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Tüm alıştırma soruları

2933 soru

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Soru 901Soru →

A practical nurse (PN) is caring for a client who is a devout Seventh-day Adventist. The client is recovering from a stage 3 pressure injury and has a prescription for a high-calorie, high-protein diet. The dietary department delivers a lunch tray containing a pulled pork sandwich, baked beans, a side salad, and iced black tea. Which of the following is the priority action by the PN?

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Cevap: Return the tray to the dietary department and request a lacto-ovo vegetarian meal with a decaffeinated beverage.

Cevap

Return the tray to the dietary department and request a lacto-ovo vegetarian meal with a decaffeinated beverage.
Clients who practice the Seventh-day Adventist faith typically observe strict dietary laws that prohibit the consumption of pork products and caffeine (such as black tea or coffee). Additionally, many adherents practice a lacto-ovo vegetarian diet. Returning the entire tray and requesting an appropriate protein substitute (such as eggs, dairy, or legumes) alongside a caffeine-free beverage ensures that both the client's spiritual convictions and medical needs for wound healing are fully honored.

Adım Adım Çözüm

1
Analyze the client's specific religious dietary restrictions.
Seventh-day Adventists typically avoid pork, shellfish, and caffeine. Many also adhere to a lacto-ovo vegetarian diet.
Understanding specific cultural and spiritual practices is essential for providing holistic, client-centered care.
2
Evaluate the provided meal tray against the client's spiritual beliefs and medical needs.
The pulled pork (prohibited meat) and iced black tea (caffeinated) violate the client's religious beliefs. However, the client still requires high protein for wound healing.
Identifying conflicts between standard hospital provisions and spiritual requirements prevents cultural harm.
3
Determine the priority nursing intervention.
The PN must withhold the inappropriate tray and collaborate with the dietary department to obtain a suitable high-protein substitute (e.g., eggs, dairy, or soy) and a caffeine-free beverage.
This action directly advocates for the client's spiritual integrity while safely maintaining the therapeutic goal of the prescribed diet.

Anahtar Kavram

Religious and Spiritual Dietary Accommodations
Soru 902Soru →

While assisting a client with morning hygiene, a practical nurse (PN) notices that an electrical outlet has sparked and ignited the privacy curtain. The flames are quickly growing. The client is sitting in a wheelchair nearby. Arrange the following emergency response actions in the correct priority sequence from first to last.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence follows the RACE protocol: Move the client to safety (Rescue), pull the fire alarm (Alarm), close the room door (Contain), and obtain a fire extinguisher (Extinguish).
In the event of a fire in a healthcare facility, all staff must follow the RACE protocol. The first priority is always to Rescue or remove clients in immediate danger. The second step is to sound the Alarm to alert others and emergency services. The third step is to Contain the fire by closing doors and windows. The final step is to Extinguish the fire using an appropriate extinguisher, provided it is small and safe to do so.

Adım Adım Çözüm

1
Move the client in the wheelchair out of the room to a designated safe zone.
The client is removed from immediate danger.
The 'R' in the RACE acronym stands for Rescue or Remove. Life safety is always the highest priority.
2
Pull the nearest manual fire alarm station to alert the facility.
The facility's emergency response system is activated.
The 'A' stands for Alarm. Once immediate safety is secured, alerting others ensures a coordinated facility response and dispatch of emergency services.
3
Close the door to the client's room to prevent the fire from spreading.
The fire and smoke are confined to the room of origin.
The 'C' stands for Contain or Confine. Closing doors removes the oxygen supply to the fire and protects the evacuation routes.
4
Obtain a fire extinguisher and attempt to put out the fire if it remains small.
The fire is actively fought if safe to do so.
The 'E' stands for Extinguish. This is the final step, performed only after clients are safe, the alarm is sounding, and the fire is contained.

Anahtar Kavram

The RACE protocol is the standard procedure for responding to a fire emergency in a healthcare facility: Rescue, Alarm, Contain, Extinguish.
Soru 903Soru →

An adult client is resting in a medical-surgical unit on the first postoperative day following a right-sided modified radical mastectomy with axillary lymph node dissection. While assisting the client with morning care, the practical nurse must ensure the affected extremity is positioned correctly to prevent lymphedema. Which of the following is the most appropriate placement for the client's right arm?

