not to move, immediately securing the skin breach afterward to prevent air entry, and finally evaluating the client for procedural complications.

Adım Adım Çözüm

Obtain baseline vital signs and perform a focused respiratory assessment.

Pre-procedure baseline clinical data is established.

Accurate pre-procedure vitals and breath sounds are necessary to recognize subtle physiological changes or respiratory distress later.

Position the client sitting upright on the edge of the bed while leaning forward over an overbed table.

The client is secured in the orthopneic position.

This specific position opens the intercostal spaces, giving the provider clear access to the pleural fluid and minimizing the risk of visceral organ injury.

Instruct the client to remain completely still and refrain from coughing or talking during needle insertion.

The client understands how to cooperate safely during the invasive portion of the procedure.

Any sudden movement, such as coughing or taking a deep breath, can shift the lung tissue into the path of the needle, risking a traumatic pneumothorax.

Apply a sterile dressing to the puncture site once the needle is withdrawn.

The puncture site is immediately sealed and protected.

Immediate application of a sterile dressing prevents environmental contamination and blocks atmospheric air from entering the negative-pressure pleural cavity.

Auscultate bilateral breath sounds and monitor for asymmetrical chest expansion.

The client's post-procedure respiratory status is evaluated.

Comparing these findings to the baseline assessment helps the nurse rapidly identify complications, such as a pneumothorax or hemothorax, if breath sounds are diminished on the affected side.

Anahtar Kavram

Reduction of Risk Potential: Assisting with Thoracentesis

Soru 885Soru →

During shift report on an acute medical unit, the care team discusses the needs of a newly admitted client. The client requires a central line insertion, has physical findings suggestive of neglect, and has an incomplete admission database. As the practical nurse (PN) assumes care, which action represents the appropriate application of legal and ethical nursing standards?

Informing the charge nurse that completing the initial comprehensive admission assessment is outside the practical nursing scope of practice.

Explaining the risks and alternatives of the central line insertion before having the client sign the informed consent form.

Waiting to notify adult protective services about the suspected neglect until concrete evidence is found in the medical record.

Consulting with an off-duty nurse about the client's complex history while riding in the facility's public elevator.

Cevabı ve açıklamayı göster

Cevap: Informing the charge nurse that completing the initial comprehensive admission assessment is outside the practical nursing scope of practice.

Cevap

The correct action is informing the charge nurse that completing the initial comprehensive admission assessment is outside the practical nursing scope of practice.

The correct answer demonstrates the practical nurse (PN) safely adhering to their legal scope of practice. Under standard Nurse Practice Acts, the Registered Nurse (RN) is responsible for the initial comprehensive assessment, which involves complex clinical judgment and care planning. A PN cannot legally accept the delegation of this task and must advocate for safe assignment boundaries by respectfully declining it.

Adım Adım Çözüm

Analyze the scope of practice boundary regarding admission documentation.

The PN recognizes that the initial comprehensive admission assessment requires advanced clinical judgment.

Standard Nurse Practice Acts restrict initial comprehensive assessments to the RN role. A PN must legally decline this delegated task to provide safe, ethical care.

Evaluate the PN's role in the informed consent process.

The PN identifies that explaining procedure risks and alternatives is strictly the healthcare provider's responsibility.

The PN's legal role in informed consent is only to witness the client's signature and verify their voluntary understanding of what the provider explained.

Review mandatory reporting laws for vulnerable populations.

The PN notes that suspected abuse or neglect must be reported based on reasonable suspicion alone.

Waiting for definitive proof violates the legal duty of a mandated reporter and delays necessary intervention for the client's safety.

Assess the action against confidentiality and HIPAA requirements.

The PN understands that discussing patient information in a public elevator is a breach of privacy.

Patient information must only be shared in private settings with individuals who are directly involved in the client's care.

Anahtar Kavram

Legal and Ethical Practice: Scope of Practice, Informed Consent, Mandatory Reporting, and Confidentiality

Soru 886Soru →

A practical nurse is observing clients in a pediatric clinic's waiting area. Arrange the following observed play behaviors in chronological order from the earliest developmental stage to the most advanced.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct chronological sequence of play development is solitary play, followed by parallel play, then associative play, and finally cooperative play.

The development of play progresses sequentially as a child's cognitive and social skills mature. It begins with solitary play in infancy, advances to parallel play in toddlerhood, moves to associative play in the preschool years, and culminates in cooperative play during the school-age years.

