Tüm alıştırma soruları

2933 soru

Soru 1081Soru →

An interprofessional healthcare team is coordinating care for a client who was recently admitted with acute pyelonephritis and an exacerbation of chronic heart failure. As the licensed practical/vocational nurse (LPN/VN) on the team reviews the prescribed interventions, which of the following actions fall within their legal scope of practice? (Select all that apply)

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Inserting a straight urinary catheter to obtain a sterile urine specimen as prescribed.; Administering a scheduled oral sulfonamide antibiotic and monitoring for expected therapeutic effects.; Auscultating lung sounds and collecting data on peripheral edema to monitor the client's chronic heart failure status.

Cevap

The actions within the LPN/VN scope of practice include inserting a straight urinary catheter, administering scheduled oral antibiotics, and auscultating lung sounds to monitor chronic heart failure.
The correct selections represent tasks that align with established LPN/VN delegation guidelines. Inserting a urinary catheter is a standard sterile procedure included in practical nursing education. Administering routine oral medications is a primary responsibility for the LPN/VN. Additionally, auscultating lung sounds and checking for edema in a client with a known history of heart failure is considered focused data collection rather than an initial comprehensive assessment. These actions involve gathering objective data on predictable conditions to report back to the registered nurse (RN).

Adım Adım Çözüm

1
Analyze the clinical scenario and the client's current acuity.
The client has acute pyelonephritis and a history of chronic heart failure, requiring interventions of varying complexity.
Understanding client stability and condition predictability is essential for determining which tasks can be safely performed by the LPN/VN.
2
Evaluate each intervention against the LPN/VN legal scope of practice regarding data collection versus comprehensive assessment.
Auscultating lung sounds for a known condition constitutes focused data collection, which is allowed, whereas developing a primary care plan involves RN-level comprehensive assessment.
LPN/VNs gather data to contribute to the overall care plan but do not autonomously formulate the initial plan or perform comprehensive assessments.
3
Evaluate medication administration and procedural tasks for scope compliance.
Sterile catheterization and oral medication administration are acceptable. Administering IV push medications for acute respiratory distress and explaining procedure risks exceed the scope.
High-risk, complex interventions and obtaining informed consent must be escalated to the RN or provider.

Anahtar Kavram

The LPN/VN scope of practice centers on focused data collection, executing established interventions on stable clients, and contributing to the care plan, while avoiding tasks that require independent comprehensive assessment, clinical judgment for unstable clients, or provider-level responsibilities.
Soru 1082Soru →

A 78-year-old client is 12 hours postoperative following a laparotomy and bowel resection. The practical nurse (PN) answers the call light and finds the client restless, repeatedly attempting to pull at their intravenous tubing, and stating that they are 'waiting for the bus.' The client's abdominal dressing is dry and intact. Vital signs are temperature 98.4°F (36.9°C), heart rate 114 beats/min, respiratory rate 24 breaths/min, and blood pressure 106/60 mm Hg. The preoperative blood pressure was 148/82 mm Hg. Which action should the PN take first?

Cevabı ve açıklamayı göster

Cevap: Elevate the client's lower extremities and immediately notify the registered nurse (RN).

Cevap

Elevate the client's lower extremities and immediately notify the registered nurse (RN).
The client is exhibiting early, classic signs of hypovolemic shock, likely due to internal hemorrhage following the laparotomy. Restlessness and acute confusion are often the earliest indicators of decreased cerebral perfusion. A heart rate of 114 beats/min and a blood pressure of 106/60 mm Hg (a significant drop of 42 mm Hg from the systolic baseline) represent compensatory tachycardia and relative hypotension. Because the abdominal dressing is dry, the bleeding is internal and masked. The priority action is to improve venous return and cardiac output by elevating the client's lower extremities and to immediately alert the registered nurse for collaborative medical interventions.

Adım Adım Çözüm

1
Analyze the client's vital signs and compare them to the preoperative baseline data.
The heart rate is elevated (114 beats/min) and the blood pressure is significantly decreased from baseline (106/60 mm Hg down from 148/82 mm Hg), indicating relative hypotension.
Identifying relative changes, rather than just relying on absolute parameters, is crucial for recognizing early physiological decompensation.
2
Evaluate the client's neurological status and behavior in the context of recent surgery.
The client is exhibiting new-onset restlessness, disorientation, and agitation.
Acute changes in mental status are early, critical signs of decreased cerebral tissue perfusion associated with hypovolemic shock.
3
Synthesize the clinical findings to determine the priority physiological need.
The combined findings of tachycardia, relative hypotension, and acute confusion in a postoperative client indicate impending hypovolemic shock, likely from internal hemorrhage.
According to the ABCs (Airway, Breathing, Circulation) prioritization framework, circulation is severely and acutely compromised.
4
Select the nursing intervention that immediately addresses the circulation deficit while remaining within the PN scope of practice.
Elevating the client's legs increases venous return, and notifying the RN escalates the situation for rapid medical intervention.
This is the safest and most effective initial response to stabilize a client with suspected hemorrhagic shock.