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Cevap: Elevated on a pillow so that the hand is positioned higher than the elbow, and the elbow is higher than the heart

Cevap

Elevate the right arm on a pillow with the hand positioned higher than the elbow, and the elbow higher than the heart.
Following a mastectomy involving axillary lymph node dissection, the natural drainage of lymphatic fluid from the arm is significantly compromised. Elevating the arm on a pillow in a graduated slope (hand higher than elbow, elbow higher than the heart) utilizes gravity to assist the return of lymphatic fluid and venous blood to the central circulation. This prevents fluid from accumulating in the tissues of the arm, thereby reducing the risk of developing painful and debilitating lymphedema.

Adım Adım Çözüm

1
Identify the surgical procedure and its risks.
The client had a mastectomy with axillary lymph node dissection, which disrupts the normal lymphatic drainage pathways of the right arm.
Understanding the anatomical changes helps anticipate complications such as lymphedema.
2
Determine the physical principle that aids in fluid management.
Gravity can assist in draining lymphatic and venous fluid from the distal parts of the arm back toward the central circulation.
Proper positioning leverages gravity to compensate for the compromised lymphatic system.
3
Select the correct positioning strategy.
The arm should be elevated on a pillow in a graduated manner: hand higher than elbow, and elbow higher than the level of the heart.
This specific upward slope creates a clear path for fluid to drain downwards toward the body, preventing pooling and swelling.

Anahtar Kavram

Post-mastectomy Lymphedema Prevention and Positioning
Soru 904Soru →

A practical nurse (PN) is providing care for a group of clients on a medical-surgical unit. Which nursing actions demonstrate the appropriate implementation of accident, error, and injury prevention strategies? (Select all that apply.)

Geçerli olan tümünü seçin

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Cevap: Verifying two distinct client identifiers prior to delivering a regular diet food tray to a newly admitted client.; Using a mechanical lift and two staff members to transfer a completely immobile client from the bed to a chair.; Placing a fall risk alert bracelet on a client who is receiving newly prescribed opioid analgesics for postoperative pain.

Cevap

The correct actions include verifying two client identifiers before delivering a food tray, using a mechanical lift with two staff members for an immobile client, and placing a fall risk bracelet on a client receiving opioids.
The correct interventions directly support a safe care environment. Using two distinct identifiers prevents critical errors in dietary and medication administration. Employing a mechanical lift with two staff members prevents physical injury to both the immobile client and the healthcare workers. Applying a fall risk bracelet for a client on opioids proactively addresses the risk of falls caused by medication-induced dizziness or sedation.

Adım Adım Çözüm

1
Evaluate each nursing action against established patient safety standards and the practical nurse's scope of practice.
Identify which actions actively prevent injury and which introduce risk.
Accident and injury prevention requires a comprehensive understanding of proper protocols across multiple domains of care.
2
Identify the proactive safety measures among the choices.
Proper identification, safe mechanical transfers, and fall risk mitigation are confirmed as correct safety implementations.
These actions directly eliminate environmental hazards, prevent medication/dietary errors, and protect physical integrity.
3
Recognize and exclude the unsafe practices.
Using four side rails as a restraint, inappropriately delegating assessments, and normalizing acute confusion are identified as unsafe.
These actions violate safety guidelines, exceed delegation limits, and risk missing acute clinical deterioration.

Anahtar Kavram

Accident, Error, and Injury Prevention involves a multidisciplinary approach including proper patient identification, safe equipment use, fall prevention, appropriate delegation, and restraint avoidance.
Soru 905Soru →

After assisting a client who is positive for *Clostridioides difficile*, a practical nurse prepares to wash their hands with soap and water. Arrange the following steps of the hand hygiene procedure in the correct chronological sequence.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence for hand hygiene is: wet hands keeping them below the elbows, apply soap, scrub vigorously for at least 20 seconds, rinse from wrists to fingertips, and finally dry the hands and turn off the faucet with a clean paper towel.
The standard CDC procedure for handwashing ensures that hands are cleaned effectively without recontaminating them or the arms. Wetting hands first creates a base for lather, friction removes microbes, downward rinsing washes them away safely, and using a separate towel for the faucet prevents recontamination from environmental surfaces.

