Tüm alıştırma soruları

2933 soru

Soru 981Soru →

A nursing assistant reports updated vital signs for a client who underwent a percutaneous liver biopsy 33 hours ago. The client's current blood pressure is 102/66102/66 mm Hg and heart rate is 112112 beats/min, compared to a pre-procedure baseline of 130/82130/82 mm Hg and 7878 beats/min. The client reports new, mild right shoulder pain. A review of the morning laboratory data shows a platelet count of 82,000/mm382,000/\text{mm}^3. Which action should the practical nurse take first?

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Cevap: Examine the right upper quadrant dressing for saturation and gently palpate the abdomen for rigidity.

Cevap

The correct action is to examine the right upper quadrant dressing for saturation and gently palpate the abdomen for rigidity.
The correct answer involves inspecting the biopsy site and abdomen. The client's trend of falling blood pressure and rising heart rate, combined with a low platelet count and right shoulder pain (referred pain from diaphragmatic irritation), strongly suggests internal hemorrhage following the liver biopsy. Within the practical nurse scope of practice, the immediate priority is to gather focused, direct assessment data regarding the potential complication before urgently notifying the registered nurse.

Adım Adım Çözüm

1
Analyze the client's vital sign trends and presenting symptoms.
The client has a narrowing pulse pressure, hypotension, and tachycardia compared to baseline, alongside new right shoulder pain.
These are classic indicators of early hypovolemic shock and diaphragmatic irritation, strongly pointing to internal bleeding.
2
Correlate the clinical presentation with the morning laboratory results and recent procedure.
The client underwent a biopsy of a highly vascular organ (the liver) and has thrombocytopenia (low platelets).
A low platelet count significantly increases the risk of severe post-procedural hemorrhage, making the vital sign changes highly alarming.
3
Determine the priority nursing action within the practical nurse scope of practice.
The practical nurse must immediately perform a focused physical assessment of the surgical site and abdomen.
Gathering specific, direct clinical data about the potential bleeding site is required before urgently escalating the critical situation to the registered nurse.

Anahtar Kavram

Recognizing and prioritizing early signs of hemorrhagic shock and complications following invasive procedures.
Tahmini Süre:1m 30s
Soru 982Soru →

During hourly rounds on a medical-surgical unit, the practical nurse observes that an 81-year-old client being treated for bacterial pneumonia has become highly agitated and is picking at the bedsheets. The client's resting heart rate has increased to 112 beats per minute, and blood pressure has decreased to 102/62 mmHg from a morning baseline of 136/82 mmHg. Which action should the practical nurse take first?

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Cevap: Obtain a peripheral oxygen saturation reading

Cevap

Obtain a peripheral oxygen saturation reading
The correct answer prioritizes the assessment of oxygenation. In clients with respiratory conditions like pneumonia, sudden agitation or restlessness is often the earliest sign of hypoxia. The accompanying tachycardia and hypotension further suggest acute physiological decompensation. The practical nurse must immediately gather focused respiratory data to determine if the client is experiencing compromised breathing and circulation.

Adım Adım Çözüm

1
Analyze the clinical cues presented by the client.
The client has a respiratory infection, new-onset agitation, tachycardia (112 bpm), and dropping blood pressure (102/62 mmHg).
Identifying the combination of neurological and cardiovascular changes helps recognize acute physiological decompensation.
2
Apply the ABC (Airway, Breathing, Circulation) priority framework.
The symptoms suggest impaired oxygenation (Breathing) or early shock (Circulation).
Sudden confusion or agitation in an older adult, especially with an underlying respiratory illness, is a classic sign of hypoxia and must be investigated immediately.
3
Determine the most appropriate immediate action within the practical nurse scope.
Obtaining an oxygen saturation reading rapidly assesses the client's respiratory status.
Measuring oxygen saturation directly evaluates the most likely life-threatening cause of the client's sudden status change.

Anahtar Kavram

Prioritization of Airway, Breathing, and Circulation in Acute Decompensation
Soru 983Soru →

An older adult client with generalized weakness is prescribed to sit in a wheelchair for meals. The nurse is preparing to perform a stand-and-pivot transfer using a gait belt. Place the following steps in the correct chronological order.

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Cevap

The correct sequence ensures environmental safety first, prepares the client physically, secures the safety equipment, utilizes proper body mechanics, and then executes the movement.
Safe transfer protocols require a systematic approach that prioritizes environmental safety (locking wheels), patient readiness (dangling, feet flat), application of safety devices (gait belt), nurse ergonomics (wide base, bent knees), and finally the execution of the physical movement.