Anahtar Kavram

Early recognition of hypovolemic shock requires comparing current vital signs to the client's baseline and interpreting acute mental status changes as indicators of poor cerebral perfusion.
Tahmini Süre:1m 30s
Soru 1083Soru →

A client who underwent a complete left-sided pneumonectomy three days ago requires routine hygiene and repositioning to prevent skin breakdown. The client is currently resting in a supine position but reports stiffness and back discomfort. Which positioning action by the practical nurse is the safest and most appropriate for this client?

Cevabı ve açıklamayı göster

Cevap: Assist the client into a left lateral position with a pillow providing back support.

Cevap

The safest positioning action is to assist the client into a left lateral position with appropriate pillow support.
The correct action is to position the client on their left side. Following a complete pneumonectomy, the client must be positioned on their back or on the operative side (the side where the lung was removed). Because this client had a left-sided pneumonectomy, placing them on the left side ensures that the remaining right lung is positioned uppermost. This allows the healthy lung to expand fully with gravity's assistance and prevents the mediastinum and heart from shifting and compressing the only functional lung.

Adım Adım Çözüm

1
Identify the specific surgical procedure and the affected anatomical side.
The client had a left-sided pneumonectomy, meaning the left lung was entirely removed, leaving only the right lung functional.
Surgical alterations dictate precise postoperative positioning limitations to ensure client safety.
2
Determine the primary physiological goal of positioning for this specific surgery.
The goal is to maximize the expansion and ventilation of the remaining right lung while preventing a fluid or tissue shift into the empty pleural space (mediastinal shift).
Proper oxygenation relies entirely on the single unoperative lung, which must not be restricted.
3
Select the position that fulfills this physiological safety requirement.
Positioning the client on the operative side (the left side) allows the good lung (right side) to remain uppermost and expand fully without compression from abdominal or mediastinal structures.
Lying on the unoperative (good) side would cause the heart and mediastinum to compress the only functional lung, leading to respiratory failure.

Anahtar Kavram

Postoperative Positioning for Pulmonary Surgeries
Soru 1084Soru →

A practical nurse (PN) is reviewing the assessment data of an older adult client who is 24 hours postoperative following a partial bowel resection. Which findings indicate a potential complication that requires immediate escalation to the registered nurse? Select all that apply.

Geçerli olan tümünü seçin

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Cevap: A morning serum potassium level of 2.8 mEq/L (2.8 mmol/L); A resting heart rate of 118 beats per minute with a blood pressure of 90/58 mm Hg; New-onset restlessness with a respiratory rate of 28 breaths per minute

Cevap

The findings that require immediate escalation are the serum potassium level of 2.8 mEq/L, the heart rate of 118 beats per minute with hypotension, and the new-onset restlessness with tachypnea.
A serum potassium level of 2.8 mEq/L is critically low (normal is 3.5-5.0 mEq/L) and places the client at risk for severe cardiac dysrhythmias. A heart rate of 118 beats per minute combined with a blood pressure of 90/58 mm Hg indicates potential hypovolemic shock or internal bleeding. New-onset restlessness and tachypnea are classic early, subtle signs of hypoxia or a pulmonary embolism. All of these findings indicate instability and require immediate RN assessment and provider notification.

Adım Adım Çözüm

1
Analyze the client's postoperative timeframe and expected physiological responses.
The client is 24 hours postoperative, a period where mild inflammation and mild incisional pain are expected, but fluid shifts, hemorrhage, and electrolyte imbalances pose high risks.
Differentiating normal postoperative healing findings from early signs of shock or metabolic derangement is critical for the practical nurse.
2
Evaluate the laboratory values and vital signs against critical thresholds.
The potassium of 2.8 mEq/L is critically low. The vital signs (tachycardia and hypotension) indicate potential shock. The restlessness with tachypnea suggests hypoxia.
These findings are life-threatening and fall outside the scope of independent PN management, requiring immediate RN collaboration.
3
Eliminate the expected, benign postoperative findings from the choices.
The slightly elevated WBC count, low-grade temperature, and small amount of serosanguineous drainage are normal 24 hours after surgery.
These findings can be safely monitored and documented by the PN without the need for immediate emergency escalation.

Anahtar Kavram

Reduction of Risk Potential: Recognizing Postoperative Complications
Soru 1085Soru →

A practical nurse (PN) is reviewing the electronic health records of four assigned clients before beginning morning rounds. Which client should the PN see first?

Cevabı ve açıklamayı göster

Cevap: A client who is 4 hours postoperative following an appendectomy and has a blood pressure of 90/58 mm Hg and a heart rate of 118/min

Cevap

The client who is 4 hours postoperative following an appendectomy and has a blood pressure of 90/58 mm Hg and a heart rate of 118/min.
The client with a blood pressure of 90/58 mm Hg and a heart rate of 118/min is demonstrating early signs of hypovolemic shock, a critical and potentially life-threatening complication of surgery. This circulatory instability takes the highest priority and requires immediate data collection and reporting to the registered nurse.