Adım Adım Çözüm

1
Wet hands and wrists
Skin is moistened and ready for soap application.
Wetting hands first minimizes skin irritation and helps the soap lather effectively. Keeping hands below elbows prevents contaminated water from flowing back up the arms.
2
Apply liquid soap
Soap is distributed on the hands.
Adequate soap ensures sufficient coverage of all hand surfaces for effective cleaning.
3
Scrub for at least 20 seconds
Pathogens and debris are mechanically loosened.
Friction is the most important component of handwashing. A minimum of 20 seconds is required to physically remove transient flora and spores like C. difficile.
4
Rinse from wrists to fingertips
Soap and pathogens are washed away into the sink.
Water must flow from the least contaminated area (wrists) to the most contaminated area (fingertips) to prevent recontamination.
5
Dry hands and turn off the faucet
Hands are dry and remain uncontaminated.
Drying prevents microbial growth in residual moisture. Using a separate, dry paper towel to turn off the faucet ensures clean hands do not touch the contaminated faucet handle.

Anahtar Kavram

Hand Hygiene Procedure and Standard Precautions
Tahmini Süre:1m 0s
Soru 906Soru →

An older adult resident in a long-term memory care facility begins pacing the hallway rapidly, clenching their fists, and glaring at other individuals. The resident loudly states, 'Everyone is plotting against me, and I will not let it happen!' Which action should the practical nurse (PN) take first?

Cevabı ve açıklamayı göster

Cevap: Approach the resident calmly from a slight angle and offer to walk together to a quiet, low-stimulation environment.

Cevap

The correct action is to approach the resident calmly and offer to relocate them to a quiet, low-stimulation environment.
Approaching the individual calmly from a slight angle (which is non-threatening) and guiding them to a quiet area is the priority de-escalation technique. This action prioritizes safety, uses the least restrictive intervention available, and helps reduce the sensory overload that may be fueling the paranoia and agitation.

Adım Adım Çözüm

1
Analyze the client's behavior and the clinical environment.
The resident is demonstrating signs of severe agitation, paranoia, and potential escalation toward violence.
Recognizing the phase of behavioral escalation is necessary to determine the appropriate intervention.
2
Determine the immediate priority of care.
The priority is to maintain the safety of the resident, staff, and milieu using the least restrictive means possible.
Safety and the principle of least restrictive intervention are foundational to psychiatric nursing care.
3
Select the most appropriate nursing action.
Relocating the client to a low-stimulation area removes triggers and audience, facilitating de-escalation without physical force.
This approach addresses the immediate safety risk while respecting the client's autonomy and avoiding non-therapeutic communication or premature restraints.

Anahtar Kavram

Crisis De-escalation and Least Restrictive Interventions
Soru 907Soru →

A resident in a long-term care facility is diagnosed with crusted (Norwegian) scabies. The LPN/LVN is reviewing infection control protocols with the nursing team. Which directive must the LPN/LVN emphasize regarding this resident's care?

Cevabı ve açıklamayı göster

Cevap: Dedicate reusable medical equipment, such as a stethoscope and blood pressure cuff, to remain inside the resident's room.

Cevap

The correct action is to dedicate reusable medical equipment to the resident's room.
Crusted (Norwegian) scabies is highly contagious and is transmitted through direct contact. It strictly requires Contact Precautions. According to evidence-based infection control guidelines, reusable medical equipment (such as vital sign machines or stethoscopes) should be dedicated solely to the infected client and left inside the room to prevent cross-contamination to other residents.

Adım Adım Çözüm

1
Identify the mode of transmission for crusted (Norwegian) scabies.
Scabies mites are highly contagious and are transmitted through direct skin-to-skin contact or contact with contaminated items.
Understanding the transmission route determines the correct isolation protocol.
2
Determine the required transmission-based precautions.
The resident requires strict Contact Precautions.
Contact Precautions are mandated for infections spread by direct or indirect contact with the client or their environment.
3
Evaluate the nursing directives against standard Contact Precaution guidelines.
Contact Precautions require a private room, gown, gloves, and dedicated reusable client care equipment.
Ensuring equipment stays in the room prevents cross-contamination to other vulnerable residents.

Anahtar Kavram

Contact Precautions for Parasitic Infestations
Soru 908Soru →

A practical nurse (PN) is caring for an older adult client on a medical unit. The client abruptly becomes highly agitated and begins pulling continuously at an indwelling urinary catheter. A family member at the bedside insists that the nursing staff secure the client's hands to the bed. Which action should the PN take first?

Cevabı ve açıklamayı göster

Cevap: Check the catheter tubing for kinks and assess the client for a distended bladder.