Adım Adım Çözüm

Identify the developmental stage associated with independent play using a rattle.

This behavior represents solitary play, which occurs in infancy (birth to 1 year).

Infants lack the cognitive and social development to interact meaningfully with peers during play, making this the earliest stage.

Identify the stage associated with playing beside, but not with, another child.

This behavior represents parallel play, typical of the toddler stage (1 to 3 years).

Toddlers are egocentric and aware of others but do not yet have the skills to coordinate joint play activities.

Identify the stage where children share materials and interact loosely without a common goal.

This behavior represents associative play, which is characteristic of the preschool age (3 to 6 years).

Preschoolers develop increased social awareness and begin interacting, but their play remains relatively unorganized.

Identify the stage involving structured games with rules and teamwork.

This behavior represents cooperative play, typical of school-age children (6 to 12 years).

School-age children have the cognitive ability to understand rules, take turns, and work toward a shared objective.

Anahtar Kavram

Stages of Play in Pediatric Development

Soru 887Soru →

A practical nurse (PN) is assigned to care for a client who has a prescription for a scheduled dose of oral lithium carbonate. Prior to administration, the PN reviews the client's most recent laboratory report, which reveals a serum lithium level of 2.3 mEq/L. Which of the following actions should the PN take in response to this finding?

Withhold the medication and promptly notify the supervising registered nurse or healthcare provider.

Proceed with administering the scheduled dose since the laboratory value is within the expected therapeutic range.

Administer a partial dose of the medication to slowly lower the serum level back to the baseline.

Provide the client with a large glass of water along with the medication to help dilute the elevated serum level.

Cevabı ve açıklamayı göster

Cevap: Withhold the medication and promptly notify the supervising registered nurse or healthcare provider.

Cevap

The correct action is to withhold the medication and promptly notify the supervising registered nurse or healthcare provider.

The therapeutic range for serum lithium is generally 0.6 to 1.2 mEq/L. A level of 2.3 mEq/L indicates severe toxicity. The priority and safest action for the practical nurse is to withhold the dose to prevent further harm and immediately report the critical laboratory value to the supervising registered nurse or healthcare provider for further medical intervention.

Adım Adım Çözüm

Analyze the client's laboratory results in relation to the prescribed medication.

The serum lithium level of 2.3 mEq/L is identified as being significantly above the normal therapeutic range (0.6 to 1.2 mEq/L).

Safe medication administration requires knowing therapeutic ranges and recognizing laboratory values that indicate drug toxicity.

Determine the appropriate nursing intervention based on the practical nursing scope of practice.

The medication must be withheld to prevent further toxicity, and the abnormal finding must be escalated.

A level of 2.3 mEq/L indicates severe lithium toxicity, which is a critical finding that requires immediate medical evaluation and intervention.

Anahtar Kavram

Recognizing medication toxicity and escalating critical laboratory values.

Soru 888Soru →

An adult client is receiving care for an acute asthma exacerbation and has a comorbidity of essential hypertension. The medication administration record indicates a new prescription for oral propranolol $40\text{ mg}$ twice daily. The unit's automated medication dispenser supplies $20\text{ mg}$ scored tablets. The client's current assessment reveals audible expiratory wheezing, an $O_2$ saturation of $90\%$ on room air, a heart rate of $98\text{ bpm}$ , and a blood pressure of $138/86\text{ mmHg}$ . Based on this clinical data, what is the most appropriate action for the practical nurse (PN) to take?

Withhold the medication and immediately notify the registered nurse (RN) or healthcare provider.

Administer

0.5

tablets of propranolol to cautiously manage the client's blood pressure.

Administer

2

tablets of propranolol to address the tachycardia, as the heart rate is the highest priority.

Administer

2

tablets of propranolol and independently perform a comprehensive respiratory assessment to monitor for bronchospasm.

Cevabı ve açıklamayı göster

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

Cevap

The PN must withhold the propranolol and immediately report the prescription to the RN or healthcare provider due to the risk of severe bronchoconstriction.

Propranolol is a non-selective beta-blocker that inhibits both beta-1 (cardiac) and beta-2 (pulmonary) receptors. Blocking beta-2 receptors leads to bronchoconstriction. In a client already experiencing an acute asthma exacerbation with active wheezing and hypoxia, this medication can trigger a fatal respiratory crisis. The safest and most appropriate action within the PN's scope of practice is to withhold the scheduled dose and immediately notify the RN or healthcare provider to have the prescription changed.