Adım Adım Çözüm

1
Analyze the vital signs of the postoperative client with a blood pressure of 90/58 mm Hg and heart rate of 118/min.
Identified as early signs of hypovolemic shock (hypotension and tachycardia), a critical circulatory complication.
Recognizing signs of shock immediately is essential for preventing rapid clinical deterioration.
2
Evaluate the condition of the client with a fractured femur reporting severe pain.
Identified as a high-priority comfort need, but not an immediate life-threatening physiological emergency.
Using the ABC (Airway, Breathing, Circulation) framework, circulation takes precedence over pain.
3
Review the status of the client with a total hip arthroplasty utilizing an abduction pillow.
Identified as an expected and appropriate postoperative positioning intervention.
Abduction pillows are standard care to prevent hip dislocation after arthroplasty and do not require troubleshooting.
4
Assess the potassium level of the client receiving intravenous fluids.
Identified a laboratory value of 4.0 mEq/L, which is within the normal expected range.
Normal laboratory values do not indicate an acute or unstable physiological problem.
5
Compare all client scenarios to determine the highest overall priority for the nurse.
The postoperative client with signs of shock is selected as the top priority.
Acute circulatory compromise presents the most immediate risk to client safety and requires the most urgent assessment.

Anahtar Kavram

Prioritization using the ABCs framework and early recognition of hypovolemic shock.
Soru 1086Soru →

A client recovering from an ischemic stroke is receiving continuous enteral nutrition via a percutaneous endoscopic gastrostomy (PEG) tube. The client's medication administration record includes scheduled morning doses of extended-release nifedipine and liquid acetaminophen. Which action by the practical nurse demonstrates safe pharmacological practice?

Cevabı ve açıklamayı göster

Cevap: Withhold the extended-release nifedipine, administer the liquid acetaminophen, and notify the registered nurse to request an appropriate immediate-release alternative.

Cevap

The safe action is to withhold the extended-release nifedipine, administer the liquid acetaminophen, and collaborate with the registered nurse to request a therapeutically equivalent immediate-release or liquid alternative.
Extended-release (ER) medications are formulated to release their active ingredients slowly over an extended period. They must never be crushed, chewed, or opened. Doing so destroys the delayed-release mechanism, causing a rapid absorption of the entire dose at once (dose dumping), which can lead to severe adverse effects such as profound hypotension. Because intact capsules cannot be given via a percutaneous endoscopic gastrostomy tube, the safest action is to withhold the medication, safely administer the liquid acetaminophen, and collaborate with the registered nurse or healthcare provider to obtain a therapeutically equivalent liquid or immediate-release formulation.

Adım Adım Çözüm

1
Review the prescribed medication properties against the ordered route of administration.
Nifedipine is prescribed as an extended-release capsule, while acetaminophen is a liquid. The route is a PEG tube, which requires medications to be in liquid form or crushed and dissolved.
To determine if the physical properties of the medications allow for safe administration via the prescribed enteral tube.
2
Analyze the compatibility of extended-release medications with feeding tube administration.
Extended-release formulations cannot be crushed, chewed, or opened without destroying their time-release mechanism.
Crushing an extended-release antihypertensive causes rapid, uncontrolled absorption known as 'dose dumping,' leading to severe systemic toxicity such as profound hypotension.
3
Determine the appropriate nursing intervention within the practical nurse scope of practice.
The practical nurse must safely administer the liquid medication (acetaminophen), withhold the contraindicated extended-release medication (nifedipine), and immediately collaborate with the registered nurse.
To ensure client safety and facilitate securing a viable alternative formulation from the healthcare provider or pharmacist.

Anahtar Kavram

Safe Administration of Enteral Tube Medications and Formulation Limitations
Tahmini Süre:1m 30s
Soru 1087Soru →

During routine hourly rounds, a practical nurse evaluates a 42-year-old client who returned from a total abdominal hysterectomy 4 hours ago. The client appears very restless and requests water, stating they are extremely thirsty. The client's heart rate has increased from 82 to 110 beats per minute over the past hour, while the blood pressure is currently 108/68 mm Hg. What is the most appropriate initial action for the nurse to take?

Cevabı ve açıklamayı göster

Cevap: Inspect the surgical dressing and perineal pad for evidence of excessive bleeding

Cevap

Inspect the surgical dressing and perineal pad for evidence of excessive bleeding
The correct action is to inspect the surgical dressing and perineal pad. The client's restlessness, severe thirst, and increasing heart rate (tachycardia) are classic early compensatory signs of hypovolemic shock, often caused by internal or external hemorrhage following major surgery. Even though the blood pressure is currently maintained, the nurse must immediately assess for the source of potential bleeding to gather critical data before notifying the registered nurse or provider.

Adım Adım Çözüm

1
Analyze the client's new clinical signs: restlessness, extreme thirst, and an increasing heart rate.
Identify that these are classic early compensatory signs of hypovolemic shock.
Recognizing early shock is critical before the blood pressure begins to drop.
2
Determine the most likely cause of hypovolemia in a client 4 hours post-hysterectomy.
The most likely cause is postoperative hemorrhage.
Surgical patients are at high risk for internal or external bleeding in the immediate postoperative period.
3
Select the nursing action that prioritizes assessing the circulatory status.
The nurse must inspect the operative site and perineum for bleeding.
Direct assessment of the surgical site provides critical data about potential hemorrhage to report to the registered nurse.

