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Soru 101Soru →

A client with a history of angina is prescribed a daily nitroglycerin transdermal patch. Place the following steps for administering this transdermal medication in the correct chronological order.

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Cevap

The correct sequence requires the nurse to first protect themselves by putting on gloves, then remove the old patch, clean both sites, prepare the new patch without touching the adhesive, and finally apply it securely to a new site.
Applying a transdermal patch requires sequential steps to ensure client safety and protect the nurse. The nurse must first put on gloves to avoid absorbing the medication. Next, the old patch is removed and disposed of to prevent an overdose. The skin at both the old and new sites is washed to remove residual medication and ensure proper adhesion. The backing of the new patch is then peeled off carefully, avoiding the adhesive. Finally, the patch is applied to a clean, hairless site and pressed firmly to secure it.

Adım Adım Çözüm

1
Perform hand hygiene and put on clean gloves.
The nurse's hands are protected from the medication.
Nitroglycerin is readily absorbed through the skin; gloves prevent the nurse from experiencing adverse effects like headaches or hypotension.
2
Remove the existing transdermal patch and fold it with the adhesive sides together.
The continuous delivery of the previous dose is stopped.
Leaving the old patch on while applying a new one causes medication overdose and severe hypotension.
3
Cleanse the previous application site and the newly selected site with mild soap and water.
Residual medication is removed and the new site is prepared.
This prevents continued absorption from the old site and removes oils or debris from the new site to ensure the patch sticks properly.
4
Peel the protective backing from the new patch without touching the medication surface.
The adhesive is exposed while keeping the dose intact.
Touching the adhesive can rub off some of the medication, leading to an inaccurate dose.
5
Apply the patch to a clean, hairless area of the upper body and press firmly.
The patch is secured for the prescribed duration.
Firm pressure ensures an adequate seal against the skin for steady absorption, while a hairless site prevents the patch from loosening.

Anahtar Kavram

Safe Administration of Transdermal Medications
Soru 102Soru →

A practical nurse is preparing a client who is scheduled for an abdominal paracentesis to treat severe ascites. In what order should the nurse perform the following preparatory actions? Arrange the steps from first to last.

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Cevap

The correct sequence of actions is to first verify informed consent, then have the client empty their bladder, followed by obtaining baseline measurements, and finally positioning the client upright.
The standard of care for assisting with a paracentesis dictates a specific logical flow to ensure client safety. Administrative and legal checks (consent) must occur first. Next, the client must empty their bladder while they are still ambulatory or easily movable to eliminate the primary procedural risk (bladder puncture). Once the bladder is empty, true baseline measurements of weight, girth, and vital signs can be taken immediately prior to the intervention. Finally, the client is placed in the optimal anatomical position (upright) for the provider to begin the sterile procedure.

Adım Adım Çözüm

1
Verify that the informed consent document has been signed.
Legal and facility requirements for the invasive procedure are met.
Consent is the absolute first prerequisite before any invasive procedure preparations begin.
2
Instruct the client to empty their bladder completely.
The bladder size is reduced, moving it down into the pelvic cavity.
This greatly reduces the risk of accidental bladder perforation during needle insertion, which is a major safety priority.
3
Measure baseline vital signs and abdominal girth.
Accurate pre-procedure data is recorded.
Because fluid removal can cause fluid shifts leading to hypotension or hypovolemic shock, having an immediate pre-procedure baseline is essential for comparison.
4
Assist the client into a sitting position on the edge of the bed.
The client is in the correct position for the healthcare provider to begin.
Gravity pulls the fluid down to the lower abdomen, minimizing the risk of puncturing the bowel or other internal organs.

Anahtar Kavram

Preparation for a paracentesis requires specific risk reduction measures, most notably having the client empty their bladder to prevent accidental puncture, and establishing vital sign baselines to monitor for subsequent hypovolemia.
Tahmini Süre:1m 0s
Soru 103Soru →

A licensed practical nurse is tasked with giving a prescribed dose of iron dextran via intramuscular injection using the Z-track method. To ensure client safety and proper medication delivery, in what chronological order should the nurse perform the following procedural steps?

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Cevap

The correct sequence is: pull the skin laterally, insert the needle at a 90-degree angle, slowly depress the plunger to instill the medication, wait 10 seconds, and finally withdraw the needle while releasing the skin.
The Z-track method is specifically utilized for intramuscular administration of highly irritating or staining medications, such as iron dextran. The technique physically misaligns the tissue layers by pulling the skin and subcutaneous tissue to the side before insertion. The needle is inserted at a 90-degree angle, followed by slow instillation of the drug. Crucially, the nurse must wait 10 seconds before removing the needle to allow tissue accommodation. Finally, withdrawing the needle and releasing the skin simultaneously creates a broken, zigzag pathway that securely traps the medication deeply within the muscle, preventing tracking into the subcutaneous layer.