Adım Adım Çözüm

Analyze the client's current physiological data.

The client has an acute asthma exacerbation with active airway compromise (wheezing, SpO2 90%).

Establishing the current baseline is required before safely administering any medication.

Identify the pharmacological class and mechanism of the prescribed medication.

Propranolol is identified as a non-selective beta-adrenergic antagonist.

Understanding the drug class reveals its systemic effects, specifically its action on both beta-1 (cardiac) and beta-2 (pulmonary) receptors.

Synthesize the clinical data with the medication mechanism to determine safety.

Blocking beta-2 receptors in the lungs prevents bronchodilation and induces bronchospasm, which is strictly contraindicated in acute asthma.

Administering the medication would directly worsen the client's already compromised airway.

Determine the appropriate intervention within the PN scope of practice.

The PN withholds the dose and escalates the finding to the RN or provider.

The PN is responsible for recognizing critical contraindications, safeguarding the client, and communicating urgent findings to the supervising RN or prescribing provider.

Anahtar Kavram

Contraindications of non-selective beta-blockers in respiratory compromise and PN scope of practice in medication safety.

Tahmini Süre:1m 30s

Soru 889Soru →

It is time for a client's scheduled transdermal fentanyl patch replacement. To ensure safe medication administration, arrange the following steps in the correct chronological sequence.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence begins with verifying client identity, followed by removing the old patch while wearing gloves, preparing a new site, labeling the new patch, and finally applying it to the skin.

Safe transdermal medication administration requires strict adherence to a specific procedural sequence. Verifying identity ensures the intervention reaches the correct client. Removing the old patch first (while wearing gloves) prevents toxicity and nurse exposure. Preparing the new site promotes proper absorption and prevents skin breakdown. Labeling the patch prior to application prevents client discomfort from writing pressure. Finally, applying firm pressure secures the patch for its duration of use.

Adım Adım Çözüm

Verify client identity and perform hand hygiene.

The correct client is confirmed and infection transmission risk is minimized.

This adheres to the basic rights of medication administration and standard safety precautions.

Don clean gloves and remove the old fentanyl patch.

The previous medication source is safely discontinued.

Gloves prevent the nurse from absorbing fentanyl dermally, and removing the old patch prevents accidental overdose.

Cleanse a new, hairless application site and let it dry.

A fresh area of skin is prepared for the new patch.

Rotating sites prevents skin breakdown. A clean, dry surface ensures the new patch will adhere properly and medication will absorb consistently.

Label the new patch with the date, time, and initials.

The patch is clearly marked before it goes on the client's body.

Writing on the patch after application can cause discomfort and may unintentionally push a bolus of medication into the client's tissues.

Remove the protective liner, apply to the skin, and press firmly for 30 seconds.

The new fentanyl patch is securely attached and actively delivering medication.

Firm pressure, especially around the edges, ensures the adhesive matrix bonds tightly to the skin for the entire duration of the order.

Anahtar Kavram

Safe Administration of Transdermal Medications

Soru 890Soru →

Assistive personnel at an assisted living facility report to the practical nurse that an 83-year-old resident, who is typically alert and independent, has suddenly become highly agitated and disoriented over the past six hours. Which of the following conclusions should the practical nurse make regarding the resident's change in condition?

The resident is experiencing an acute physiological issue such as delirium, which is distinct from expected developmental changes of aging.

The resident's symptoms represent the expected onset of senile dementia, which is a normal transition in the older adult population.

The resident is exhibiting normal age-related cognitive decline that frequently manifests abruptly during periods of stress.

The resident's sudden confusion is a harmless, expected psychological adaptation to the aging process that requires only routine monitoring.

Cevabı ve açıklamayı göster

Cevap: The resident is experiencing an acute physiological issue such as delirium, which is distinct from expected developmental changes of aging.

Cevap

The resident is experiencing an acute physiological issue such as delirium, which is distinct from expected developmental changes of aging.

The correct answer accurately identifies that sudden, acute onset of confusion and agitation is a hallmark sign of delirium. Delirium is a secondary manifestation of an underlying physical illness (such as a urinary tract infection, hypoxia, or medication toxicity). It is an acute medical issue and is never considered a normal developmental change or an expected transition in the older adult.

Adım Adım Çözüm

Analyze the timeline of the resident's cognitive change.

The resident transitioned from being completely alert and independent to highly agitated and disoriented within a short six-hour window.