Cevap

Check the catheter tubing for kinks and assess the client for a distended bladder.
Agitation and pulling at medical devices are often signs of acute physical discomfort or unmet needs. Identifying and resolving the root cause, such as a blocked catheter causing painful urinary retention, is the primary alternative to utilizing physical restraints. The nurse must always address physiological needs before considering restrictive measures.

Adım Adım Çözüm

1
Analyze the client's behavior and the family's request for restraints.
The client is experiencing sudden agitation and the family is requesting a physical safety device.
Establishing the clinical situation determines the necessary safety protocol and immediate nursing priorities.
2
Recall the standard guidelines for restraint application.
Physical restraints are a measure of last resort and cannot be applied without exhausting less restrictive alternatives.
Safety standards mandate prioritizing alternative interventions to prevent the hazards associated with physical restraints.
3
Identify the least restrictive intervention that addresses the root cause of the behavior.
The client's agitation may be caused by a painful full bladder due to a blocked catheter. Checking the device addresses the potential root cause.
Resolving underlying physiological discomfort often eliminates the behavior and the need for restraints entirely.

Anahtar Kavram

Prioritizing alternative interventions and identifying the root causes of agitation before considering physical restraints.
Soru 909Soru →

A client is recovering on the surgical unit the day after undergoing a right posterolateral total hip arthroplasty. The practical nurse is preparing to cleanse the client's back and sacral area. Which action should the nurse take to maintain proper joint alignment and prevent dislocation?

Cevabı ve açıklamayı göster

Cevap: Place an abductor pillow between the client's legs and turn them onto the non-operative side.

Cevap

Place an abductor pillow between the client's legs and turn them onto the non-operative side.
Following a posterolateral total hip arthroplasty, the client is at high risk for hip dislocation if the hip is flexed past 90 degrees, adducted, or internally rotated. Placing an abductor pillow between the legs maintains continuous abduction and proper alignment while safely turning the client onto their non-operative side.

Adım Adım Çözüm

1
Identify the surgical approach and its specific precautions.
The client had a posterolateral total hip arthroplasty, which requires avoiding hip flexion greater than 90 degrees, adduction, and internal rotation.
These specific movements can cause the head of the femur to pop out of the acetabular cup.
2
Evaluate the safest positioning method for providing back care.
Turning the client safely requires keeping the legs apart to maintain alignment.
An abductor pillow securely maintains the legs in abduction, preventing the operative leg from crossing the body's midline.
3
Select the correct turning action.
The nurse places the abductor pillow and turns the client to the non-operative side.
This complies with all hip precautions while allowing necessary access to the sacral area.

Anahtar Kavram

Postoperative Positioning for Total Hip Arthroplasty
Soru 910Soru →

An 88-year-old pediatric client is prescribed 320 mg320\text{ mg} of liquid acetaminophen for a mild fever. The clinic's medication supply provides acetaminophen at a concentration of 160 mg160\text{ mg} per 5 mL5\text{ mL}. What is the correct volume in milliliters (mL\text{mL}) that the practical nurse should administer?

Cevabı ve açıklamayı göster

Cevap: 10 mL10\text{ mL}

Cevap

The correct answer is 10 mL10\text{ mL}.
To determine the correct volume, the nurse uses the formula: (Desired / Have) ×\times Volume. Plugging in the clinical values gives (320 mg160 mg\frac{320\text{ mg}}{160\text{ mg}}) ×\times 5 mL5\text{ mL}. The ratio of 320320 to 160160 simplifies to 22. Multiplying 22 by 5 mL5\text{ mL} yields a final answer of 10 mL10\text{ mL}. Administering this exact volume ensures the client receives the prescribed therapeutic dose safely.

Adım Adım Çözüm

1
Identify the desired dose prescribed by the provider.
Desired dose = 320 mg320\text{ mg}.
This establishes the numerator for the dosage calculation formula.
2
Identify the available medication concentration (the dose on hand and its volume).
Have = 160 mg160\text{ mg}, Volume = 5 mL5\text{ mL}.
These values are required to complete the denominator and volume multiplier in the formula.
3
Set up the calculation using the desired-over-have formula.
320 mg160 mg×5 mL\frac{320\text{ mg}}{160\text{ mg}} \times 5\text{ mL}.
This formula ensures the dose is properly converted into the correct liquid volume.
4
Perform the mathematical calculation to find the final volume.
2×5 mL=10 mL2 \times 5\text{ mL} = 10\text{ mL}.
Solving the equation provides the exact milliliter amount to administer to the client.

