Tüm alıştırma soruları

2933 soru

Soru 1361Soru →

A practical nurse accidentally drops a glass medication ampule on the floor, causing it to shatter. To prevent injury and manage the hazard safely, arrange the following actions in the correct chronological sequence.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence is to first secure the immediate area, then put on protective gloves, use a broom and dustpan to sweep up the glass, and finally dispose of the fragments in a rigid sharps container.
Safe hazard management dictates a specific order of operations: protect the public, protect oneself, mitigate the hazard safely, and dispose of it properly. Securing the area ensures no immediate harm comes to others. Donning gloves provides essential personal protection. Using a dustpan avoids hand-to-glass contact, and using a sharps container ensures the hazard does not injure waste disposal personnel.

Adım Adım Çözüm

1
Secure the area.
Prevents immediate accidental injury to bystanders.
Restricting access is the first step in hazard management to stop anyone from unknowingly interacting with the danger.
2
Don utility gloves.
Protects the nurse's hands.
Personal protective equipment must be worn before retrieving cleaning tools or getting close to the hazardous material.
3
Sweep up fragments with a broom and dustpan.
Safely gathers the broken glass without direct contact.
Mechanical means must always be used to collect broken glass to eliminate the risk of accidental cuts.
4
Dispose of glass in a sharps container.
Eliminates the hazard entirely.
Puncture-resistant containers contain the sharp objects safely, preventing subsequent injuries during waste management.

Anahtar Kavram

Hazard Management and Sharp Object Safety
Soru 1362Soru →

A licensed practical/vocational nurse (LPN/VN) is working in an outpatient oncology clinic alongside a registered nurse (RN) and assistive personnel (AP). Which action by the LPN/VN demonstrates an appropriate understanding of care assignments and scope of practice?

Cevabı ve açıklamayı göster

Cevap: Administering a routine oral antiemetic medication to a stable client prior to their scheduled chemotherapy.

Cevap

The correct action is administering a routine oral antiemetic medication to a stable client prior to their scheduled chemotherapy.
Administering a scheduled oral medication to a stable client is a standard, predictable task that falls safely within the licensed practical/vocational nurse (LPN/VN) scope of practice. It does not require complex RN-level assessment or critical care judgment.

Adım Adım Çözüm

1
Analyze the LPN/VN scope of practice regarding medication administration and task delegation.
LPN/VNs can safely administer routine oral medications to stable clients.
This is a fundamental and predictable skill within the practical nursing scope of practice.
2
Evaluate the other options against legal, ethical, and scope-of-practice standards.
Initial assessments, providing detailed procedural explanations for consent, and sharing unauthorized medical information fall outside the LPN/VN scope or violate ethical standards.
These actions require RN-level clinical judgment, healthcare provider responsibility, or directly violate HIPAA privacy regulations.

Anahtar Kavram

Client Care Assignments and LPN/VN Scope of Practice
Soru 1363Soru →

A practical nurse is caring for a client admitted with a suspected seasonal influenza infection. Which infection control interventions should the nurse implement? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Assign the client to a private room.; Don a standard surgical mask upon entering the client's room.; Apply a standard surgical mask to the client when transport outside the room is necessary.

Cevap

The nurse should assign the client to a private room, don a standard surgical mask upon entering the room, and apply a standard surgical mask to the client when transport is necessary.
Seasonal influenza is transmitted through large respiratory droplets. Appropriate droplet precautions require the client to be placed in a private room to prevent cross-contamination. Any healthcare worker entering the room must wear a standard surgical mask to protect their mucous membranes from droplet exposure. Furthermore, if the client must leave the room for necessary procedures or transport, placing a standard surgical mask on the client effectively contains their respiratory secretions at the source.

Adım Adım Çözüm

1
Identify the mode of transmission for seasonal influenza.
Influenza is transmitted via large respiratory droplets.
Knowing the mode of transmission determines the correct isolation precautions.
2
Determine the appropriate room assignment and personal protective equipment (PPE).
The client requires a private room and healthcare staff must wear a standard surgical mask.
These interventions are the core requirements of droplet precautions.
3
Determine the protocol for transporting the client outside the isolation room.
The client must wear a standard surgical mask during transport.
The mask contains the client's infectious respiratory droplets, protecting others in the facility.