Establishing the onset timeline is critical to differentiate between chronic conditions and acute medical emergencies.

Correlate the findings with knowledge of expected older adult developmental transitions.

Expected cognitive changes associated with aging occur gradually over years. Sudden confusion is an abnormal finding.

A core competency of practical nursing is distinguishing normal age-related variations from pathological processes.

Formulate a clinical conclusion based on the acute change.

The rapid onset of altered mental status indicates acute delirium, which is typically secondary to a physiological trigger like an infection, dehydration, or medication toxicity.

Recognizing delirium ensures the nurse will promptly report the findings and initiate urgent data collection.

Anahtar Kavram

Differentiating normal cognitive changes of aging from acute delirium

Soru 891Soru →

A practical nurse is preparing to administer a scheduled dose of subcutaneous enoxaparin to a client who is two days postoperative following a left total knee arthroplasty. While reviewing the client's morning assessment data and electronic health record, which finding requires the nurse to withhold the medication and immediately escalate to the registered nurse?

A decrease in systolic blood pressure from

122 \text{ mm Hg}

108 \text{ mm Hg}

with a resting heart rate of

88 \text{ beats/minute}

An alert indicating that the client's identification barcode wristband was removed during morning hygiene care.

A client report of localized, throbbing incisional pain rated as a

5

on a

0

-to-

10

numerical scale.

A complete blood count indicating a platelet level of

42,000 \text{ /mm}^3

(

42 \times 10^9 \text{ /L}

Cevabı ve açıklamayı göster

Cevap: A complete blood count indicating a platelet level of $42,000 \text{ /mm}^3$ ( $42 \times 10^9 \text{ /L}$ ).

Cevap

The correct action is to withhold the medication due to the complete blood count indicating a platelet level of 42,000 /mm³ (42 × 10⁹ /L).

The correct answer identifies a critical laboratory value that directly contraindicates the prescribed medication. Enoxaparin is an anticoagulant. Administering this medication to a client with a platelet count of

42,000 \text{ /mm}^3

(normal is

150,000

400,000 \text{ /mm}^3

) places the client at imminent risk for severe, potentially fatal hemorrhage. The practical nurse must prioritize risk reduction by holding the dose and immediately notifying the registered nurse or healthcare provider.

Adım Adım Çözüm

Analyze the prescribed medication and its primary physiological mechanism.

Enoxaparin is a low-molecular-weight heparin used for anticoagulation to prevent deep vein thrombosis.

Understanding the drug's mechanism highlights its primary adverse effect: increased bleeding risk.

Evaluate the clinical significance of each assessment finding.

The platelet count of

42,000 \text{ /mm}^3

is critically low (normal is

150,000

400,000 \text{ /mm}^3

Platelets are essential for blood clotting; severe thrombocytopenia creates an imminent bleeding risk.

Synthesize the findings to prioritize client safety and determine the required nursing action.

Administering an anticoagulant to a severely thrombocytopenic client is directly contraindicated.

The practical nurse must apply principles of risk reduction by holding the dose and immediately notifying the registered nurse.

Anahtar Kavram

Correlating critical laboratory values (thrombocytopenia) with pharmacological interventions (anticoagulants) to reduce the risk of severe complications.

Tahmini Süre:1m 30s

Soru 892Soru →

A practical nurse (PN) is preparing to administer scheduled morning oral medications to a client on a medical-surgical unit. Which actions must the PN take to ensure safe medication administration? Select all that apply.

Geçerli olan tümünü seçin

Ask the client to state their full name and date of birth.

Confirm the client's identity by checking the room and bed number.

Administer the medication without scanning the client's barcode if the client is well known to the nurse.

Document the medication administration in the electronic health record immediately after the client takes the medication.

Review the client's allergy band and confirm allergy status verbally prior to administration.

Cevabı ve açıklamayı göster

Cevap: Ask the client to state their full name and date of birth.; Document the medication administration in the electronic health record immediately after the client takes the medication.; Review the client's allergy band and confirm allergy status verbally prior to administration.

Cevap

The correct actions are to ask the client to state their full name and date of birth, document the administration immediately after giving the medication, and review the allergy band while confirming verbally.

Safe medication administration requires strict adherence to safety protocols. Asking the client to state their full name and date of birth utilizes two approved patient identifiers, fulfilling the 'right client' check. Documenting immediately after administration ensures the medical record is accurate and prevents duplicate dosing by other healthcare staff. Checking the allergy band and verbally confirming allergies is a crucial assessment step that prevents adverse allergic reactions.