Adım Adım Çözüm

1
Position and lock the wheelchair on the client's stronger side.
The receiving equipment is secure and properly angled.
Prevents the chair from rolling away during the transfer, minimizing fall risk.
2
Assist the client to sit at the bedside with feet flat.
The client is in a stable starting position.
Allows for equalization of blood pressure and establishes a base of support for the client.
3
Apply the gait belt around the waist.
The safety device is properly fitted.
Provides a secure handle for the nurse to guide the client without pulling on their arms or shoulders.
4
Grasp the belt and brace the client's knees and feet.
The nurse is in an ergonomic lifting posture.
Maintains the nurse's center of gravity and prevents the client's knees from buckling.
5
Execute the stand and pivot motion.
The client safely transitions from the bed to the wheelchair.
Completes the transfer using coordinated momentum and proper alignment.

Anahtar Kavram

Safe patient handling and proper body mechanics during a stand-and-pivot transfer
Soru 984Soru →

A practical nurse (PN) is admitting a young adult client to an ambulatory surgery center for an elective upper endoscopy. The client has already signed the informed consent document. While the PN is taking the client's vital signs, the client suddenly becomes tearful and states, "I cannot go through with this. I want to cancel the test right now." In what order should the PN perform the following actions? Arrange the steps from first to last.

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Cevap

The correct sequence is to first immediately cease all physical preparations to respect the client's autonomy. Next, the practical nurse should ask open-ended questions to explore the client's concerns. Following this data collection, the nurse must notify the healthcare provider and supervising registered nurse. The practical nurse then observes while the healthcare provider discusses the implications of refusal. Finally, the nurse documents the entire event in the health record.
The nursing process and client advocacy dictate the sequence of actions when a client revokes informed consent. The most immediate priority is to ensure the client's autonomy and physical safety by halting any further preparation. Once the procedure is paused, the practical nurse (PN) must collect data by exploring the client's concerns to understand the situation fully. After gathering this information, the PN must promptly communicate the client's decision to the supervising RN and the healthcare provider, as it is the provider's legal responsibility to address the refusal. The PN then remains to support the client while the provider explains the risks and consequences of canceling the procedure. Finally, the PN must provide a comprehensive legal record of the entire event, including the client's exact words and the actions taken, in the medical chart.

Adım Adım Çözüm

1
Cease all preoperative physical preparations immediately.
The client's right to refuse is respected and physical preparation is halted.
Continuing with preparations after a client withdraws consent constitutes battery; immediate cessation is required.
2
Ask open-ended questions to determine the reason for the client's change of mind.
The PN gathers crucial information about the client's sudden anxiety or concern.
Data collection follows immediate safety interventions in the nursing process, helping to clarify the root cause of the refusal.
3
Notify the healthcare provider and the supervising registered nurse.
The care team and the acting physician are alerted to the client's decision.
The provider must be notified immediately as it is their legal responsibility to address procedure cancellations and informed consent issues.
4
Observe as the healthcare provider discusses the implications of refusal with the client.
The client receives the necessary medical information regarding their refusal.
Explaining the risks and alternatives of refusing a procedure falls strictly under the provider's scope of practice, not the PN's.
5
Document the client's verbal refusal and the provider's intervention in the health record.
A legal and accurate account of the incident is created.
Documentation should occur only after the client's immediate needs and safety have been fully addressed.

Anahtar Kavram

Client's Right to Revoke Consent and the Nursing Process
Soru 985Soru →

A practical nurse (PN) is reviewing the medication administration record (MAR) for a client admitted with a blood pressure of 158/92 mmHg158/92\text{ mmHg} and a documented medical history of severe asthma. The provider has prescribed propranolol 40 mg40\text{ mg} orally every 12 hours and an albuterol metered-dose inhaler (MDI) as needed. Which action should the PN take first?

Cevabı ve açıklamayı göster

Cevap: Withhold the propranolol and notify the registered nurse (RN) to clarify the prescription with the provider.

Cevap

The correct action is to withhold the propranolol and notify the registered nurse (RN) to clarify the prescription with the provider.
The correct answer addresses the critical contraindication of administering a non-selective beta-blocker (propranolol) to a client with severe asthma. Propranolol blocks beta-2 receptors in the lungs, which can trigger severe, potentially fatal bronchospasm. The practical nurse must recognize this risk, withhold the dose, and notify the RN or provider to advocate for a safer alternative, such as a cardioselective beta-blocker.

Adım Adım Çözüm

1
Review the client's medical history and the newly prescribed medications.
The client has a history of severe asthma and is prescribed propranolol, a non-selective beta-blocker.
Identifying potential drug-disease interactions is a critical component of safe medication administration.
2
Analyze the pharmacological effects of the prescribed medication in relation to the client's underlying conditions.
Non-selective beta-blockers inhibit both beta-1 (cardiac) and beta-2 (pulmonary) receptors, which can induce dangerous bronchospasm in a client with asthma.
Understanding the mechanism of action helps predict severe adverse effects that compromise the airway.
3
Determine the appropriate nursing intervention within the practical nurse (PN) scope of practice.
The PN must withhold the unsafe medication and immediately escalate the concern to the RN or provider.
The PN is responsible for ensuring client safety by refusing to administer contraindicated medications and reporting to the supervising RN.