Anahtar Kavram

Droplet Precautions
Soru 1364Soru →

While working in a perioperative unit, a practical nurse (PN) prepares a client for an urgent laparoscopic appendectomy. The surgeon's notes indicate that the risks, benefits, and alternatives of the surgery were discussed with the client earlier in the shift. The charge nurse asks the PN to obtain the client's signature on the consent document. As the PN hands over the pen, the client states, "If the doctor finds cysts on my right ovary during the operation, does signing this give them the right to take it out?" What is the most appropriate action for the PN to take?

Cevabı ve açıklamayı göster

Cevap: Withhold the consent document and notify the surgeon that the client requires clarification regarding the specific boundaries of the procedure.

Cevap

Withhold the consent document and notify the surgeon that the client requires clarification regarding the specific boundaries of the procedure.
The correct answer recognizes that the provider performing the procedure holds the legal responsibility to explain its scope, including what actions will be taken if unexpected findings occur. The PN's role is solely to witness the signature of a fully informed client. Because the client has an unresolved question about the medical boundaries of the surgery, the PN must halt the consent process and notify the surgeon.

Adım Adım Çözüm

1
Analyze the client's statement to determine their current level of understanding.
The client's question about whether the surgeon can remove additional organs (ovary cysts) indicates a lack of understanding regarding the extent and scope of the scheduled surgery.
Informed consent requires the client to fully comprehend the procedure, including its boundaries and what might happen if unexpected findings occur, before signing.
2
Evaluate the PN's scope of practice concerning informed consent.
The PN is legally permitted to witness the signature and confirm voluntary agreement, but cannot explain medical details, surgical parameters, or assess the depth of competency.
Explaining the specifics of a medical or surgical intervention is strictly the responsibility of the healthcare provider performing the procedure.
3
Determine the appropriate intervention based on the identified knowledge deficit.
The PN must halt the consent process and ensure the surgeon is contacted to address the client's question.
Witnessing the signature of a client who has lingering procedural questions is legally invalid; the provider must clarify before the process continues.

Anahtar Kavram

The PN's role in informed consent is limited to witnessing the client's signature and ensuring voluntary agreement. Any questions regarding the medical procedure's scope must be directed to the healthcare provider.
Tahmini Süre:1m 30s
Soru 1365Soru →

A practical nurse (PN) is assigned to care for an infant who is admitted with respiratory syncytial virus (RSV). The facility policy requires both contact and droplet precautions for this diagnosis. Which of the following infection control actions should the PN take? (Select all that apply.)

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Put on a surgical mask, gown, and clean gloves before entering the client's room.; Dedicate noncritical medical equipment, such as a stethoscope, exclusively for use on this client.; Remove the gown and gloves inside the client's room prior to exiting.

Cevap

The correct actions are to put on a surgical mask, gown, and clean gloves before entering the room; dedicate noncritical medical equipment exclusively for this client; and remove the gown and gloves inside the client's room prior to exiting.
Clients with RSV require both contact and droplet precautions. Safe practice mandates donning a surgical mask, gown, and gloves prior to entering the room. To prevent cross-contamination, noncritical equipment must be dedicated to the client, and contaminated PPE (gown and gloves) must be removed inside the room before exiting.

Adım Adım Çözüm

1
Identify the required precautions for the specified pathogen.
RSV requires both contact and droplet precautions.
RSV is transmitted through large respiratory droplets and by direct or indirect contact with contaminated secretions or surfaces.
2
Determine the appropriate personal protective equipment (PPE) for donning.
A surgical mask (droplet), along with a gown and gloves (contact), must be put on before entering the room.
Preventing exposure requires creating a barrier before entering the contaminated environment.
3
Establish the correct protocol for equipment use and PPE doffing.
Equipment must be dedicated to the client, and PPE (except respirators) must be removed inside the room in the correct sequence.
Dedicating equipment and doffing inside the room prevents cross-contamination of other clients and clean facility areas.

Anahtar Kavram

Standard and Transmission-Based Precautions for Contact and Droplet Isolation
Tahmini Süre:1m 30s
Soru 1366Soru →

A practical nurse (PN) is providing care for several clients on a long-term care unit. Which of the following actions by the PN demonstrate appropriate protection of client confidentiality? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Logging off the electronic health record (EHR) immediately before stepping away from the medication cart.; Requesting a caller to provide the client's pre-assigned privacy code before sharing a health update.; Closing the door to the client's private room prior to asking questions about their recent medical history.