Adım Adım Çözüm

Review the established rights of medication administration.

Identify that the right client, right documentation, and right assessment (including allergies) are critical components of safety.

Adhering to these core principles prevents potentially fatal medication errors.

Evaluate each option against safe medication administration protocols.

Identifying the client with two distinct personal identifiers, documenting immediately after administration, and verifying allergies are safe practices. Using room numbers or bypassing barcode scanning are unsafe practices.

Safety protocols require active verification and strictly prohibit the use of environmental markers (like room numbers) or bypassing automated safety checks.

Anahtar Kavram

Rights of Medication Administration and Patient Safety Protocols

Soru 893Soru →

Following a percutaneous liver biopsy, a client is transferred back to the medical unit. To promote comfort and minimize the risk of internal bleeding, which position should the practical nurse assist the client into?

Left side-lying position with the head of the bed elevated 45 degrees

Right side-lying position with a small towel placed under the puncture site

Supine position with the lower extremities elevated on two pillows

High-Fowler's position with the knees comfortably flexed

Cevabı ve açıklamayı göster

Cevap: Right side-lying position with a small towel placed under the puncture site

Cevap

The client should be assisted into a right side-lying position with a small towel placed under the puncture site to apply direct pressure to the liver.

The liver is a highly vascular organ located in the right upper quadrant of the abdomen. After a percutaneous liver biopsy, the primary complication to prevent is hemorrhage. Assisting the client into a right side-lying position utilizes the client's own body weight to apply direct pressure to the puncture site, promoting hemostasis and minimizing the risk of bleeding.

Adım Adım Çözüm

Identify the anatomical location of the organ involved in the procedure.

The liver is located in the right upper quadrant of the abdomen.

Knowing the anatomy determines where pressure needs to be applied post-procedure.

Determine the primary physiological risk following a percutaneous biopsy.

The most significant risk is internal hemorrhage or bleeding from the puncture site.

The liver is a highly vascular organ, making bleeding a primary concern.

Select the nursing intervention that directly mitigates this risk.

Applying direct physical pressure to the puncture site.

Pressure promotes hemostasis (blood clotting) and stops active bleeding.

Choose the client position that naturally achieves this intervention.

Right side-lying position.

Using the client's own body weight against the mattress applies continuous, even pressure to the liver capsule.

Anahtar Kavram

Post-procedure positioning to prevent bleeding

Soru 894Soru →

A practical nurse (PN) is providing care for a group of clients on a medical-surgical unit. Which of the following actions by the PN correctly demonstrate advocacy and the protection of client rights? Select all that apply.

Geçerli olan tümünü seçin

Verifying that a client has signed the surgical informed consent form before administering a preoperative sedative

Declining to provide a medical update to a telephone caller who is unable to provide the client's designated privacy code

Ensuring that a copy of a client's newly provided living will is uploaded to their electronic health record

Explaining the specific surgical risks and alternative treatments to a client who expresses hesitation about an upcoming procedure

Applying soft wrist restraints to a frequently wandering client to ensure safety without first attempting less restrictive interventions

Delaying the report of suspected elder abuse to the appropriate authorities until definitive evidence can be obtained

Cevabı ve açıklamayı göster

Cevap: Verifying that a client has signed the surgical informed consent form before administering a preoperative sedative; Declining to provide a medical update to a telephone caller who is unable to provide the client's designated privacy code; Ensuring that a copy of a client's newly provided living will is uploaded to their electronic health record

Cevap

The correct actions are verifying the surgical consent before giving sedatives, declining to share updates without a privacy code, and ensuring the living will is in the medical record.

The correct actions demonstrate strong client advocacy by upholding the right to make informed decisions while cognitively intact, protecting health information under HIPAA, and ensuring advance directives are documented to guide future care.

Adım Adım Çözüm

Evaluate each action against the principles of client rights, including informed consent, confidentiality, and self-determination.

Actions protecting these rights are identified.

To differentiate between appropriate advocacy and actions that violate scope of practice or client rights.

Analyze the action regarding informed consent and sedatives.

Verifying consent before sedation is correct.

Sedatives alter cognition, rendering the client legally unable to provide informed consent.

Analyze the action regarding telephone callers and privacy.

Requiring a privacy code is correct.

HIPAA mandates that protected health information is only shared with authorized individuals.

Analyze the action regarding the living will.

Placing the advance directive in the record is correct.