Anahtar Kavram

Medication Contraindications and Patient Safety
Tahmini Süre:1m 15s
Soru 986Soru →

While administering a prescribed intramuscular injection to a client, a practical nurse sustains an accidental needlestick injury to the index finger. Arrange the following actions the nurse must take in the correct chronological order to comply with standard precautions and occupational safety guidelines.

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Cevap

The correct sequence for managing an occupational needlestick exposure is: first aid (washing the site), notifying the supervisor, seeking immediate medical evaluation, obtaining baseline testing, and completing long-term follow-up.
According to the Centers for Disease Control and Prevention (CDC) guidelines for occupational exposure to bloodborne pathogens, the immediate priority is first aid: washing the site with soap and water. Squeezing the wound or using harsh chemicals like bleach should be avoided. Once first aid is complete, the nurse must notify the supervisor to activate the exposure protocol. The nurse is then directed to occupational health or the emergency department for a time-sensitive risk assessment, as post-exposure prophylaxis (PEP) should be started within hours if indicated. Baseline serology is drawn during this initial visit, followed by scheduled serial testing in the months following the exposure to monitor for delayed seroconversion.

Adım Adım Çözüm

1
Cleanse the needlestick site immediately with soap and running water.
Physical removal of potential pathogens from the wound site.
Immediate first aid is the highest priority to minimize the viral load and reduce the risk of systemic infection.
2
Notify the unit charge nurse or nursing supervisor about the exposure.
Activation of the facility's exposure control plan.
Leadership must be informed to ensure the nurse is relieved of clinical duties to seek immediate care and to begin the process of evaluating the source client.
3
Proceed to the employee health department for an exposure risk assessment.
Clinical evaluation by an occupational health provider.
Immediate medical assessment is required to determine if post-exposure prophylaxis (PEP) is indicated. PEP for HIV is most effective when initiated within 1 to 2 hours of exposure.
4
Provide a blood sample for baseline serologic testing.
Establishment of the nurse's baseline serostatus.
Baseline testing is necessary for workers' compensation and to determine if any subsequent infection was a direct result of this specific occupational exposure.
5
Return for follow-up serologic testing at scheduled intervals.
Long-term monitoring for seroconversion.
Because bloodborne pathogens have an incubation period, follow-up testing is required to ensure no infection occurred over time.

Anahtar Kavram

Occupational Exposure Protocol for Bloodborne Pathogens
Soru 987Soru →

A practical nurse (PN) is collecting data on a client who is receiving rapid intravenous (IV) fluid therapy for severe dehydration. Which of the following findings should alert the PN that the client is developing fluid volume overload? Select all that apply.

Geçerli olan tümünü seçin

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Cevap: New onset of fine crackles auscultated in the bilateral lung bases; Jugular venous distention visible when the head of the bed is elevated; Increased respiratory rate of 28 breaths/min with shortness of breath

Cevap

The correct findings indicating fluid volume overload are new onset of fine crackles in the lung bases, jugular venous distention, and an increased respiratory rate with shortness of breath.
Fluid volume overload occurs when intravenous fluids are administered faster than the cardiovascular and renal systems can process them. This excess volume backs up into the pulmonary circulation (causing crackles, tachypnea, and shortness of breath) and the systemic circulation (causing jugular venous distention). Recognizing these acute Airway, Breathing, and Circulation (ABC) cues is critical for immediate PN escalation.

Adım Adım Çözüm

1
Analyze the client's current treatment and risk factors.
The client is receiving rapid IV fluids, placing them at high risk for circulatory overload if the body cannot process the volume quickly enough.
Identifying the intervention (rapid fluids) directly points to the potential complication (fluid volume excess).
2
Evaluate each finding for signs of excess fluid in the pulmonary or systemic circulation.
Crackles, rapid breathing, and jugular venous distention all demonstrate fluid backing up into the lungs and venous system.
These are the classic physiological adaptations indicating that the heart cannot pump the sudden excess volume effectively.
3
Differentiate between signs of improvement and signs of deterioration.
A normalizing heart rate (82 beats/min) is a sign of improvement from dehydration, and minor IV site pain is a local issue, neither of which indicates overload.
Recognizing expected therapeutic responses prevents the unnecessary escalation of normal findings.

Anahtar Kavram

Fluid Volume Overload Recognition
Soru 988Soru →

A practical nurse (PN) reviews the morning laboratory results for a client with heart failure who is scheduled to receive a daily dose of digoxin. The client's serum potassium level is 3.1 mEq/L3.1\text{ mEq/L}. During data collection, the client reports new-onset nausea and generalized weakness. Which action should the PN take first?

Cevabı ve açıklamayı göster

Cevap: Withhold the digoxin dose and immediately report the findings to the registered nurse (RN).