Adım Adım Çözüm

1
Identify the first distinct step of the Z-track method prior to needle insertion.
Pull the skin and subcutaneous tissue laterally 1 to 1.5 inches from the injection site.
Displacing the tissue is the defining first physical manipulation of the Z-track technique, setting up the shifted pathway.
2
Determine the correct needle insertion technique once the skin is displaced.
Insert the needle at a 90-degree angle to penetrate the deep muscle layer.
The needle must be inserted perpendicularly while the non-dominant hand maintains the tissue displacement.
3
Identify the action for actual drug delivery.
Depress the plunger slowly to instill the medication.
Slow injection minimizes tissue trauma and promotes gradual absorption.
4
Determine the necessary pause before needle removal.
Maintain the needle in the muscle for 10 seconds.
This dwell time provides an opportunity for the medication to disperse locally rather than forcing its way back up the needle track.
5
Identify the final coordinated step to seal the track.
Withdraw the needle smoothly and immediately release the displaced skin.
Releasing the tissue shifts the superficial puncture site away from the muscle puncture site, locking the medication deep within the tissue.

Anahtar Kavram

Z-track method for intramuscular injections
Soru 104Soru →

A practical nurse (PN) is caring for a client who is receiving continuous enteral tube feedings. The client suddenly begins coughing vigorously, becomes cyanotic, and exhibits intercostal retractions. In what order should the PN perform the following actions? Arrange the actions from first to last.

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Cevap

The correct sequence is: Stop the feeding, elevate the head of the bed, obtain vital signs, notify the RN, and then document the event.
In any acute emergency, the practical nurse must follow the Airway, Breathing, Circulation (ABC) framework. When a client receiving an enteral feeding shows signs of respiratory distress (coughing, cyanosis), aspiration is suspected. The absolute first action is to stop the feeding (Airway protection). Next, positioning the client upright assists with Breathing. Once these immediate life-saving interventions are done, the nurse assesses the client (vital signs) to gather data. This data is then reported to the RN for further intervention. Documentation is always the final step after the client's immediate needs are met.

Adım Adım Çözüm

1
Stop the continuous enteral tube feeding.
The flow of formula is halted.
This is a potential aspiration event. The Airway must be protected first by removing the source of the aspiration.
2
Elevate the head of the bed to a high-Fowler's position.
The client is sitting upright.
This position facilitates optimal lung expansion, eases work of breathing, and uses gravity to keep stomach contents away from the airway.
3
Obtain current vital signs and oxygen saturation.
Baseline physiological data during the acute event is collected.
Once the immediate airway and breathing interventions are applied, the PN must gather data to determine the severity of the client's respiratory distress.
4
Notify the supervising registered nurse (RN).
The RN is made aware of the emergency.
The PN must report the acute change and the obtained vital signs so the RN can assess the client and coordinate further medical interventions.
5
Document the sudden change in condition and actions taken.
The event is recorded in the medical record.
Accurate documentation is legally and clinically necessary but is always the lowest priority during an active bedside emergency.

Anahtar Kavram

Airway, Breathing, Circulation (ABC) Prioritization in Acute Emergencies
Soru 105Soru →

A practical nurse is initiating a 24-hour urine collection for a client to evaluate kidney function. In what order should the nurse perform the following actions to ensure an accurate diagnostic test result?

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Cevap

The correct sequence is to first have the client empty their bladder and discard the urine, record that exact time as the start, collect all subsequent voids on ice, ask for one final void at the 24-hour mark, and finally add that void to the container to send to the lab.
A 24-hour urine collection must reflect exactly 24 hours of kidney function. By discarding the first void, the nurse ensures the bladder is empty at the exact start time. Documenting the time establishes the 24-hour clock. Keeping subsequent voids on ice prevents specimen degradation. The final void at exactly 24 hours ensures the bladder is emptied at the end of the collection period, completing the exact timeframe before the specimen is sent to the laboratory.

Adım Adım Çözüm

1
Instruct the client to empty their bladder and discard the initial urine.
The bladder is completely empty, ensuring no previously formed urine is included.
The 24-hour collection period must begin with an empty bladder to maintain an accurate measurement of urine output and concentration over the exact time frame.
2
Document the exact time of the discarded void.
A clear, precise 24-hour clock is initiated.
Recording the start time prevents timing errors and ensures the diagnostic test is not artificially shortened or extended.
3
Collect all subsequent urine in a container kept on ice.
All urine produced during the 24 hours is preserved.
Chilling the container prevents bacterial growth and degradation of the biochemical substances being measured by the laboratory.
4
Have the client void one last time exactly 24 hours after the start time.
The final amount of urine produced in the period is obtained.
This captures the final fraction of urine for the exact 24-hour window, ensuring the collection is fully complete.
5
Add the final void to the main container and send to the laboratory.
The collection is finalized and ready for processing.
Immediate transport prevents further degradation of the sample once the collection timeframe ends.