Anahtar Kavram

Liquid Medication Dosage Calculation
Soru 911Soru →

An older adult client with a confirmed norovirus infection is experiencing acute confusion and repeatedly attempts to wander out of their room into the facility's common dining area. The client requires contact precautions. Which action by the practical nurse demonstrates appropriate care management?

Cevabı ve açıklamayı göster

Cevap: Implement frequent room checks, apply a bed alarm, and ensure all personnel don a gown and gloves prior to entering the client's room.

Cevap

Implement frequent room checks, apply a bed alarm, and ensure all personnel don a gown and gloves prior to entering the client's room.
The correct action successfully addresses both the infection control mandates and the client's immediate safety needs. Contact precautions (gown and gloves) are absolutely necessary for norovirus to prevent environmental contamination and cross-transmission. Simultaneously, utilizing bed alarms and increasing the frequency of room checks are appropriate, least-restrictive interventions to manage the wandering behavior associated with acute confusion.

Adım Adım Çözüm

1
Identify the required transmission-based precautions for the specific pathogen.
Norovirus is transmitted via the fecal-oral route and contaminated surfaces, requiring strict contact precautions (gown and gloves) for any room entry.
Maintaining a barrier is essential to prevent the spread of the pathogen to healthcare workers and the facility environment.
2
Evaluate the safety risk posed by the client's wandering behavior.
The confused client risks spreading the infection to common areas and exposing vulnerable residents.
Clients with infectious diseases who cannot adhere to isolation protocols require active nursing interventions to protect public health.
3
Select the nursing intervention that safely manages the behavior while adhering to legal and ethical standards.
Utilizing bed alarms and frequent monitoring provides necessary safety without inappropriately using physical restraints or delegating assessments.
Restraints are a measure of last resort, and nursing assessments cannot be delegated. Proper PPE must always be maintained during these interventions.

Anahtar Kavram

Balancing strict transmission-based precautions with least-restrictive safety interventions for a cognitively impaired client.
Soru 912Soru →

A practical nurse is assisting with health maintenance visits at a community wellness clinic. A 67-year-old client is establishing care for routine preventative services. Which of the following actions by the nurse support appropriate health promotion and disease prevention for this client? (Select all that apply)

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Administering the prescribed recombinant zoster vaccine to prevent viral reactivation.; Reinforcing the provider's instructions on how to collect a stool sample at home for colorectal cancer screening.; Inquiring about the client's traditional food preferences before reviewing a newly prescribed low-sodium diet.

Cevap

The correct actions include administering the recombinant zoster vaccine, reinforcing instructions for home stool sample collection, and inquiring about traditional food preferences before diet teaching.
Appropriate health promotion for a 67-year-old includes administering age-indicated primary preventions (like the recombinant zoster vaccine for adults over 50), supporting secondary prevention (like at-home stool collection for cancer screening), and providing culturally competent care by assessing traditional food preferences before issuing diet modifications.

Adım Adım Çözüm

1
Evaluate the client's age (67 years) and care context (preventative wellness visit).
Identify that the client requires age-appropriate primary and secondary prevention strategies, such as specific vaccinations and cancer screenings.
Health promotion for older adults focuses on preventing functional decline, avoiding preventable diseases, and early detection.
2
Analyze each intervention for safety, appropriateness, and alignment with the practical nursing scope of practice.
Determine that the zoster vaccine, colorectal screening instruction, and culturally sensitive dietary assessment are safe and appropriate. The live flu vaccine is contraindicated by age, and acute confusion requires immediate reporting.
Applying safe medication administration principles and recognizing acute physiological changes are core nursing responsibilities.
3
Select the options that represent correct, safe health promotion interventions.
Select the options regarding the zoster vaccine, stool collection instructions, and cultural food inquiry.
These choices actively support disease prevention while avoiding contraindications and clinical errors.

Anahtar Kavram

Health Promotion and Disease Prevention
Soru 913Soru →

During shift handoff on a busy nephrology and general medical unit, a registered nurse (RN) is determining safe delegations for the nursing staff. Which of the following specific client care activities is appropriate to assign to a practical/vocational nurse (LPN/VN)?

Cevabı ve açıklamayı göster

Cevap: Performing a focused data collection, including lung sound auscultation, for a stable client with a history of heart failure.