Cevap

The PN must withhold the digoxin dose and immediately report the findings to the registered nurse (RN).
The correct answer is to withhold the medication and notify the RN. The client's potassium level is low (normal is 3.5 to 5.0 mEq/L), which strongly predisposes the client to digoxin toxicity. Combined with the clinical symptoms of nausea and weakness, these findings strongly suggest early toxicity. The safest action within the practical nurse's scope of practice is to hold the drug and escalate the data for further medical evaluation.

Adım Adım Çözüm

1
Analyze the client's laboratory data.
The potassium level is 3.1 mEq/L, which indicates hypokalemia (normal is 3.5 to 5.0 mEq/L).
Identifying abnormal lab values is a crucial safety step before administering high-alert medications.
2
Correlate the lab findings and clinical symptoms with the scheduled medication.
Hypokalemia increases the risk for digoxin toxicity. Furthermore, nausea and generalized weakness are early clinical indicators of toxicity.
Recognizing the interaction between electrolyte imbalances and medication adverse effects is essential to prevent severe complications.
3
Determine the appropriate nursing action within the PN scope of practice.
The medication must be withheld and the critical findings escalated to the RN immediately.
The PN must ensure client safety by intervening when contraindications are present and reporting unstable conditions to the supervising RN.

Anahtar Kavram

Digoxin Toxicity and Hypokalemia
Soru 989Soru →

At 0200 on a medical-surgical floor, an older adult admitted for severe pneumonia suddenly attempts to climb over the bed rails. The client, who has a history of mild dementia and anxiety, is visibly terrified and shouts about intruders hiding in the ceiling. What is the priority action for the practical nurse to take?

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Cevap: Stay at the bedside, speak in a low and soothing voice, and gently redirect the client back to the center of the bed.

Cevap

The practical nurse should remain at the bedside, use a calm and soothing tone, and gently redirect the client back to a safe position in bed.
The client is displaying signs of acute delirium likely secondary to pneumonia, which presents a high risk for injury. The immediate priority is maintaining physical safety using the least restrictive means. Staying at the bedside provides the necessary supervision to prevent a fall, while a calm voice and gentle physical redirection help de-escalate the client's severe agitation without increasing their fear.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
The client is exhibiting sudden-onset severe agitation and visual hallucinations.
Differentiating between the client's baseline mild dementia and the acute onset of delirium (likely triggered by pneumonia) is critical for determining the appropriate intervention.
2
Identify the primary risk to the client.
The client is in immediate danger of falling or injuring themselves by climbing over the bed rails.
In any psychiatric or behavioral emergency, maintaining physical safety is always the highest priority.
3
Select the safest, least restrictive intervention.
Remaining with the client and using verbal and gentle physical redirection prevents injury without escalating the crisis.
Using logic, leaving the room, or immediately applying restraints will either fail to address the safety risk or worsen the client's agitation.

Anahtar Kavram

Management of Acute Delirium and Client Safety
Soru 990Soru →

A practical nurse is providing care for a hospice client who suddenly begins experiencing severe air hunger, tachypnea, and restlessness. The client has standing PRN orders for end-of-life symptom management. In what order should the nurse perform the following actions? (Arrange from first to last)

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Cevap

The correct sequence is to first elevate the head of the bed, followed by administering the sublingual morphine, directing a fan toward the client's face, supporting and educating the family, and finally documenting the event.
When a hospice client experiences severe terminal dyspnea (air hunger), the nurse must prioritize interventions using the ABCs (Airway, Breathing, Circulation) and Maslow's hierarchy of needs. The most immediate, non-pharmacological action is elevating the head of the bed to facilitate lung expansion. Next, administering the prescribed sublingual morphine is critical, as it is the primary pharmacological treatment for air hunger. Applying a fan provides additional, evidence-based symptom relief by stimulating the trigeminal nerve. Only after the client's acute physical symptoms are managed should the nurse transition to providing psychosocial support and explanation to the family. Finally, nursing documentation is completed after all direct care is safely rendered.

Adım Adım Çözüm

1
Elevate the head of the client's bed to maximize lung expansion.
The diaphragm lowers and chest expansion improves.
According to the ABCs (Airway, Breathing, Circulation) of prioritization, opening and optimizing the airway through physical positioning is always the first, fastest response to respiratory distress.
2
Administer the prescribed PRN sublingual morphine.
The client receives medication to decrease the respiratory drive and reduce anxiety.
Morphine is the primary pharmacological intervention for air hunger at the end of life; administering it immediately after positioning allows it time to absorb and take effect.
3
Turn on a bedside fan to direct cool air toward the client's face.
The client's trigeminal nerve is stimulated by the cool airflow.
Using a fan is a proven non-pharmacological comfort measure that alters the perception of breathlessness, acting as an excellent adjunct while the medication begins to work.
4
Explain to the family members that these measures will help ease the client's breathing.
The family receives reassurance and education about the dying process.
Psychosocial support is crucial in end-of-life care, but according to Maslow's hierarchy of needs, physiological stability of the client must be secured before addressing the family's emotional needs.
5
Document the respiratory episode and the client's response to the interventions.
The client's medical record is accurately updated.
Documentation is necessary for legal and communication purposes but is always the lowest priority during an acute symptom crisis.