Anahtar Kavram

Accurate Specimen Collection and Diagnostic Preparation
Tahmini Süre:1m 30s
Soru 106Soru →

A practical nurse is preparing to administer 10 units of regular insulin and 15 units of NPH insulin subcutaneously to a client with type 2 diabetes mellitus. Arrange the steps for preparing this medication in the correct chronological sequence.

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Cevap

The correct sequence for mixing insulins is: 1) Roll the NPH vial, 2) Inject air into NPH, 3) Inject air into regular, 4) Withdraw regular insulin, 5) Withdraw NPH insulin.
When mixing intermediate-acting (NPH, cloudy) and short-acting (regular, clear) insulins, the standard sequence 'clear before cloudy' prevents the contamination of the short-acting insulin with the longer-acting insulin. The nurse must first gently roll the NPH vial to resuspend the particles. Next, air must be injected into both vials to equalize pressure, starting with the NPH vial to ensure the needle does not inadvertently carry NPH insulin into the regular insulin vial. Finally, the regular insulin is drawn up, followed by the NPH insulin.

Adım Adım Çözüm

1
Identify the types of insulins being mixed.
NPH is an intermediate-acting (cloudy) insulin, and regular is a short-acting (clear) insulin.
Understanding the medication characteristics dictates the 'clear before cloudy' safety rule.
2
Sequence the air injections.
Air is injected into the NPH vial first, followed by the regular insulin vial.
This equalizes pressure in both vials while ensuring the needle does not touch the cloudy insulin before entering the clear insulin vial.
3
Sequence the insulin withdrawal.
Regular insulin is withdrawn first, followed by the NPH insulin.
Drawing the clear insulin first prevents accidental contamination of the regular insulin vial with the longer-acting NPH insulin.

Anahtar Kavram

Safe Medication Administration: Mixing Insulins
Tahmini Süre:1m 30s
Soru 107Soru →

While performing a routine assessment for a client who is 3 days postoperative from an exploratory laparotomy, a practical nurse observes a loop of bowel protruding through the abdominal incision after the client forcefully sneezes. The client reports a sudden 'popping' feeling. Arrange the following emergency interventions in the correct priority sequence.

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Cevap

The correct priority sequence is to first call for assistance without leaving the client, then position the client to reduce abdominal tension, next cover the protruding organs with moist sterile dressings, and finally assess vital signs to monitor for shock.
Wound evisceration is a surgical emergency. The nurse's first action is to stay with the client and call for immediate assistance. Next, placing the client in a low Fowler's position with knees flexed reduces tension on the abdominal wall, preventing further evisceration. Once supplies are brought to the room, the nurse covers the protruding organs with sterile, saline-soaked dressings to prevent necrosis. Finally, the nurse obtains vital signs to monitor for shock while preparing the client for emergency surgery.

Adım Adım Çözüm

1
Remain at the bedside and activate the emergency call system to request assistance.
Help is mobilized without leaving the client unattended.
Wound evisceration is a medical emergency requiring the RN and surgeon. The nurse must not leave the client alone.
2
Position the client in a low Fowler's position with the knees flexed.
Tension on the abdominal wall is reduced.
Bending the knees and slightly elevating the head relaxes the abdominal muscles, preventing further evisceration.
3
Apply sterile dressings moistened with sterile 0.9% sodium chloride over the exposed bowel.
The exposed bowel is protected from drying and infection.
Keeping the organs moist is critical to prevent tissue necrosis until the client can be returned to the operating room.
4
Obtain a complete set of vital signs to evaluate for impending hypovolemic shock.
Baseline physiological stability is determined.
Evisceration can lead to rapid fluid loss and shock. Vital signs guide further emergency interventions and surgical preparation.

Anahtar Kavram

Emergency management of surgical wound evisceration
Soru 108Soru →

An adult client is prescribed iron dextran via intramuscular injection. To prevent tissue irritation and skin staining, the practical nurse utilizes the Z-track technique. Place the steps of this administration technique in the appropriate chronological order, assuming standard pre-administration safety checks and hand hygiene have already been completed.

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Cevap

The correct sequence for administering a Z-track intramuscular injection is to first displace the skin laterally, then insert the needle at a 90-degree angle, slowly inject the medication, hold the needle in place for 10 seconds, and finally withdraw the needle while simultaneously releasing the skin.
The Z-track method relies on misaligning tissue layers prior to injection. By displacing the skin first, inserting the needle, injecting, waiting for dispersion, and then releasing the skin simultaneously as the needle is removed, a broken (zigzag) path is created. This permanently traps the medication in the muscle layer.