Cevap

Performing a focused data collection, including lung sound auscultation, for a stable client with a history of heart failure.
The correct answer involves performing a focused data collection for a stable client. The LPN/VN scope of practice includes gathering ongoing, focused data (such as auscultating lung sounds) on clients who are clinically stable with predictable outcomes. This contrasts directly with the RN's exclusive responsibility for initial comprehensive assessments and evaluation of unstable conditions.

Adım Adım Çözüm

1
Analyze the role and scope of practice of the LPN/VN.
The LPN/VN is responsible for providing care to stable clients with predictable outcomes. Their role emphasizes focused data collection, reinforcement of teaching, and executing established care plans.
Understanding scope boundaries is foundational to recognizing safe and legal delegation.
2
Evaluate the clinical stability of the clients and the complexity of the interventions described in each option.
Options involving initial admission assessments, unstable clients requiring IV push medications, and obtaining informed consent fall outside the LPN/VN scope. The stable client with heart failure requires only focused data collection, which is a permissible task.
Delegation decisions must align with both client stability and the legal boundaries of nursing practice.

Anahtar Kavram

The LPN/VN role centers on focused data collection and caring for stable clients, whereas the RN is responsible for comprehensive assessments, managing unstable clients, and complex clinical evaluation.
Soru 914Soru →

A practical nurse (PN) is gathering supplies in the unit's clean utility room. A staff member from a different department enters and asks, "I heard a rumor that our former nursing supervisor was admitted to your floor this morning. Is it true, and how is she doing?" Which response by the PN is most appropriate?

Cevabı ve açıklamayı göster

Cevap: "I cannot confirm whether she is a client here or discuss any health information."

Cevap

The most appropriate response is to state that the nurse cannot confirm whether the individual is a client or discuss any health information.
Under client privacy and confidentiality regulations (such as HIPAA), a nurse must protect all aspects of a client's protected health information (PHI). This includes the mere fact that an individual is admitted to the facility. Because the inquiring staff member is not involved in the client's care, the practical nurse must neither confirm nor deny the admission, nor provide any updates on the client's status.

Adım Adım Çözüm

1
Analyze the request made by the staff member from a different department.
The staff member is asking for confirmation of a client's admission and an update on their condition.
Identifying the exact nature of the inquiry helps determine if the person is authorized to receive this information.
2
Evaluate the staff member's authorization to access this client's protected health information (PHI).
The staff member is not involved in the client's care, meaning they have no clinical 'need to know' and are unauthorized to receive PHI.
Regulations dictate that PHI should only be shared with individuals directly involved in the client's care or those who have explicit consent.
3
Determine the appropriate response to maintain confidentiality.
The PN must refuse to confirm the admission or provide any updates, regardless of the inquirer's employment status at the facility.
Even confirming a client's presence in a facility is a breach of confidentiality if the inquiring party is unauthorized.

Anahtar Kavram

Confidentiality and Information Security
Soru 915Soru →

A practical nurse is preparing to provide morning care for a pediatric client admitted with a confirmed diagnosis of measles (rubeola). Which of the following infection control measures must the nurse implement?

Cevabı ve açıklamayı göster

Cevap: Wear a fit-tested N95 respirator or higher-level respiratory protection when entering the room.

Cevap

The nurse must wear a fit-tested N95 respirator when entering the client's room.
Measles (rubeola) is transmitted through the airborne route. According to infection control guidelines, healthcare personnel must wear a fit-tested N95 respirator or a powered air-purifying respirator (PAPR) when entering the room of a client on airborne precautions to filter out microscopic infectious particles.

Adım Adım Çözüm

1
Identify the transmission route for the specific pathogen.
Measles (rubeola) is highly contagious and transmitted via the airborne route.
Different pathogens require specific isolation protocols based on how they spread.
2
Determine the required precautions for airborne transmission.
Airborne precautions require a private room with negative air pressure (AIIR) and the use of an N95 respirator or higher for anyone entering.
Airborne particles are small enough to bypass standard surgical masks and can remain suspended in the air over long distances.
3
Evaluate the options against standard airborne precaution protocols.
Wearing an N95 respirator upon entry aligns with airborne precaution requirements.
Surgical masks and open doors violate airborne protocols, and gowns are unnecessary unless contact precautions are also indicated.