Anahtar Kavram

Early recognition and assessment of hypovolemic shock
Tahmini Süre:1m 0s
Soru 1088Soru →

A school-aged child with a superficial skin infection is prescribed oral cephalexin 500 mg every 12 hours. The pharmacy dispenses cephalexin oral suspension with a concentration of 250 mg/5 mL.

How many mL should the practical nurse administer for a single dose? Record the answer as a whole number. Do not include units in the answer.

Cevabı ve açıklamayı göster

Cevap: 10

Cevap

10
To determine the correct volume to administer, use the formula DesiredHave×Volume\frac{\text{Desired}}{\text{Have}} \times \text{Volume}. The desired single dose is 500 mg, and the medication on hand is 250 mg per 5 mL. Plugging these values into the formula yields 500250×5=10\frac{500}{250} \times 5 = 10 mL.

Adım Adım Çözüm

1
Identify the desired single dose from the provider's prescription.
500 mg
This is the target amount of medication the client needs to receive at one time.
2
Identify the concentration of the medication available from the pharmacy.
250 mg in 5 mL
This determines how much liquid contains the required medication.
3
Apply the dosage calculation formula: DesiredHave×Volume\frac{\text{Desired}}{\text{Have}} \times \text{Volume}.
500250×5\frac{500}{250} \times 5
This standard formula safely converts the prescribed mass into the volume to be administered.
4
Perform the arithmetic to find the final volume.
10
Simplifying the fraction 500250\frac{500}{250} equals 2. Multiplying 2×52 \times 5 yields 10.

Anahtar Kavram

Basic Liquid Dosage Calculation
Soru 1089Soru →

Following an ultrasound-guided percutaneous liver biopsy, an adult client is brought to the medical unit for recovery. The client is drowsy from mild conscious sedation, reports mild procedural discomfort, and needs assistance finding a resting position. Which positioning action should the practical nurse implement to ensure client safety?

Cevabı ve açıklamayı göster

Cevap: Assist the client into a right lateral side-lying position with a small rolled blanket placed beneath the lower right rib cage.

Cevap

The correct action is to assist the client into a right lateral side-lying position with a small rolled blanket placed beneath the lower right rib cage.
The correct positioning intervention is to place the client on their right side with a rolled blanket under the lower right rib cage. The liver is a highly vascular organ located in the right upper quadrant. Following a percutaneous liver biopsy, the primary clinical risk is internal hemorrhage. Placing the client in a right lateral position utilizes the client's own body weight to provide direct, continuous mechanical compression to the puncture site against the chest wall. This external pressure promotes hemostasis and minimizes the risk of severe bleeding.

Adım Adım Çözüm

1
Analyze the client's recent medical procedure (percutaneous liver biopsy) and identify the primary physiological risk.
The liver is a highly vascular organ, making internal hemorrhage the most significant immediate post-procedure complication.
Understanding the primary complication risk determines the appropriate basic care and comfort measures needed for safety.
2
Determine the anatomical location of the organ and the corresponding puncture site.
The liver is located in the right upper quadrant of the abdomen, and the biopsy is performed through the right lower rib cage.
Nursing positioning must specifically target the correct anatomical side to be effective.
3
Select the nursing intervention that physically mitigates the risk of hemorrhage.
The right lateral side-lying position is selected.
Lying on the right side with a rolled blanket applies direct mechanical compression to the liver capsule against the chest wall, promoting hemostasis and preventing bleeding.

Anahtar Kavram

Post-procedure positioning following a percutaneous liver biopsy to prevent internal hemorrhage.
Soru 1090Soru →

A practical nurse is assigned to care for a client who is two hours postoperative following a subtotal thyroidectomy. To minimize swelling and protect the surgical airway, which position is most appropriate for the nurse to place the client in?

Cevabı ve açıklamayı göster

Cevap: Semi-Fowler's position with pillows supporting the head and neck

Cevap

Semi-Fowler's position with pillows supporting the head and neck
The correct action is to place the client in a Semi-Fowler's position while providing support to the head and neck. Elevating the head of the bed 30 to 45 degrees utilizes gravity to reduce postoperative swelling and venous pressure in the neck region. Supporting the head and neck with pillows ensures they remain in a neutral alignment, which prevents both flexion and hyperextension. This neutral positioning protects the surgical incision from tension, reduces pain, and ensures the airway remains fully open.

Adım Adım Çözüm

1
Identify the surgical procedure and its specific postoperative risks.
The client underwent a thyroidectomy, which carries high risks of neck edema, airway obstruction, and incision strain.
Understanding the anatomical risks dictates the appropriate basic care and positioning required for safety.
2
Determine the ideal bed angle to manage these specific risks.
The head of the bed should be elevated 30 to 45 degrees, known as Semi-Fowler's position.
Elevation uses gravity to reduce venous pressure, minimizing fluid accumulation and swelling in the delicate neck area.
3
Select the appropriate support method for the affected body part.
The head and neck must be supported in a neutral position using pillows or sandbags.
Maintaining neutral alignment prevents both hyperextension and hyperflexion, avoiding any tension on the fragile suture line.