Adım Adım Çözüm

1
Identify the purpose of the Z-track method.
The goal is to prevent medication from leaking back into the subcutaneous tissue, which is especially important for irritating or staining medications like iron dextran.
Understanding the physiological goal helps logically sequence the physical actions required.
2
Determine the initial physical action required to create the 'track'.
The skin and subcutaneous tissue must be displaced laterally before any needle insertion occurs.
If the skin is not displaced first, the needle track will be perfectly straight, defeating the purpose of the technique.
3
Sequence the insertion and injection steps.
While holding the skin displaced, the needle is inserted at a 90-degree angle, and the medication is injected slowly.
A 90-degree angle ensures intramuscular delivery, and a slow injection minimizes tissue trauma.
4
Identify the critical pause before removing the needle.
The needle must be held in place for 10 seconds after the injection is complete.
This brief pause allows the medication to begin absorbing into the muscle, reducing the risk of it tracking back up the needle path.
5
Sequence the final withdrawal step.
The needle is withdrawn and the skin is immediately released.
Releasing the skin shifts the superficial tissue layers back to their original position, breaking the needle track and trapping the medication in the muscle.

Anahtar Kavram

The Z-track method is an intramuscular injection technique designed to trap medication in the muscle layer and prevent it from leaking into the subcutaneous tissue, thereby reducing irritation and staining.
Tahmini Süre:1m 0s
Soru 109Soru →

A client who is 2 days post-operative following a right hip replacement suddenly complains of stabbing chest discomfort and difficulty breathing. In what chronological order should the practical nurse (PN) perform the following actions?

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Cevap

The correct sequence is: repositioning the client, assessing vital signs, administering oxygen, escalating to the RN, and documenting the event.
In any acute physiological crisis, the practical nurse must prioritize actions based on the ABCs (Airway, Breathing, Circulation) and the nursing process. The immediate priority is to facilitate breathing by repositioning the client into a high-Fowler's position. Next, rapid assessment of vital signs provides the necessary data to safely implement a PRN oxygen order. Once the client is temporarily stabilized with these initial measures, escalating the situation to the registered nurse ensures advanced care for a potential pulmonary embolism. Documentation is always the final step after client safety is secured.

Adım Adım Çözüm

1
Reposition the client into a high-Fowler's alignment.
Maximizes lung expansion.
Addresses the immediate 'Breathing' component of the ABCs.
2
Measure the current oxygen saturation and vital signs.
Provides objective clinical data.
Guides further immediate interventions and establishes a baseline.
3
Initiate prescribed PRN supplemental oxygen therapy.
Increases circulating oxygen levels.
Treats the identified hypoxia based on assessment data.
4
Communicate the critical findings to the supervising registered nurse.
Escalates care for a potential pulmonary embolism.
Ensures the client receives advanced medical assessment.
5
Document the acute event, interventions provided, and client response.
Creates a permanent legal record.
Must be done after the client is stabilized and the team is notified.

Anahtar Kavram

Prioritization of care during acute respiratory distress using the ABC framework and the nursing process
Soru 110Soru →

A practical nurse (PN) enters the room of a client with type 1 diabetes mellitus. The client is pale, diaphoretic, and states, 'I feel very shaky.' The PN checks the capillary blood glucose, which is 42 mg/dL (2.3 mmol/L). The client is conscious and able to swallow. In what order should the PN perform the following actions? (Arrange the items in the correct sequence from first to last.)

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Cevap

The correct sequence is to first treat the hypoglycemia with a fast-acting carbohydrate, wait 15 minutes, recheck the blood glucose, provide a stabilizing snack, and finally document the event.
The 'Rule of 15' is the standard evidence-based protocol for managing hypoglycemia in a conscious client. It dictates administering 15 grams of fast-acting carbohydrates, waiting 15 minutes, and rechecking the blood glucose. Once the glucose is above 70 mg/dL, a complex carbohydrate and protein snack is given to maintain stability, followed by accurate documentation of the entire event.

Adım Adım Çözüm

1
Administer 15 grams of a fast-acting simple carbohydrate.
The client receives an immediate source of glucose.
Symptomatic hypoglycemia is an acute emergency. A conscious client who can swallow should immediately receive 15 grams of simple carbohydrates to rapidly increase blood sugar.
2
Wait 15 minutes.
Time is given for digestion and absorption.
It takes approximately 15 minutes for simple carbohydrates to absorb and affect the capillary blood glucose level.
3
Reassess the capillary blood glucose level.
The effectiveness of the initial intervention is measured.
Checking the glucose confirms if it has risen above 70 mg/dL or if the 15-minute rule needs to be repeated.
4
Provide a complex carbohydrate and protein snack.
The client's blood sugar is stabilized.
Simple sugars metabolize quickly. A complex carbohydrate and protein provide sustained energy to prevent recurrent hypoglycemia.
5
Document the event and response.
The medical record is accurately updated.
Documentation occurs after the client is safe and stabilized to ensure an accurate record of the emergency and the client's response.

Anahtar Kavram

Hypoglycemia Management (Rule of 15)
Soru 111Soru →

A practical nurse is preparing to administer a combined dose of NPH insulin and regular insulin in a single syringe for a client with diabetes mellitus. In what order should the nurse perform the following steps to safely mix these medications?