It ensures the healthcare team is aware of the client's end-of-life wishes, upholding self-determination.

Identify the incorrect actions related to scope of practice, restraints, and mandated reporting.

Explaining surgical risks, applying restraints without trying alternatives, and delaying abuse reporting are incorrect.

These actions violate the PN scope of practice, the right to a least restrictive environment, and mandatory reporting laws, respectively.

Anahtar Kavram

Client Rights, Advocacy, and Scope of Practice for the Practical Nurse

Soru 895Soru →

While completing an annual wellness screening at a manufacturing plant, an employee tells the practical nurse (PN), "I smoke a joint during my lunch break to manage chronic shoulder pain. It helps me focus better when I go back to operating the forklift." Which action should the PN take first?

Instruct the employee to stop operating the machinery and immediately report the finding to the supervising registered nurse.

Inform the employee that they must complete a mandatory urine toxicology screen before returning to the warehouse floor.

Ask the employee, "Why would you risk your safety and your employment by using illicit drugs at work?"

Provide the employee with educational materials about non-pharmacological interventions for chronic shoulder pain.

Cevabı ve açıklamayı göster

Cevap: Instruct the employee to stop operating the machinery and immediately report the finding to the supervising registered nurse.

Cevap

The practical nurse should instruct the employee to stop operating the machinery and immediately report the finding to the supervising registered nurse.

The correct answer directly addresses the acute safety threat. Operating heavy machinery while under the influence of a substance is a severe high-risk behavior. The PN must prioritize immediate safety by ensuring the employee does not return to the forklift, and then promptly report the situation to the RN or supervisor in accordance with the chain of command.

Adım Adım Çözüm

Analyze the client's statement to identify any immediate safety risks.

The client admits to using a mind-altering substance (marijuana) immediately prior to operating heavy machinery (a forklift).

Recognizing high-risk behaviors is essential for preventing workplace injuries and maintaining a safe environment.

Determine the priority of care based on the identified risk.

Immediate intervention is required to prevent the employee from returning to the forklift.

Safety takes precedence over ongoing health education or exploring the root cause of the client's pain.

Select the intervention that aligns with the PN scope of practice.

The PN must halt the dangerous activity and report the critical safety concern to the supervising RN or facility management.

The PN cannot independently order drug screens or clear the employee for work, necessitating immediate escalation.

Anahtar Kavram

Prioritization of Safety and Scope of Practice in Occupational Health

Soru 896Soru →

An individual is recovering on the surgical unit twelve hours after an open cholecystectomy. The morning laboratory report indicates a hemoglobin of 8.2 g/dL (82 g/L). The practical nurse obtains the client's current vital signs, noting a heart rate of 114 beats per minute and a blood pressure of 98/60 mm Hg. Based on these findings, which action is the priority for the practical nurse?

Promptly notify the supervising registered nurse about the client's vital signs and the recent laboratory values

Document the data in the electronic health record, recognizing that a moderate decrease in hemoglobin is typical after abdominal surgery

Wait to reassess the heart rate and blood pressure in one hour, as mild tachycardia can commonly result from post-operative pain

Obtain the prescribed unit of packed red blood cells from the blood bank and independently initiate the transfusion

Cevabı ve açıklamayı göster

Cevap: Promptly notify the supervising registered nurse about the client's vital signs and the recent laboratory values

Cevap

Promptly notify the supervising registered nurse about the client's vital signs and the recent laboratory values.

The client is exhibiting classic signs of hemorrhagic shock, specifically tachycardia and hypotension, combined with a significantly low hemoglobin level. The practical nurse must immediately escalate these life-threatening findings to the registered nurse for prompt intervention, as the client's condition is unstable and requires care beyond the practical nurse scope.

Adım Adım Çözüm

Analyze the client's vital signs.

The heart rate of 114 beats per minute (tachycardia) and blood pressure of 98/60 mm Hg (hypotension) are identified as abnormal.

Recognizing deviations from normal vital sign ranges is the first step in identifying postoperative complications.

Evaluate the morning laboratory results in conjunction with the physical assessment data.

The significantly low hemoglobin of 8.2 g/dL aligns with the unstable vital signs.

Correlating laboratory data with clinical signs helps pinpoint the specific complication, which in this case points to acute blood loss.

Synthesize the findings to determine the immediate clinical risk.

The combination of tachycardia, hypotension, and low hemoglobin indicates a high risk for internal postoperative hemorrhage and hypovolemic shock.