Anahtar Kavram

Airborne Precautions Requirements
Tahmini Süre:1m 0s
Soru 916Soru →

A 5-year-old child arrives at the outpatient clinic for routine school vaccinations, which includes the live attenuated measles, mumps, and rubella (MMR) vaccine. While gathering the health history, the parent states the child has been taking a high-dose oral corticosteroid for the past two weeks to manage a severe asthma flare-up. What is the most appropriate action for the nurse to take?

Cevabı ve açıklamayı göster

Cevap: Defer the immunization and discuss the child's current medication therapy with the primary healthcare provider.

Cevap

Defer the immunization and discuss the child's current medication therapy with the primary healthcare provider.
The MMR vaccine contains live attenuated viruses. High-dose oral corticosteroids suppress the immune system, making the administration of live vaccines highly dangerous due to the risk of active, uncontrolled infection. The nurse must recognize this critical pharmacological contraindication, withhold the administration, and promptly consult the prescribing healthcare provider.

Adım Adım Çözüm

1
Identify the properties of the prescribed vaccine.
The MMR is recognized as a live attenuated virus vaccine.
Live vaccines carry specific administration risks and require competent immune function.
2
Evaluate the client's current pharmacological regimen.
The child is currently taking high-dose systemic corticosteroids.
Systemic corticosteroids induce immunosuppression, altering how the body responds to pathogens.
3
Determine the safest nursing intervention based on pharmacological interactions.
The nurse must pause the procedure and escalate the finding.
Administering a live vaccine to an immunosuppressed client is heavily contraindicated as it can cause a severe active infection.

Anahtar Kavram

Live Vaccine Contraindications and Immunosuppressive Therapy
Soru 917Soru →

A practical nurse (PN) is collecting health history from a 20-year-old client at a community clinic. The client reports recently receiving a large tattoo and multiple body piercings at an unlicensed residential gathering, using shared equipment. The client states, "My friends and I didn't use any special cleaning solutions, but it looks fine for now." Which of the following actions should the PN take? (Select all that apply.)

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Determine the client's current tetanus immunization status.; Inspect the tattoo and piercing sites for localized erythema, edema, and purulent drainage.; Reinforce education on the risks of contracting Hepatitis B, Hepatitis C, and HIV from shared needles.

Cevap

The correct actions are to determine the client's tetanus immunization status, inspect the tattoo and piercing sites for signs of localized infection, and reinforce education regarding the transmission risks of bloodborne pathogens.
Unregulated body modifications with shared equipment place the client at high risk for bacterial skin infections and bloodborne pathogens (such as HIV, Hepatitis B, and Hepatitis C). The PN must collect essential baseline data by inspecting the sites for localized infection and verifying the client's tetanus immunization status. Additionally, reinforcing education on these specific viral risks is a critical, evidence-based harm-reduction strategy well within the practical nursing scope of practice.

Adım Adım Çözüm

1
Analyze the clinical scenario to identify the high-risk behavior.
The client engaged in unregulated body modifications using shared equipment, creating significant risk for localized bacterial infection and systemic bloodborne pathogens.
Identifying the specific risks directs the necessary data collection and educational interventions.
2
Select appropriate physiological data collection actions.
Inspecting the sites for erythema or drainage and verifying the client's tetanus immunization status are critical, within-scope actions to identify immediate harm.
Unsterile needles can introduce Clostridium tetani and common skin flora (like Staphylococcus), necessitating immediate physical inspection and immunization review.
3
Select appropriate harm-reduction and teaching interventions.
Reinforcing education on Hepatitis B, Hepatitis C, and HIV transmission is selected as a key priority.
Shared needles directly expose the client to these bloodborne viruses, making preventative education a primary nursing responsibility.
4
Evaluate remaining options against PN scope of practice, therapeutic communication standards, and legal requirements.
Developing an initial care plan (RN scope), asking 'why' (non-therapeutic), and informing parents of an adult client (confidentiality breach) are eliminated.
Options must strictly adhere to legal boundaries and established standards of nursing care.

Anahtar Kavram

Nursing Management of High-Risk Behaviors: Unregulated Body Modifications
Soru 918Soru →

While working in a multidisciplinary primary care clinic, a practical nurse reviews the care plans for four different clients. Which nursing action correctly promotes health and prevents disease?

Cevabı ve açıklamayı göster

Cevap: Withholding a prescribed live-attenuated influenza vaccine from a client who is currently pregnant.