Anahtar Kavram

Postoperative Positioning for Airway Protection
Soru 1091Soru →

A practical nurse is preparing to apply knee-length anti-embolism stockings to a client who is resting in bed. In which order should the nurse 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 to first ensure the client rests supine to reduce swelling, then turn the stocking inside out to the heel, place it over the foot and heel, slide it up the calf, and finally smooth out any wrinkles.
To properly apply anti-embolism stockings, the practical nurse must first reduce venous swelling by having the client rest supine. Next, preparing the stocking by turning it inside out to the heel makes it easier to slip over the foot. After anchoring it on the foot and heel, the stocking is pulled up the leg. Finally, the nurse must ensure there are no wrinkles or rolled areas, which could act like a tourniquet and constrict blood flow.

Adım Adım Çözüm

1
Prepare the client's legs
The client rests supine for at least 15 minutes.
To reduce venous stasis and swelling in the lower extremities before application.
2
Prepare the stocking
The stocking is turned inside out down to the heel.
To facilitate smooth application over the foot and prevent bunching.
3
Apply to the foot
The stocking covers the toes, foot, and heel.
To properly anchor the stocking on the foot before pulling it up.
4
Apply to the leg
The stocking is pulled up the calf.
To provide the intended graduated compression to the lower leg.
5
Perform a final check
Wrinkles and rolled edges are smoothed out.
To prevent constriction of blood flow which can cause tissue damage.

Anahtar Kavram

Proper application sequence for anti-embolism stockings
Soru 1092Soru →

An adult client is undergoing post-procedure care on a medical-surgical unit following a percutaneous liver biopsy. The client is currently positioned on the right side with a rolled towel under the puncture site. During the 4-hour post-procedure assessment, the licensed practical nurse notes that the client's heart rate has climbed to 108 beats per minute from a pre-procedure baseline of 76 beats per minute. The blood pressure is currently 104/62 mm Hg, compared to a baseline of 128/74 mm Hg. The client reports new-onset, moderate pain in the right shoulder. Based on these assessment findings, which action must the nurse take to reduce the risk of a severe complication?

Cevabı ve açıklamayı göster

Cevap: Maintain the client in the current position and immediately report the findings to the supervising registered nurse.

Cevap

The nurse must maintain the client in the right side-lying position to apply continuous pressure to the biopsy site and immediately notify the supervising registered nurse of the findings.
Following a percutaneous liver biopsy, maintaining the client in a right side-lying position is essential to provide direct pressure (tamponade) to the biopsy site, preventing hemorrhage from the highly vascular liver tissue. The client's rising heart rate, dropping blood pressure, and new-onset right shoulder pain (referred pain from diaphragmatic irritation due to internal bleeding) are classic signs of early hypovolemic shock. The priority is to keep the physical pressure on the puncture site and immediately escalate these critical findings to the supervising registered nurse for rapid medical intervention.

Adım Adım Çözüm

1
Analyze the client's post-operative vital signs.
The heart rate has increased significantly (76 to 108) and blood pressure has decreased (128/74 to 104/62).
These downward trends in blood pressure paired with tachycardia are classic early indicators of hypovolemic shock, likely due to internal hemorrhage.
2
Evaluate the clinical significance of the right shoulder pain.
The pain is recognized as referred pain caused by blood accumulating under the diaphragm and irritating the phrenic nerve.
Combined with the vital sign changes, this confirms a high suspicion of active internal bleeding from the highly vascular liver.
3
Determine the priority nursing intervention within the practical nurse scope of practice.
The nurse must keep the client on the right side to maintain pressure on the liver capsule and immediately notify the RN.
Repositioning would remove the tamponade effect, and delaying escalation to draw labs or document would lead to cardiovascular collapse.

Anahtar Kavram

Early Recognition of Post-Procedure Hemorrhage and Appropriate Escalation
Soru 1093Soru →

A client who underwent a right-sided supratentorial craniotomy two days ago is currently receiving continuous enteral feedings via a nasogastric tube. The practical nurse is preparing to provide a complete bed bath and change the soiled bottom sheets. What is the safest method for the nurse to execute these care tasks?

Cevabı ve açıklamayı göster

Cevap: Maintain the bed at a 30-degree incline while turning the client laterally, ensuring the head and neck remain in a neutral midline alignment.

Cevap

The practical nurse should maintain the head of the bed at a 30-degree elevation and keep the client's head and neck in a neutral, midline position while turning them.
Following a supratentorial craniotomy, it is critical to promote venous drainage from the brain to prevent life-threatening increases in intracranial pressure. This is achieved by keeping the head of the bed elevated at 30 to 45 degrees and ensuring the neck is not flexed or rotated. Additionally, because the client is receiving continuous enteral feedings, maintaining this elevation is mandatory to prevent regurgitation and pulmonary aspiration. Turning the client laterally while preserving this 30-degree incline and neutral neck alignment perfectly balances the client's hygiene needs with their strict neurological and respiratory safety requirements.