Identifying the complication dictates the urgency of the required intervention.

Determine the appropriate action based on the practical nurse's scope of practice.

The nurse must immediately escalate the situation to the registered nurse or healthcare provider.

Unstable clients requiring complex assessment, fluid resuscitation, and blood product administration must be managed by the registered nurse and provider.

Anahtar Kavram

Reduction of Risk Potential: Recognizing and escalating signs of postoperative hemorrhage

Soru 897Soru →

A client is recovering on a surgical step-down unit 24 hours after undergoing a left total pneumonectomy. The client requests assistance to shift positions for pressure relief and improved comfort. Which positioning action is most appropriate for this client?

Turn the client onto the right side and support the upper extremities with pillows.

Place the client in a strict supine position with the head of the bed completely flat.

Assist the client onto the left side with the head of the bed elevated 30 to 45 degrees.

Position the client prone with a small towel roll placed under the abdomen.

Cevabı ve açıklamayı göster

Cevap: Assist the client onto the left side with the head of the bed elevated 30 to 45 degrees.

Cevap

Assist the client onto the left side with the head of the bed elevated 30 to 45 degrees.

Following a total pneumonectomy, the client should be positioned on the operative side (in this case, the left side) or supine with the head elevated. This specific positioning ensures that the single remaining healthy lung (the right lung) can expand fully without being restricted by the weight of the body. Furthermore, elevating the head of the bed 30 to 45 degrees promotes optimal diaphragmatic excursion and maximizes ventilation.

Adım Adım Çözüm

Identify the surgical procedure and the affected side from the clinical scenario.

The client underwent a left total pneumonectomy (complete removal of the left lung).

The specific type and location of thoracic surgery dictate the mandatory postoperative positioning guidelines.

Determine the optimal positioning rules for a total pneumonectomy.

Clients must be positioned on their back (supine with elevation) or on the operative side.

Positioning on the operative side allows the remaining healthy lung to expand without being compressed by the body's weight, and it prevents fluid in the surgical stump from draining into the healthy lung.

Select the option that correctly applies these positioning rules.

The left side is the operative side. Placing the client in a semi-Fowler's position on the left side is correct.

This intervention maximizes respiratory function, promotes comfort, and ensures client safety.

Anahtar Kavram

Post-pneumonectomy positioning requires placing the client on the operative side to maximize the expansion of the remaining healthy lung.

Soru 898Soru →

A pediatric client weighing $35.2$ pounds is prescribed cefdinir $14\text{ mg/kg/day}$ orally, to be administered in two equally divided doses. The medication is supplied as a powder for oral suspension. The bottle instructions state: "Add $38\text{ mL}$ of purified water in two portions to yield $60\text{ mL}$ of suspension with a concentration of $125\text{ mg}/5\text{ mL}$ ." After correctly reconstituting the medication, how many mL should the practical nurse administer for a single dose? Record the answer to the nearest tenth. Do not include units in the answer.

Cevabı ve açıklamayı göster

Cevap: 4.5

Cevap

4.5

To administer the correct dose, the practical nurse must systematically follow dosage calculation steps. First, the child's weight is converted to kilograms (

35.2 \div 2.2 = 16\text{ kg}

). Then, the total daily dose is calculated by multiplying the weight by the order (

16 \times 14 = 224\text{ mg/day}

). Because the medication is divided into two doses, the single dose is

112\text{ mg}

. Finally, the nurse uses the final reconstituted concentration of

125\text{ mg}/5\text{ mL}

to find the volume:

(112 \div 125) \times 5 = 4.48\text{ mL}

, which rounds to

4.5

. The instructions regarding

38\text{ mL}

and

60\text{ mL}

are necessary for pharmacy preparation but act as distractors during dose calculation.

Adım Adım Çözüm

Convert the client's weight from pounds to kilograms.

16\text{ kg}

The prescribed medication dosage is based on kilograms (

14\text{ mg/kg/day}

Calculate the total daily dose in milligrams.

224\text{ mg/day}

Multiply the child's weight in kg (

16\text{ kg}

) by the daily dosage rate (

14\text{ mg/kg/day}

Determine the amount of medication needed for a single dose.

112\text{ mg/dose}

The prescription states the medication is to be administered in two equally divided doses (

224\text{ mg} \div 2

Calculate the volume of liquid needed for one dose.