Cevap

The correct action is to withhold the live-attenuated influenza vaccine from a pregnant client.
Live-attenuated vaccines, such as the intranasal influenza vaccine, contain a weakened form of the live virus. They are strictly contraindicated during pregnancy due to the theoretical risk of transmitting the infection to the developing fetus. Withholding this vaccine prevents potential fetal harm, which demonstrates excellent disease prevention and safe nursing practice.

Adım Adım Çözüm

1
Evaluate the action regarding the pregnant client.
Recognizes that live-attenuated vaccines are contraindicated during pregnancy.
Preventing harm from teratogenic or infectious agents is a primary disease prevention strategy.
2
Evaluate the action regarding the 9-month-old infant.
Identifies that stacking six blocks is a milestone for a 2-year-old, not a 9-month-old.
Normal infant development at 9 months includes sitting without support and using a pincer grasp, making the instruction incorrect.
3
Evaluate the action regarding the older adult client.
Recognizes that sudden confusion indicates acute delirium or infection, not normal aging.
Acute mental status changes in older adults require immediate medical investigation, making reassurance inappropriate.
4
Evaluate the action regarding the dietary substitution.
Determines that substituting a vegetarian meal with beef violates cultural or religious practices.
Health promotion includes respecting and integrating a client's cultural dietary beliefs into their care plan.

Anahtar Kavram

Health promotion and disease prevention across the lifespan
Soru 919Soru →

An older adult client is resting in bed following a right total hip arthroplasty (posterior approach). The nurse is reviewing the client's care plan regarding mobility and comfort. Which of the following positioning actions is appropriate for this client?

Cevabı ve açıklamayı göster

Cevap: Place an abductor wedge between the client's legs.

Cevap

The appropriate positioning action is to place an abductor wedge between the client's legs.
Following a posterior total hip arthroplasty, the client's legs must remain abducted to prevent the new prosthetic joint from dislocating. An abductor wedge effectively maintains this safe alignment.

Adım Adım Çözüm

1
Identify the surgical procedure and approach.
The client had a right total hip arthroplasty using a posterior approach.
Different surgical approaches have specific postoperative precautions to prevent complications.
2
Recall the positioning restrictions for a posterior hip arthroplasty.
Hip flexion greater than 90 degrees, adduction, and internal rotation must be avoided.
These movements can cause the head of the femur to pop out of the acetabulum, leading to dislocation.
3
Evaluate the given positioning options against these restrictions.
Sitting at 90 degrees causes excessive flexion. Crossing the legs causes adduction. Placing a roll under the knee risks contracture and DVT. Using an abductor wedge maintains proper alignment.
Only the abductor wedge aligns with safe postoperative care for this specific procedure.

Anahtar Kavram

Postoperative positioning and joint precautions following a posterior total hip arthroplasty.
Soru 920Soru →

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

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence is to first perform hand hygiene and don gloves, then displace the skin laterally, insert the needle at a 90-degree angle, inject the medication slowly, and finally withdraw the needle while releasing the displaced skin.
The Z-track method is designed to prevent medication from leaking into the subcutaneous tissue. To perform this correctly, infection control (hand hygiene and gloves) is always the first step. Next, the nurse displaces the skin to misalign the tissue layers. While holding the skin displaced, the needle is inserted at 90 degrees to reach the muscle, and the medication is injected. Finally, the needle is withdrawn and the skin is released simultaneously to create a zig-zag track that seals the medication in the muscle.

Adım Adım Çözüm

1
Ensure infection control
Hand hygiene is performed and gloves are donned.
To maintain standard precautions and prevent the transmission of microorganisms before touching the client.
2
Prepare the tissue using the Z-track technique
Skin and subcutaneous tissue are displaced laterally.
This creates a zig-zag path that will prevent the medication from leaking back up the needle track.
3
Puncture the skin
Needle is inserted at a 90-degree angle.
This angle is required to bypass the subcutaneous layer and deposit the medication directly into the deep muscle.
4
Administer the medication
Medication is injected slowly and steadily.
Slow administration promotes comfort and allows the muscle fibers to absorb the fluid volume.
5
Seal the injection track
Needle is withdrawn and the displaced skin is released.
Releasing the tissue seals the track, trapping the medication in the muscle and preventing skin irritation.

Anahtar Kavram

Z-track intramuscular injection technique
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Tüm alıştırma soruları — NCLEX-PN | Examkin