Anahtar Kavram

Prioritization of physiological and psychosocial interventions for terminal dyspnea.
Soru 991Soru →

A client is recovering from a lumbar laminectomy. The nursing care plan requires turning the client every two hours. Which sequence of actions should the practical nurse implement to reposition this client safely from a supine to a lateral position?

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Cevap

The nurse must first flatten the bed, prepare the client's body alignment by placing a pillow between the legs and crossing the arms, execute the turn as a single unit, and finally support the new lateral position with pillows.
Safe repositioning after spinal surgery requires the 'logrolling' technique. This procedural sequence ensures that the spine remains in strict alignment throughout the entire movement by flattening the bed, securing the extremities, turning the body as one solid unit, and providing postoperative support.

Adım Adım Çözüm

1
Flatten the bed completely.
The client's spine rests perfectly horizontal.
Any elevation can cause twisting or bending of the spinal column during movement.
2
Place a pillow between the client's legs and have them cross their arms.
The hips, pelvis, and upper body are stabilized.
This maintains the alignment of the spine and prevents the extremities from causing rotation during the turn.
3
Roll the client as a single, straight unit.
The client is turned onto their side without twisting.
Moving the head, shoulders, and hips simultaneously (logrolling) prevents any torsion on the surgical site.
4
Position supportive pillows along the back and under the limbs.
The client rests securely and comfortably in the lateral position.
Proper support maintains spinal alignment and prevents the client from inadvertently rolling back.

Anahtar Kavram

Spinal alignment and logrolling technique
Soru 992Soru →

During an annual wellness visit, a female client asks the practical nurse for a review on how to check her breasts for lumps at home. How should the nurse sequence the instructions for this screening procedure? Arrange the steps in the correct chronological order.

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Cevap

The correct sequence for breast self-examination begins with three visual inspection steps (arms at sides, arms raised, hands on hips), followed by assuming a supine position to evenly distribute the tissue, and concludes with systematic palpation using the finger pads.
Breast self-examination is an important secondary prevention strategy that requires a specific sequence for maximum effectiveness. The procedure starts with a comprehensive visual inspection in three distinct postures to identify superficial changes, dimpling, or asymmetry. Following the visual inspection, the client must transition to a supine position. Lying down is critical because it evenly flattens the breast tissue against the chest wall, enhancing the ability to palpate deeper structures. Finally, systematic palpation using the sensitive pads of the middle fingers ensures that all breast tissue is thoroughly evaluated.

Adım Adım Çözüm

1
Stand facing a mirror with arms resting naturally at the sides to inspect for visible changes.
The client observes the baseline appearance of the breasts.
Visual inspection in a relaxed position allows for the detection of obvious superficial changes.
2
Raise both arms straight up overhead to look for dimpling or contour abnormalities.
The client inspects the breasts with altered suspensory ligament tension.
Raising the arms pulls the skin and ligaments, which can reveal dimpling indicative of an underlying mass.
3
Press hands firmly on the hips to flex the chest muscles and observe for asymmetry.
The client inspects the breasts with contracted pectoral muscles.
Flexing the chest muscles highlights subtle skin retractions that may not be visible when muscles are relaxed.
4
Assume a supine position and place a folded towel under the shoulder of the side being examined.
The client is positioned optimally for palpation.
Lying supine flattens and spreads the breast tissue evenly over the chest wall, making it easier to detect deeper lumps.
5
Palpate the breast tissue systematically using the flat pads of the three middle fingers.
The client thoroughly palpates all quadrants of the breast tissue.
The finger pads are highly sensitive, and using a structured pattern ensures a comprehensive assessment.

Anahtar Kavram

Secondary Prevention: Client education on proper technique for breast self-examination (BSE).
Tahmini Süre:1m 30s
Soru 993Soru →

An older adult client in a residential care facility has a baseline of early-stage dementia but consistently dresses independently after the practical nurse (PN) lays out their clothing in the correct sequence. This morning, the PN observes the client attempting to put their trousers on their arms, speaking in disorganized sentences, and appearing flushed and diaphoretic. Which action should the PN take first?

Cevabı ve açıklamayı göster

Cevap: Suspend the self-care activity, remain with the client, and promptly obtain a complete set of vital signs.

Cevap

Suspend the self-care activity, remain with the client, and promptly obtain a complete set of vital signs.
The client is exhibiting signs of acute delirium (sudden confusion, disorganized speech, diaphoresis), which represents an acute physiological deterioration rather than expected chronic cognitive decline. The priority is to ensure safety, halt the self-care task, and collect baseline data (vital signs) to report to the registered nurse or provider for further evaluation.