Adım Adım Çözüm

1
Analyze the client's surgical history.
The client had a supratentorial craniotomy two days ago.
This surgery requires specific positioning to promote cerebral venous drainage and prevent increased intracranial pressure (ICP), specifically elevating the head of the bed 30 to 45 degrees and maintaining neutral head alignment.
2
Identify the risks associated with the ongoing therapy.
The client is receiving continuous enteral feedings and is at high risk for aspiration.
Keeping the head of the bed elevated at least 30 degrees is mandatory to prevent regurgitation and pulmonary aspiration of the feeding formula.
3
Evaluate the proposed basic care techniques against these constraints.
Turning the client must be accomplished without lowering the bed flat and without flexing or hyperextending the neck.
Flat positioning or neck flexion would dangerously spike ICP and simultaneously increase aspiration risk.

Anahtar Kavram

Positioning principles for clients with increased intracranial pressure risk and continuous enteral feedings.
Soru 1094Soru →

An older adult client is receiving care on a medical unit for a suspected upper gastrointestinal bleed. The morning laboratory report indicates a hemoglobin level of 6.9 g/dL6.9 \text{ g/dL} and a serum potassium of 2.8 mEq/L2.8 \text{ mEq/L}. The client's current vital signs are: blood pressure 96/60 mm Hg96/60 \text{ mm Hg}, apical pulse 116 beats/minute116 \text{ beats/minute}, and respirations 22/minute22 \text{/minute}. A registered nurse (RN) prepares a prescribed intravenous (IV) piggyback of potassium chloride, hands the bag to the practical nurse (PN), and delegates the medication administration and subsequent monitoring of this client. Which action is most appropriate for the PN to take?

Cevabı ve açıklamayı göster

Cevap: Decline the delegation, as caring for a hemodynamically unstable client with critical laboratory abnormalities requires continuous registered nurse (RN) assessment.

Cevap

The practical nurse must decline the delegation because the client is exhibiting signs of hemodynamic instability and hypovolemic shock, which requires the advanced assessment skills of a registered nurse.
The client is demonstrating clear signs of active bleeding and hypovolemic shock (hemoglobin 6.9 g/dL6.9 \text{ g/dL}, hypotension, tachycardia) alongside severe hypokalemia. Caring for a hemodynamically unstable client requires advanced physiological assessment, clinical judgment, and immediate intervention that falls exclusively within the scope of practice of a registered nurse (RN). The practical nurse (PN) must advocate for client safety by declining this inappropriate delegation.

Adım Adım Çözüm

1
Analyze the laboratory data provided in the scenario.
The client has a hemoglobin of 6.9 g/dL6.9 \text{ g/dL} (critically low, indicating severe blood loss) and a potassium of 2.8 mEq/L2.8 \text{ mEq/L} (critically low, risking cardiac dysrhythmias).
Identifying abnormal laboratory values is essential for recognizing physiological risk.
2
Analyze the vital signs in the context of the client's diagnosis.
A blood pressure of 96/60 mm Hg96/60 \text{ mm Hg} and a heart rate of 116 beats/minute116 \text{ beats/minute} in a client with a suspected gastrointestinal bleed indicate compensatory tachycardia and hypotension.
These are classic early signs of hypovolemic shock, meaning the client's condition is actively deteriorating.
3
Evaluate the appropriateness of the RN's delegation.
The RN is delegating the care, medication administration, and monitoring of a highly unstable client to the PN.
The PN scope of practice involves caring for clients with predictable outcomes. Unstable clients require advanced assessment and clinical judgment.
4
Determine the correct nursing action based on scope of practice.
The PN must decline the unsafe assignment to protect the client and practice safely within legal boundaries.
Accepting an unstable client assignment violates the PN scope of practice and places the client at severe risk for adverse outcomes.

Anahtar Kavram

Reduction of Risk Potential through appropriate delegation and recognition of hemodynamic instability.
Soru 1095Soru →

The electronic barcode scanner on a unit's medication cart is unexpectedly malfunctioning due to a network outage. A practical nurse is preparing to administer a scheduled dose of oral amlodipine to an alert client who is resting in bed. Which action must the nurse take to ensure safe medication administration?

Cevabı ve açıklamayı göster

Cevap: Ask the client to state their full name and date of birth, comparing this information against the wristband and the medication administration record.

Cevap

The nurse must manually ask the client to state their full name and date of birth, and compare this against the client's wristband and the medication administration record.
Safe medication administration requires the nurse to verify two distinct client identifiers, typically the client's full name and date of birth. When an electronic barcode scanner is malfunctioning, the nurse must manually ask the alert client to state these identifiers and compare them directly against the identification wristband and the medication administration record (MAR) to guarantee the medication is given to the correct individual.