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Cevap

The correct sequence is to first inject air into the NPH vial, then inject air into the regular vial, withdraw the regular insulin, and finally withdraw the NPH insulin.
The established standard for mixing NPH (cloudy) and regular (clear) insulins is to inject air into the cloudy vial, inject air into the clear vial, withdraw the clear insulin, and then withdraw the cloudy insulin. This strict sequence ensures that the rapid or short-acting insulin vial is never contaminated with intermediate-acting insulin, maintaining the purity and expected pharmacokinetics of the clear insulin for future use.

Adım Adım Çözüm

1
Inject air into the NPH (cloudy) vial.
The NPH vial is pressurized for later withdrawal.
Pressurizing the vial prevents a vacuum from forming, making withdrawal easier, while avoiding contamination by the clear insulin at this early stage.
2
Inject air into the regular (clear) vial.
The regular insulin vial is pressurized.
This prepares the clear insulin vial for immediate withdrawal.
3
Withdraw the regular (clear) insulin.
The precise dose of short-acting insulin is drawn into the syringe.
Drawing clear before cloudy prevents contaminating the short-acting vial with intermediate-acting insulin, which could dangerously alter its properties for future doses.
4
Withdraw the NPH (cloudy) insulin.
The correct combined volume is achieved in the syringe.
This completes the mixture safely. The nurse must be careful not to push any regular insulin into the NPH vial during this final step.

Anahtar Kavram

When mixing insulins, the standard protocol is 'clear before cloudy' to prevent the contamination of short-acting insulin with intermediate-acting insulin.
Soru 112Soru →

A practical nurse (PN) is caring for a client who is 4 days post-operative following a colon resection. The client experiences a severe coughing fit and reports, 'I felt something pop in my stomach.' Upon inspection, the PN notes that the surgical incision has separated and loops of bowel are protruding. In what order should the PN perform the following actions? Arrange the actions from first to last.

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Cevap

The correct sequence is to first stay with the client and call for assistance, then position the client in a low Fowler's position with knees flexed, followed by covering the protruding organs with sterile, saline-moistened dressings, and finally obtaining vital signs.
The correct sequence prioritizes immediate client safety, prevention of further evisceration, tissue protection, and systemic monitoring. Calling for assistance while staying with the client ensures help arrives with necessary supplies without leaving the client unsafe. Positioning in low Fowler's with bent knees immediately reduces tension on the abdominal suture line. Covering the protruding bowel with sterile, saline-moistened dressings prevents necrosis and infection. Finally, monitoring vital signs assesses for complications such as hypovolemic shock while awaiting emergency surgical intervention.

Adım Adım Çözüm

1
Ensure immediate safety and obtain assistance.
The nurse stays with the client and calls for help.
Leaving the client could result in further injury or panic; another staff member must bring sterile supplies to the room while the nurse remains at the bedside.
2
Minimize abdominal tension.
The client is placed in a low Fowler's position with knees flexed.
This physical position directly relaxes the abdominal muscles and prevents further protrusion of the bowel.
3
Protect the eviscerated tissue.
The protruding organs are covered with sterile, saline-soaked dressings.
Exposed bowel can quickly become necrotic if it dries out. A moist, sterile environment prevents tissue damage and infection.
4
Assess systemic status.
Vital signs are obtained and continuously monitored.
Wound evisceration can lead to rapid fluid shifts and hypovolemic shock, requiring close hemodynamic monitoring while awaiting emergency surgical intervention.

Anahtar Kavram

Management and prioritization of surgical wound evisceration
Soru 113Soru →

An LPN/LVN is assisting a female client with limited mobility in collecting a midstream clean-catch urine specimen. To reduce the risk of sample contamination, arrange the following steps in the correct sequence.

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Cevap

The nurse should first perform hand hygiene and don gloves, then cleanse the meatus from front to back. Next, the client should begin voiding to flush the urethra. The nurse then catches the midstream sample and removes the cup before the voiding is complete.
To obtain an uncontaminated midstream clean-catch urine specimen, the nurse must follow a strict procedural sequence: apply personal protective equipment, cleanse the meatus from front to back, allow the initial stream to flush the urethra, collect the midstream sample, and remove the cup before the client finishes voiding. This ensures the laboratory results reflect the actual bladder contents rather than external flora.