Adım Adım Çözüm

1
Compare the client's current presentation to their established baseline.
The client usually dresses independently but is currently exhibiting sudden confusion, inappropriate use of objects, and physical symptoms (diaphoresis).
Differentiating between expected chronic limitations (dementia) and acute deterioration (delirium) is essential for safe care.
2
Prioritize the client's needs based on the assessment data.
The acute physiological change takes immediate precedence over promoting independence in activities of daily living.
Acute delirium is often a sign of a life-threatening underlying issue, such as infection or hypoxia, requiring immediate medical attention.
3
Determine the safest, within-scope intervention.
The PN stops the dressing task, ensures the client is safe, and collects objective data (vital signs) to report to the registered nurse.
Data collection is within the PN scope, while diagnosing or performing comprehensive neurological exams is not.

Anahtar Kavram

Discriminating between expected chronic cognitive limitations and acute physiological deterioration during self-care activities.
Soru 994Soru →

A client receives news from the healthcare provider that their physical therapy progress has plateaued and they will not regain full mobility. Shortly after the provider leaves, the client yells at the practical nurse, "This facility is useless, the food is terrible, and none of you know how to do your jobs!" Which response by the practical nurse is most appropriate?

Cevabı ve açıklamayı göster

Cevap: You are experiencing a lot of frustration right now. I have time to sit and listen if you want to talk.

Cevap

The response that acknowledges the client's frustration and offers to sit and listen.
The correct response utilizes therapeutic communication techniques such as reflecting feelings and offering self. When a client displaces anger onto staff following distressing news, acknowledging their emotional state without judgment provides a safe space for them to process their feelings of loss and frustration.

Adım Adım Çözüm

1
Identify the underlying cause of the client's behavior.
The client is using displacement, a defense mechanism, to project their anger and grief about their plateaued physical therapy progress onto the facility and staff.
Recognizing the defense mechanism helps the nurse avoid taking the anger personally and guides a therapeutic response.
2
Evaluate the nurse's role and appropriate interventions.
The practical nurse must maintain a safe, supportive environment using therapeutic communication to help the client process their distress.
Addressing the emotional need rather than the literal words validates the client's feelings.
3
Analyze the provided options against therapeutic communication standards.
Eliminate options that use blocks such as asking 'why', defending the facility, giving false reassurance, or changing the subject.
Non-therapeutic blocks shut down dialogue and can escalate the client's anxiety or anger.
4
Select the most therapeutic response.
The option offering self and reflecting the client's frustration is chosen as the correct action.
This approach builds trust and encourages the client to discuss the true source of their distress.

Anahtar Kavram

Therapeutic Communication in Response to Displacement
Soru 995Soru →

A young adult client arrives at the urgent care clinic experiencing an acute asthma exacerbation. The client is leaning forward, speaking in two-word phrases, and using accessory muscles to breathe. Audible wheezing is present. Which of the following actions should the practical nurse take immediately? (Select all that apply)

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Position the client in a high-Fowler's or orthopneic position; Administer the prescribed inhaled albuterol treatment; Apply prescribed supplemental oxygen to maintain adequate saturation

Cevap

The correct actions are to position the client in a high-Fowler's or orthopneic position, administer the prescribed inhaled albuterol treatment, and apply prescribed supplemental oxygen.
An acute asthma exacerbation is a medical emergency requiring rapid intervention to ensure airway patency and adequate oxygenation. Positioning the client upright facilitates maximal lung expansion. Administering a short-acting bronchodilator relieves acute bronchospasm, while supplemental oxygen treats immediate hypoxia.

Adım Adım Çözüm

1
Recognize signs of an acute respiratory emergency.
The client's use of accessory muscles, tripod positioning, and inability to speak in full sentences indicate severe airway compromise.
Identifying acute physiological decompensation is the critical first step in prioritizing care.
2
Prioritize airway and breathing interventions.
Upright positioning, bronchodilators, and oxygen therapy are initiated immediately.
These rapid actions directly relieve airway constriction, improve oxygenation, and reduce the immediate threat to life.
3
Defer non-emergent or potentially harmful tasks.
Detailed history taking and oral fluid administration are avoided.
Non-emergent tasks delay life-saving care, and offering oral fluids presents a significant aspiration risk during severe dyspnea.

Anahtar Kavram

Acute Asthma Exacerbation Prioritization
Soru 996Soru →

A practical nurse (PN) creates a text-only post for a personal social media page to share an inspiring story from the workday. The PN writes about a 15-year-old client who required a massive blood transfusion after a severe motor vehicle crash, deliberately omitting the client's name and the hospital's name. Which of the following statements indicates the correct nursing understanding of client confidentiality?

Cevabı ve açıklamayı göster

Cevap: Posting this information is a breach of confidentiality because the unique clinical details could allow others to identify the client.

Cevap

Posting this information is a breach of confidentiality because the unique clinical details could allow others to identify the client.
Even without names or locations, sharing specific clinical details such as age, the mechanism of injury, and the treatments provided can allow community members to identify the client. This constitutes a violation of confidentiality and privacy laws such as HIPAA.