4.48\text{ mL}

Using the concentration of the reconstituted suspension (

125\text{ mg}

5\text{ mL}

), use dimensional analysis or the desired/have formula:

\frac{112\text{ mg}}{125\text{ mg}} \times 5\text{ mL}

Round the final calculated volume to the nearest tenth.

4.5

The question instructions explicitly require rounding the final answer to the nearest tenth.

Anahtar Kavram

Weight-based pediatric dosage calculation and reconstitution

Soru 899Soru →

During preparation for the morning medication administration, a practical nurse examines the electronic health record of a client prescribed subcutaneous heparin. The chart indicates that the client has a current platelet count of $45,000/\text{mm}^3$ ( $45 \times 10^9/\text{L}$ ). Which of the following is the most appropriate action for the nurse to take?

Proceed with administering the injection and observe the client's skin for petechiae.

Direct the unlicensed assistive personnel to assess the client's body for any signs of active bleeding.

Hold the scheduled dose and immediately inform the registered nurse about the finding.

Document the laboratory value in the electronic health record and administer the medication as ordered.

Cevabı ve açıklamayı göster

Cevap: Hold the scheduled dose and immediately inform the registered nurse about the finding.

Cevap

Hold the scheduled dose and immediately inform the registered nurse about the finding.

The correct answer identifies that a platelet count of

45,000/\text{mm}^3

indicates severe thrombocytopenia (normal is

150,000

400,000/\text{mm}^3

). Because heparin is an anticoagulant, giving this medication to a client who already lacks the platelets needed for blood clotting places them at an imminent risk for severe, spontaneous bleeding. The practical nurse must prioritize client safety by withholding the dose and immediately escalating the finding.

Adım Adım Çözüm

Analyze the client's laboratory values against normal reference ranges.

The client's platelet count is

45,000/\text{mm}^3

, which is significantly below the normal range of

150,000

400,000/\text{mm}^3

Identifying abnormal labs is the first step in recognizing potential contraindications for medications.

Correlate the abnormal laboratory finding with the prescribed medication.

Heparin is an anticoagulant that prevents clotting; administering it to a client with severe thrombocytopenia creates an extreme risk for spontaneous hemorrhage.

Understanding the pharmacodynamics of a drug ensures safe administration and reduces risk potential.

Determine the safest nursing action within the practical nurse's scope of practice.

The nurse must withhold the medication to prevent harm and immediately escalate the critical lab value to the registered nurse or healthcare provider.

Protecting the client from harm and escalating critical findings are fundamental responsibilities of the practical nurse.

Anahtar Kavram

Reduction of risk potential by evaluating critical laboratory values prior to medication administration.

Soru 900Soru →

During morning hygiene care at an inpatient hospice facility, a young adult client with terminal melanoma begins to cry and states to the practical nurse, 'My children are still in elementary school. I cannot stand the thought of missing their graduations.' Which response by the nurse is the most therapeutic?

This must be an incredibly heavy thought to carry. Would you like to tell me more about your children?

Let's focus on getting you comfortable right now. I can ask the social worker to arrange a special visit with your kids.

It is expected to feel angry and try to bargain during this stage, but finding a way to accept the situation will eventually bring you peace.

Try to stay positive; researchers are developing new treatments every day that might give you more time to spend with them.

Cevabı ve açıklamayı göster

Cevap: This must be an incredibly heavy thought to carry. Would you like to tell me more about your children?

Cevap

The most therapeutic response is to acknowledge the heavy burden of the thought and invite the client to talk more about their children.

The correct response directly addresses the client's emotional pain with empathy and uses an open-ended question to encourage further sharing. This active listening technique validates the client's feelings of loss and provides a safe space for them to process their anticipatory grief without judgment.

Adım Adım Çözüm

Analyze the client's statement to identify the core psychosocial need.

The client is expressing deep anticipatory grief and distress over premature separation from their young children.

Understanding the underlying emotion is essential to selecting a response that provides empathy and validation.

Evaluate the nursing responses against principles of therapeutic communication.

Identify which options use active listening and validation versus those that rely on communication blocks like false reassurance or changing the subject.

Therapeutic communication at the end of life must focus on the client's current feelings rather than minimizing their pain or enforcing a specific grieving process.

Select the option that best supports the client's emotional expression.

The response that validates the heavy thought and asks an open-ended question about the children is selected.

This approach demonstrates empathy, maintains a patient-centered focus, and facilitates healthy processing of grief.

Anahtar Kavram

Therapeutic Communication in End of Life Care

ÖncekiSayfa 45 / 147Sonraki

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