Adım Adım Çözüm

1
Perform hand hygiene and apply clean exam gloves.
The nurse is prepared to assist the client using standard precautions.
Prevents the introduction of the nurse's flora to the client and protects the nurse from exposure to body fluids.
2
Cleanse the urethral meatus using antiseptic wipes in a front-to-back motion.
The external genitalia are cleansed of surface bacteria.
Front-to-back cleansing prevents the introduction of gastrointestinal pathogens into the urinary tract and specimen.
3
Direct the client to begin voiding a small amount of urine into the toilet or bedpan.
The distal urethra is flushed with the initial flow of urine.
The initial stream clears microorganisms that naturally colonize the urethral opening.
4
Position the sterile collection cup into the active stream of urine.
The midstream urine is collected in the sterile container.
Midstream urine provides the most accurate reflection of bladder contents for laboratory testing.
5
Remove the specimen container from the stream before the client completely finishes voiding.
The collection is completed without contamination from the end of the urinary stream.
The final drops of urine can pick up skin flora from the external genitalia, potentially skewing the test results.

Anahtar Kavram

The purpose of a midstream clean-catch urine specimen is to obtain a sample that is free of external contamination. Proper sequencing ensures that external flora and urethral contaminants are cleared before the actual sample is collected into the sterile container.
Tahmini Süre:1m 30s
Soru 114Soru →

A practical nurse is preparing to administer prescribed ophthalmic drops to a client diagnosed with glaucoma. Arrange the steps of the procedure in the correct chronological order. All steps must be used.

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Cevap

First cleanse the eye from inner to outer canthus, then position the client looking up, expose the conjunctival sac, instill the drops into the sac, and finally apply pressure to the nasolacrimal duct.
This chronological sequence ensures optimal medication delivery while prioritizing client safety. Cleaning the eye prevents infection, correct positioning reduces the blink reflex, exposing the sac ensures accurate delivery, and nasolacrimal pressure limits unintended systemic absorption.

Adım Adım Çözüm

1
Cleanse the eyelid and eyelashes.
The eye area is free of drainage and debris.
Wiping from the inner to outer canthus prevents sweeping pathogens into the nasolacrimal duct.
2
Position the client's head backward and instruct them to look up.
The cornea rotates away from the lower lid.
Looking up decreases the natural blink reflex and prevents the medication drop from directly hitting the sensitive cornea.
3
Pull the lower eyelid downward.
The conjunctival sac is exposed.
This creates a trough or pocket to safely catch and hold the liquid medication.
4
Instill the prescribed number of drops into the conjunctival sac.
The medication is delivered to the eye.
Holding the dropper 1 to 2 cm away prevents accidental contact with the eye, which could cause injury or contaminate the dropper.
5
Apply gentle pressure to the nasolacrimal duct.
The tear duct is temporarily occluded.
Occluding the duct prevents the medication from draining into the nasal cavity and entering the systemic circulation, reducing the risk of systemic side effects.

Anahtar Kavram

Safe Administration of Ophthalmic Medications
Soru 115Soru →

A practical nurse is preparing to administer a newly prescribed transdermal nitroglycerin patch to a client with a history of stable angina. Arrange the steps of this medication administration procedure in the correct chronological sequence.

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Cevap

The correct sequence is to first don clean gloves, remove the old patch and clean the site, label the new patch, apply it to a suitable hairless area, and finally press it firmly into place without massaging.
Safe application of a transdermal nitroglycerin patch requires a systematic approach to protect both the client and the nurse. The nurse must first wear gloves to prevent self-dosing, then remove the previous patch to prevent overdose. Labeling the new patch prior to application ensures proper documentation without pressing a pen into the client. Finally, selecting a hairless site and pressing without massaging ensures the drug is absorbed at a safe, controlled rate.

Adım Adım Çözüm

1
Protect the nurse from unintended medication exposure.
Don clean gloves.
Nitroglycerin is readily absorbed through the skin. Handling the patch with bare hands can cause the nurse to experience adverse effects.
2
Prepare the client for the new dose.
Remove the old patch and wash the old site.
Leaving an old patch on while applying a new one leads to toxicity and nitrate tolerance. Washing removes leftover medication residue.
3
Prepare the new medication for tracking.
Label the new patch with the date, time, and initials.
Writing on the patch before applying it ensures necessary communication with the healthcare team and prevents applying pressure from a pen directly onto the client's body.
4
Administer the medication.
Place the patch on a hairless, intact area of skin.
Scar tissue, cuts, or thick hair can alter the absorption rate of the transdermal medication.
5
Secure the medication.
Press firmly for 10 seconds without rubbing.
Friction from massaging increases local circulation, which can cause an unsafe, rapid absorption of the vasodilator.

Anahtar Kavram

Safe administration of transdermal medications
Soru 116Soru →

A practical nurse (PN) is preparing to discontinue a peripheral intravenous (IV) catheter for a client who is receiving continuous anticoagulant therapy. The IV infusion has already been stopped. Arrange the following steps in the correct sequence to safely remove the catheter and minimize the risk of complications. All options must be used.