Adım Adım Çözüm

1
Analyze the proposed social media post for Protected Health Information (PHI).
The post contains specific details (15-year-old, massive blood transfusion, severe motor vehicle crash) even though the name and facility are omitted.
Confidentiality laws require the protection of all information that could reasonably be used to identify a client.
2
Evaluate the risk of identification from the shared details.
Unique clinical situations combined with demographic details can easily allow community members or acquaintances to deduce the client's identity.
True de-identification requires the removal of all identifying elements, not just names and locations.
3
Determine the legal and ethical implications of the action.
Sharing these details on a personal social media account constitutes a confidentiality breach.
Nurses are ethically and legally bound to maintain client privacy at all times, including on digital platforms.

Anahtar Kavram

Client confidentiality extends to social media; omitting a name does not prevent a breach if other descriptive clinical or demographic details allow for client identification.
Soru 997Soru →

A client is recovering on the surgical unit following a vaginal hysterectomy performed earlier in the day. During an afternoon assessment, the practical nurse (PN) notes that the client's heart rate has climbed from a baseline of 78 bpm to 112 bpm, while the blood pressure has decreased from 126/82 mm Hg to 102/60 mm Hg. A stat hemoglobin result from the laboratory is 7.4 g/dL (74 g/L). Which of the following actions should the PN take? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Examine the perineal pads and the linens beneath the client for evidence of excessive bleeding.; Immediately communicate the changing physiological parameters and laboratory values to the registered nurse (RN).; Confirm the patency of the client's existing peripheral intravenous (IV) catheter.

Cevap

The correct actions include examining the perineal pads and linens for bleeding, communicating the findings to the RN immediately, and confirming the patency of the client's peripheral IV catheter.
The client's increasing heart rate, decreasing blood pressure, and low hemoglobin of 7.4 g/dL (74 g/L) are classic signs of hypovolemic shock, likely due to post-operative hemorrhage. The appropriate nursing actions within the practical nurse scope involve immediately assessing for the source of the bleeding (perineal pads and linens), urgently escalating the critical findings to the registered nurse for provider notification, and ensuring that peripheral IV access is patent in anticipation of fluid or blood administration.

Adım Adım Çözüm

1
Analyze the client's clinical data and identify trends.
The client has an increasing heart rate (78 to 112 bpm), a decreasing blood pressure (126/82 to 102/60 mm Hg), and a critically low hemoglobin of 7.4 g/dL.
Identifying changes from baseline is essential to detect acute post-operative complications.
2
Recognize the underlying clinical complication.
The combination of tachycardia, hypotension, and anemia in a post-surgical client strongly indicates hypovolemic shock secondary to hemorrhage.
Tachycardia is often the earliest compensatory sign of shock, followed by a drop in blood pressure.
3
Determine the appropriate PN interventions to mitigate risk.
The PN must assess for the source of bleeding, escalate the critical findings to the RN, and prepare for potential resuscitation by checking IV access.
These actions fall safely within the PN scope of practice and directly address the life-threatening risk without overstepping into independent medical intervention.

Anahtar Kavram

Post-Operative Hemorrhage and Hypovolemic Shock Recognition
Soru 998Soru →

A practical nurse (PN) is participating in an annual compliance review at a long-term care facility. Match each observed staff action with the correct confidentiality determination.

Soldaki öğeye tıklayın, sonra eşleşen sağdaki öğeye tıklayın

Öğeler

Capturing an image of a resident's sacral pressure injury using a personal smartphone to consult a specialist
Giving a list of residents and their room numbers to a community religious leader visiting the facility
Providing a detailed shift handoff regarding a resident's new medications while eating in the facility cafeteria
Submitting a resident's diagnostic laboratory results to the state health department following a confirmed syphilis diagnosis

Eşleşmeler

Cevabı ve açıklamayı göster

Cevap

Properly align each clinical scenario with its correct privacy determination based on regulatory standards regarding digital security, verbal privacy, directory information, and public health exemptions.
Each correct pairing applies core confidentiality principles to everyday nursing scenarios. It distinguishes between actions that breach security protocols (unencrypted devices, public conversations, unauthorized directory releases) and those that fall under legal exemptions (mandated public health reporting).

Adım Adım Çözüm

1
Analyze the use of a personal smartphone for clinical photography.
Matches with unsecured digital transmission and storage violation.
Personal devices do not have facility-approved encryption or remote-wiping capabilities, violating information security protocols.
2
Evaluate the disclosure of resident names to a visiting religious leader.
Matches with unauthorized disclosure of facility directory information violation.
Information regarding a client's presence in a facility is protected and requires explicit authorization to be shared with community members.
3
Assess the location of the verbal shift handoff in the cafeteria.
Matches with verbal sharing of health information in a non-private setting violation.
Discussing specific client details in public areas where unauthorized individuals can overhear breaches the need-to-know basis of privacy.
4
Examine the submission of a communicable disease diagnosis to the health department.
Matches with permitted disclosure for public health safety.
Reporting specific infectious diseases is mandated by state and federal laws, superseding standard authorization requirements.