Adım Adım Çözüm

1
Identify the standard of practice for client identification when electronic barcode systems fail.
The standard requires manual verification of two distinct, approved client identifiers.
Ensuring the "right client" is a fundamental rule of safe pharmacological therapy that cannot be bypassed during equipment outages.
2
Evaluate the proposed identification methods in the options against safety protocols.
Using the client's stated name and date of birth compared to the wristband and MAR is the only approved manual method.
Room numbers, visual recognition, and delegating to assistive personnel are unsafe practices that violate medication administration protocols.

Anahtar Kavram

Medication Administration Rights and Manual Client Identification
Soru 1096Soru →

A practical nurse (PN) is reviewing the electronic health record and collecting data on a client who is 1212 hours postoperative following an exploratory laparotomy. The client's preoperative baseline data showed a hemoglobin of 13.8 g/dL13.8\text{ g/dL}, a blood pressure of 132/78 mm Hg132/78\text{ mm Hg}, and a heart rate of 76 beats/min76\text{ beats/min}. The current morning laboratory results show a hemoglobin of 9.6 g/dL9.6\text{ g/dL}. Upon assessment, the client's blood pressure is 102/64 mm Hg102/64\text{ mm Hg}, heart rate is 114 beats/min114\text{ beats/min}, and the client reports feeling restless and lightheaded when the head of the bed is elevated. Which action should the PN take first?

Cevabı ve açıklamayı göster

Cevap: Lower the head of the bed to a supine position and immediately notify the registered nurse (RN).

Cevap

Lower the head of the bed to a supine position and immediately notify the registered nurse (RN).
The client is exhibiting early signs of hypovolemic shock due to acute blood loss, evidenced by a significant drop in hemoglobin (greater than 2 g/dL2\text{ g/dL}), tachycardia, borderline hypotension, restlessness, and orthostatic symptoms. The PN must prioritize client safety by placing them supine to promote venous return to the brain and vital organs, and immediately escalate the critical findings to the RN for further assessment and intervention.

Adım Adım Çözüm

1
Compare the client's current laboratory values and vital signs to their preoperative baseline.
Hemoglobin dropped by 4.2 g/dL4.2\text{ g/dL}, heart rate increased by 38 beats/min38\text{ beats/min}, and blood pressure decreased significantly.
Identifying trends is crucial for recognizing postoperative complications like internal bleeding.
2
Correlate the objective data with the client's subjective symptoms (restlessness, lightheadedness when elevated).
The combination of findings strongly suggests reduced oxygen-carrying capacity and impending hypovolemic shock.
Restlessness is an early sign of hypoxia, and orthostatic lightheadedness indicates poor cerebral perfusion.
3
Determine the safest, most immediate action within the practical nurse scope of practice.
Position the client flat (supine) to optimize blood flow to the brain and notify the RN immediately.
The PN must mitigate immediate physical risk while escalating to the RN who can perform advanced assessments and obtain medical orders for fluid or blood resuscitation.

Anahtar Kavram

Recognizing and Escaping Early Postoperative Hypovolemic Shock
Soru 1097Soru →

A practical nurse (PN) is instructing a female client on how to collect a clean-catch midstream urine specimen for a prescribed urine culture. Arrange the following procedural steps in the correct chronological order to reduce the risk of sample contamination.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence for collecting a clean-catch midstream urine specimen ensures the sample is not contaminated by external skin flora. The nurse must first apply gloves, cleanse the area appropriately, allow the client to initiate the stream to flush the urethra, catch the midstream urine in the sterile cup, and finally secure the container.
The established standard of care for a clean-catch urine culture requires a specific sequential approach: preparation (hand hygiene/gloves), decontamination (cleaning front to back), urethral flushing (voiding a small amount), collection (midstream catch), and securement. This evidence-based order strictly reduces the risk of altering laboratory findings with environmental flora.

Adım Adım Çözüm

1
Perform hand hygiene and don clean gloves.
Readiness to handle the client and equipment safely.
Standard precautions reduce the risk of cross-contamination before beginning any clinical procedure.
2
Cleanse the urethral meatus from front to back using an antiseptic wipe.
The area around the urinary meatus is sanitized.
Prevents normal skin or intestinal flora from contaminating the urine sample.
3
Ask the client to begin voiding a small amount of urine into the toilet.
The urethra is flushed with urine.
Clears any remaining bacteria at the urethral opening that could cause a false-positive culture.
4
Pass the sterile specimen container into the active urine stream to collect the sample.
Midstream urine is collected.
Captures the most accurate representation of bladder urine.
5
Remove the container before the urine flow stops and secure the lid tightly.
The sample is safely secured for transport.
Prevents terminal stream contamination and maintains the sterility of the collected sample.