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The correct sequence is to perform hand hygiene and don gloves, remove the dressing while stabilizing the hub, place gauze lightly over the site, withdraw the catheter parallel to the skin, and finally apply firm pressure for at least 5 minutes.
Safely discontinuing an IV catheter requires standard precautions, careful site exposure, atraumatic removal, and adequate hemostasis. For a client on anticoagulant therapy, the critical risk reduction modification is applying continuous pressure for a longer duration (at least 5 minutes) immediately after the catheter is fully withdrawn to prevent excessive bleeding or hematoma formation.

Adım Adım Çözüm

1
Perform hand hygiene and don clean gloves.
Prevents the introduction of pathogens.
Standard infection control practices must be established prior to client contact.
2
Gently remove the securement dressing while stabilizing the catheter hub.
Exposes the insertion site without dislodging the catheter.
Stabilizing the hub prevents mechanical trauma to the vein and accidental premature removal.
3
Place a dry, sterile gauze pad lightly over the insertion site.
Prepares the site for immediate pressure upon removal.
Applying pressure before the catheter is fully removed can damage the vein lining.
4
Withdraw the catheter smoothly in a direction parallel to the skin.
Removes the foreign body safely.
Keeping the catheter parallel avoids puncturing the posterior wall of the vein.
5
Apply firm, continuous pressure to the site for at least 5 minutes.
Achieves hemostasis.
Clients on anticoagulants have prolonged bleeding times and require extended pressure to prevent hemorrhage or hematoma formation.

Anahtar Kavram

Discontinuation of a peripheral IV and bleeding risk reduction.
Soru 117Soru →

An LPN receives orders to mobilize an immobile bariatric client to a specialized cardiac chair for the first time post-admission. The facility protocol mandates the use of a ceiling-mounted mechanical lift with a full-body sling. Place the following steps in the correct chronological order to ensure both nurse ergonomics and client safety during this procedure. All steps must be used.

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The correct sequence prioritizes pre-procedure equipment safety verification, ergonomic environmental preparation, proper sling placement, secure attachment, an initial safety suspension check, and finally the transfer execution.
The correct chronological sequence ensures both patient safety and nurse ergonomics. Verifying equipment safety parameters must always precede patient contact. Next, the environment is secured and optimized ergonomically by adjusting the bed height. Patient positioning comes third, ensuring skin integrity. Fourth, the equipment is attached. Fifth, a critical test lift is performed slightly above the bed to confirm structural integrity before the final step of executing the full transfer to the chair.

Adım Adım Çözüm

1
Inspect the sling and verify the lift's weight capacity.
Equipment is confirmed safe for this specific bariatric client.
Using faulty equipment or exceeding weight limits can cause severe injury.
2
Lock the bed and adjust it to an ergonomic height.
The bed is stable and at a safe working level.
Proper bed height prevents back strain for the nurse during patient repositioning.
3
Turn the client and position the sling smoothly.
The sling is securely placed without wrinkles.
Wrinkles under a heavy client can cause shearing forces and pressure injuries.
4
Connect the sling loops to the overhead spreader bar.
The client is physically connected to the lifting device.
Proper attachment ensures the client will not slip out during the lift.
5
Lift the client slightly off the mattress to check attachments.
Tension is applied to verify secure connections.
An initial test lift ensures safety before the client is fully suspended away from the safety of the bed surface.
6
Guide the lift to the chair and lower the client.
The client is successfully and safely transferred.
Moving the client only after all safety checks prevents catastrophic falls.

Anahtar Kavram

Ergonomics and Safe Use of Equipment
Soru 118Soru →

A practical nurse (PN) enters the room of a client who has a T4 spinal cord injury. The client reports a sudden, severe pounding headache and blurred vision. The PN observes profuse diaphoresis above the level of the spinal injury and measures a blood pressure of 210/110 mm Hg. In which order should the PN perform the following actions? (Arrange the actions from first to last)

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The correct order of actions is to first elevate the head of the bed, followed by inspecting the urinary catheter for blockages, notifying the supervising RN, administering prescribed antihypertensive medication, and finally documenting the event.
Autonomic dysreflexia is a life-threatening hypertensive emergency that occurs in clients with spinal cord injuries at or above the T6 level. The prioritization of care must focus on immediate physiological stabilization. The absolute first action is to elevate the head of the bed to a high-Fowler's position; this immediately helps lower the blood pressure through orthostasis and reduces the risk of cerebral hemorrhage. Next, the nurse must assess for and remove the most common triggering stimulus, which is bladder distention, by checking the catheter for kinks or blockages. If the stimulus cannot be resolved or blood pressure remains high, the nurse must immediately notify the RN to escalate care, followed by administering prescribed PRN antihypertensive medications as directed. Finally, once the crisis is managed and the client is stable, the nurse documents the event, the interventions performed, and the client's response.