Anahtar Kavram

Confidentiality principles, HIPAA guidelines, and exceptions to privacy rules
Tahmini Süre:1m 30s
Soru 999Soru →

An in-patient oncology unit is exceptionally busy, and the charge nurse delegates two specific tasks to a practical nurse (PN). First, the PN is asked to conduct the comprehensive initial admission assessment for a newly arrived client. Second, the PN is instructed to explain the risks and benefits of an upcoming bone marrow aspiration to another client and subsequently obtain their signature on the informed consent form. Based on the legal scope of practice, which statement by the PN is the most appropriate response?

Cevabı ve açıklamayı göster

Cevap: I am unable to perform the initial admission assessment or explain the procedural risks, as both tasks exceed my legal scope of practice.

Cevap

The PN must decline both tasks, stating that performing an initial admission assessment and explaining procedural risks both exceed the practical nurse's legal scope of practice.
The legal scope of practice for a practical nurse (PN) prohibits performing a comprehensive initial admission assessment, which requires the advanced clinical judgment of a registered nurse (RN). Additionally, explaining the risks, benefits, and alternatives of a medical procedure is the sole legal responsibility of the healthcare provider. The PN may only act as a witness to the client's signature on an informed consent form after the provider has completed the explanation. Therefore, the PN must correctly identify that both delegated tasks fall outside their legal scope.

Adım Adım Çözüm

1
Evaluate the first delegated task: performing the initial admission assessment.
Determine that a comprehensive initial assessment is outside the PN scope of practice.
Initial comprehensive assessments require RN-level clinical judgment.
2
Evaluate the second delegated task: explaining the risks of the bone marrow aspiration.
Determine that explaining procedural risks is outside the PN scope of practice.
Only the healthcare provider performing the procedure can legally explain the risks and benefits to obtain informed consent.
3
Synthesize the evaluations to select the legally appropriate response.
Identify the statement where the PN correctly refuses both out-of-scope tasks.
A PN must advocate for client safety and legal compliance by declining assignments that exceed their legal scope of practice.

Anahtar Kavram

Scope of Practice and Delegation Limitations
Soru 1000Soru →

A 4-year-old child who weighs 41.8 lb41.8\text{ lb} is brought to the pediatric clinic with acute otitis media. The healthcare provider prescribes cefdinir oral suspension 14 mg/kg/day14\text{ mg/kg/day} to be given in two equally divided doses. The dispensed medication bottle indicates that adding 38 mL38\text{ mL} of distilled water will yield a final reconstituted concentration of 250 mg/5 mL250\text{ mg}/5\text{ mL}. How many mL\text{mL} will the nurse administer for a single dose? (Record answer to the nearest tenth. Do not include units in answer.)

Cevabı ve açıklamayı göster

Cevap: 2.7

Cevap

2.7
To determine the correct volume to administer, first convert the client's weight to kilograms (41.8 lb÷2.2=19 kg41.8\text{ lb} \div 2.2 = 19\text{ kg}). Next, find the total daily dose by multiplying the weight by the prescribed rate (19 kg×14 mg/kg=266 mg19\text{ kg} \times 14\text{ mg/kg} = 266\text{ mg}). Since this medication is given in two equally divided doses, divide by 2 to get the single dose amount (266 mg÷2=133 mg266\text{ mg} \div 2 = 133\text{ mg}). Finally, use the reconstituted concentration of 250 mg250\text{ mg} in 5 mL5\text{ mL} to find the volume to administer: (133 mg÷250 mg)×5 mL=2.66 mL(133\text{ mg} \div 250\text{ mg}) \times 5\text{ mL} = 2.66\text{ mL}. Rounding to the nearest tenth yields 2.7 mL2.7\text{ mL}. Note that the 38 mL38\text{ mL} of water mentioned is the diluent used to prepare the medication and is extraneous information designed to test critical reading skills.

Adım Adım Çözüm

1
Convert weight to kilograms
19 kg19\text{ kg}
The medication dosage is prescribed based on the client's metric weight (mg/kg).
2
Determine total daily dose
266 mg/day266\text{ mg/day}
The prescription calls for 14 mg per kg per day.
3
Calculate the single dose
133 mg/dose133\text{ mg/dose}
The total daily medication is to be divided into two equal doses.
4
Calculate the required volume based on concentration
2.66 mL2.66\text{ mL}
The final reconstituted medication concentration is 250 mg per 5 mL.
5
Round to nearest tenth
2.7
Clinical rounding rules and the question instructions require rounding to the nearest tenth.

Anahtar Kavram

Pediatric weight-based dosage calculation and identifying relevant reconstitution data.
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