Anahtar Kavram

Clean-catch midstream urine specimen collection protocol
Soru 1098Soru →

A practical nurse is instructing a female client on how to obtain a midstream (clean-catch) urine specimen for culture and sensitivity. To prevent contamination of the specimen and reduce the risk of inaccurate diagnostic laboratory results, arrange the following steps in the correct chronological order.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence begins with hand hygiene, followed by cleansing the meatus, initiating the urine stream into the toilet, catching the sample midstream, and removing the container before the stream stops.
Obtaining a midstream clean-catch urine specimen requires a specific procedural sequence to reduce the risk of false-positive diagnostic laboratory results. Hand hygiene and equipment preparation must come first to maintain sterility. Cleansing the meatus from front to back removes surface bacteria. Initiating the urine stream into the toilet flushes the lower urethra of resident flora. The sterile cup is then passed into the midstream to collect the most accurate sample of bladder urine. Finally, removing the cup before the stream stops prevents contamination from terminal drops of urine.

Adım Adım Çözüm

1
Perform hand hygiene and open the sterile container.
A clean environment is established.
Prevents the introduction of external pathogens to the sterile collection container.
2
Cleanse the urethral meatus from front to back.
Surface flora is removed.
Decreases the risk of external bacteria contaminating the urine culture.
3
Initiate the urine stream into the toilet.
The lower urethra is flushed.
Clears out distal urethral contaminants that could lead to false-positive lab results.
4
Catch the urine in the sterile container midstream.
Bladder urine is collected.
Provides the most accurate representation of potential pathogens located inside the bladder.
5
Remove the container before the urine stream stops.
Collection is completed cleanly.
Prevents contamination from the terminal flow of urine contacting the external skin.

Anahtar Kavram

Proper technique for obtaining a clean-catch midstream urine specimen
Soru 1099Soru →

The interprofessional healthcare team on an inpatient medical unit is organizing the daily workflow. Which action, if independently performed by the practical nurse (PN), demonstrates a correct understanding of their legal scope of practice and professional responsibilities?

Cevabı ve açıklamayı göster

Cevap: Administering scheduled enteral tube feedings and documenting the residual volume for a client with a stable gastrostomy tube

Cevap

The correct action is administering scheduled enteral tube feedings and documenting the residual volume for a client with a stable gastrostomy tube.
The action of administering enteral tube feedings to a client with a stable, established gastrostomy tube is a predictable, routine procedure that falls squarely within the practical nurse's scope of practice. The PN is highly trained to collect routine data, such as measuring residual volumes, and to perform standard medication and nutritional administration for stable clients.

Adım Adım Çözüm

1
Analyze the practical nurse (PN) scope of practice regarding client stability and task predictability.
PNs are authorized to care for stable clients with predictable outcomes and to perform established, routine procedures.
Scope of practice laws dictate that PNs gather data and perform standard skills, while RNs handle complex assessment, care plan development, and evaluation.
2
Evaluate each option against the legal boundaries of the PN role, informed consent rules, and privacy laws.
Only the administration of enteral feedings to a stable client falls within the accepted PN scope.
The other options involve RN-level evaluation, provider-level consent explanation, or a direct violation of HIPAA privacy standards.

Anahtar Kavram

Practical Nurse Scope of Practice and Professional Standards
Soru 1100Soru →

A practical nurse (PN) is assigned to care for an emancipated 17-year-old client who is 32 weeks pregnant and receiving observation for gestational hypertension. The client's parent arrives at the unit, states they provide the client's medical insurance, and demands to review the client's electronic health record. Simultaneously, the client tells the PN, "I refuse to take the blood pressure medication, and I am leaving the hospital right now." Which actions should the PN take? (Select all that apply.)

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Inform the parent that they cannot view the medical record without the client's explicit authorization.; Notify the prescribing healthcare provider immediately regarding the medication refusal and the client's intent to leave against medical advice.; Document the client's exact verbal statements regarding the medication refusal and desire to leave in the health record.

Cevap

The correct actions are to inform the parent that authorization is required to view the medical record, notify the healthcare provider of the refusal and intent to leave, and accurately document the client's exact statements.
Emancipated minors hold full adult rights regarding healthcare decisions and privacy. The practical nurse must advocate for these rights by protecting the client's medical record from unauthorized access by the parent. When facing a refusal of treatment and a desire to leave against medical advice, the PN operates within their scope by immediately notifying the healthcare provider and carefully documenting the client's exact words. The PN facilitates communication rather than forcing compliance.

Adım Adım Çözüm

1
Determine the client's legal status and privacy rights.
The client is an emancipated minor, meaning they possess the same legal rights as an adult, including full HIPAA protections against unauthorized disclosure to parents.
This establishes that the parent has no legal authority over the client's care or access to their health information.
2
Evaluate the practical nurse's scope of practice regarding treatment refusal.
The PN must withhold the medication, notify the provider, and document the event, but must not take on the provider's role of conducting informed refusal counseling.
Primary teaching and advanced clinical counseling fall outside the legal scope of practice for a PN.
3
Assess the legality of preventing the client from leaving.
The client has the right to leave against medical advice (AMA); physical or chemical restraint to prevent departure is illegal.
Preventing a legally competent adult or emancipated minor from leaving a facility constitutes false imprisonment.

Anahtar Kavram

Client Rights, Advocacy, and Scope of Practice for the Practical Nurse
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Tüm alıştırma soruları — NCLEX-PN | Examkin