Adım Adım Çözüm

1
Recognize the clinical presentation of autonomic dysreflexia.
Identify a life-threatening hypertensive emergency.
The client has a T4 injury (above T6), severe hypertension, headache, and diaphoresis, which are hallmark signs of autonomic dysreflexia.
2
Intervene immediately to lower blood pressure physically.
Elevate the head of the bed to 90 degrees.
This decreases venous return and utilizes orthostatic principles to lower blood pressure, reducing the immediate risk of a stroke.
3
Assess for and remove the noxious stimulus.
Inspect the urinary catheter tubing.
A distended bladder from a kinked or obstructed catheter is the most common cause of the massive sympathetic response.
4
Escalate care and provide pharmacological management.
Notify the RN and administer prescribed oral antihypertensives.
Collaboration with the RN is necessary, and medications are indicated if the physical stimulus cannot be immediately resolved.
5
Complete post-event responsibilities.
Document the findings and actions.
Accurate medical records must be maintained after the client is stable and out of immediate danger.

Anahtar Kavram

Autonomic Dysreflexia Emergency Management
Soru 119Soru →

A client with left-sided weakness is scheduled to sit in a chair for their morning meal. The client is currently lying in bed. In what order should the nurse complete the following actions to safely transfer the client to a wheelchair?

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The correct chronological order is to first position the wheelchair on the client's strong side, lock all equipment brakes, assist the client to a sitting position to dangle their legs, apply the gait belt for safety, and finally instruct the client to bear weight on their strong leg to pivot into the chair.
Safe patient transfer requires a systematic approach to prevent injury to both the client and the nurse. Equipment positioning and stabilization must occur first by placing the chair on the strong side and locking all brakes. Next, the client is prepared physiologically by sitting up and dangling the legs to prevent orthostatic hypotension. A gait belt is then applied for handling safety. Finally, the physical pivot transfer is executed, relying on the client's strong leg to safely complete the movement into the wheelchair.

Adım Adım Çözüm

1
Position the wheelchair
Equipment is correctly aligned on the strong side.
Allows the client to use their unaffected side for maximum support during the movement.
2
Lock all brakes
Bed and wheelchair are completely immobilized.
Prevents equipment from shifting during the transfer, ensuring environmental safety.
3
Dangle legs on the edge of the bed
Client accommodates to an upright position.
Minimizes the risk of dizziness or orthostatic hypotension upon standing up.
4
Apply the gait belt
Nurse has a secure grip point.
Ensures the nurse can stabilize the client's center of gravity during the physical move without grabbing the client's arms or clothing.
5
Pivot transfer
Client is safely seated in the wheelchair.
Completes the transfer using safe body mechanics and the client's remaining strength.

Anahtar Kavram

Safe Client Transfer and Mobility
Soru 120Soru →

A practical nurse (PN) arrives for the day shift on a medical-surgical unit and receives the client assignment sheet from the charge nurse. Arrange the following actions the PN should take to ensure safe and legal care in the correct chronological order.

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The correct chronological sequence is to first review the assignment, identify the out-of-scope task (blood transfusion), communicate the concern to the charge nurse, request reassignment of that client to an RN, and finally accept the modified, safe assignment.
When receiving a client assignment, the practical nurse (PN) must first systematically review the delegated tasks. If an out-of-scope task is identified, such as a blood transfusion (which requires RN-level assessment and intervention), the PN must immediately notify the delegating charge nurse. The PN must then request that the specific client be reassigned to an RN to ensure client safety and legal compliance. Only after the assignment is modified to fit the PN's legal scope of practice should the PN accept the assignment and begin receiving the shift report.

Adım Adım Çözüm

1
Review the assigned clients' diagnoses, acuities, and scheduled treatments.
The PN gains a full understanding of the expectations and care requirements for the shift.
Before accepting any assignment, a nurse must know what is being asked of them to determine if it is safe and appropriate for their licensure level.
2
Identify that one assigned client requires a blood transfusion, which is outside the PN scope of practice.
The PN recognizes a critical conflict between the assignment and their legal authorization.
PNs must practice within the boundaries defined by their state's Nurse Practice Act. Blood transfusions are an RN-level skill due to the risk of severe reactions and the need for comprehensive assessment.
3
Approach the charge nurse promptly to discuss the scope of practice limitation.
The delegating nurse is made aware of the unsafe assignment.
Professional communication is essential. The charge nurse cannot fix an unsafe assignment if they are unaware of the PN's scope limitations or the specific conflict.
4
Request that the client requiring the blood transfusion be reassigned to a registered nurse (RN).
A collaborative plan is proposed to ensure the client receives appropriate and legal care.
The PN advocates for the client by ensuring a qualified RN manages the high-acuity, complex task of a blood transfusion.
5
Accept the modified assignment and proceed to receive the shift handoff report.
The PN safely begins their shift with an appropriate client load.
Once the assignment is adjusted to fall within the PN's legal scope of practice, it is safe to accept accountability for the clients and proceed with providing care.

Anahtar Kavram

The practical nurse (PN) is legally accountable for accepting only assignments that fall within their authorized scope of practice and must promptly collaborate with the delegating nurse to resolve any unsafe assignments.
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