Cevap

The correct actions are logging off the electronic health record, requesting a privacy code from callers, and closing the client's door prior to discussing medical information.
The correct actions involve securing electronic information (logging off), validating the identity and authorization of callers (using a privacy code), and ensuring physical privacy during verbal exchanges (closing the door). These interventions prevent unauthorized access and protect the client's protected health information (PHI) in accordance with HIPAA regulations.

Adım Adım Çözüm

1
Evaluate each option against HIPAA standards and basic confidentiality principles.
Identify whether the action protects or exposes protected health information (PHI).
The practical nurse is legally and ethically obligated to prevent unauthorized disclosure of client data in verbal, written, and electronic formats.
2
Select the actions that successfully secure client information.
Logging off the EHR, using a privacy code for telephone updates, and ensuring physical privacy by closing the door are appropriate protective measures.
These actions directly prevent accidental or intentional breaches of confidentiality.

Anahtar Kavram

Confidentiality and Information Security
Soru 1367Soru →

A practical nurse (PN) is managing the care of a client with right-sided hemiparesis who is preparing for transfer to an inpatient rehabilitation facility. Arrange the PN's collaborative, delegatory, and care coordination actions in the most appropriate chronological order.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence begins with data collection, followed by interprofessional communication, RN collaboration for care plan modification, AP delegation, and concludes with documentation of the client's response.
The correct chronological order strictly adheres to the clinical nursing process and respects the legal boundaries of the PN/VN scope of practice. The PN must first collect independent data before presenting it to the interprofessional team. Once the team provides recommendations, the PN must collaborate with the RN to update the formal care plan, because independent care plan modification is outside the PN scope. Only after the care plan is updated can the PN safely and legally delegate the specific, approved transfer techniques to the Assistive Personnel (AP). Finally, the PN evaluates and documents the outcome of these delegated actions.

Adım Adım Çözüm

1
Perform focused data collection.
Current baseline functional mobility is established.
Accurate, current data is required before any care coordination or interprofessional reporting can occur.
2
Report findings to the interprofessional team.
The team receives the necessary data to formulate rehabilitation recommendations.
Effective transition of care relies on shared, up-to-date client information.
3
Collaborate with the RN.
The nursing care plan is legally and safely updated.
The PN contributes to the care plan, but formal modifications require RN collaboration and oversight.
4
Delegate to the AP.
The AP receives clear instructions on new transfer techniques.
Safe delegation under NCSBN guidelines requires an established, updated care plan outlining the authorized interventions.
5
Document the client's response.
The effectiveness of the interventions is recorded in the electronic health record.
Documentation represents the evaluation phase, completing the cycle of care coordination.

Anahtar Kavram

The practical nurse's role in care coordination emphasizes sequential data collection, interprofessional communication, adherence to scope of practice regarding care plan modification, and safe delegation based on established plans.
Soru 1368Soru →

During the night shift, a client recovering from a fractured pelvis becomes agitated and continuously attempts to climb over the bed rails. To maintain safety, what is the best initial intervention for the practical nurse to implement?

Cevabı ve açıklamayı göster

Cevap: Activate a weight-sensitive bed alarm system.

Cevap

Activate a weight-sensitive bed alarm system.
The correct answer utilizes a bed alarm, which is a highly effective, least-restrictive safety device. It promotes patient safety by notifying healthcare personnel the moment the client attempts to leave the bed, allowing for rapid response to prevent a fall without violating the client's freedom of movement.

Adım Adım Çözüm

1
Identify the immediate safety hazard.
The agitated client is at a high risk for a fall and further injury to the fractured pelvis by attempting to climb out of bed.
Prioritizing client safety and fall prevention is the fundamental goal in this clinical scenario.
2
Select the appropriate intervention based on the principle of least restrictive restraints.
A bed alarm is chosen to alert staff of movement without physically restricting the client.
Standard nursing practice requires implementing and exhausting all less restrictive alternatives before considering any form of physical restraint.

Anahtar Kavram

Accident, Error, and Injury Prevention: Restraint Alternatives
Tahmini Süre:45s
Soru 1369Soru →

A healthcare provider asks a licensed practical nurse to obtain a signature on an informed consent document for a client's scheduled cholecystectomy. Upon entering the room, the client states, "I am really scared, and I do not understand what they will do to my gallbladder." Which action is most appropriate for the nurse to take?

Cevabı ve açıklamayı göster

Cevap: Delay obtaining the signature and notify the healthcare provider to speak with the client.

Cevap

The most appropriate action is to delay obtaining the signature and notify the healthcare provider to speak with the client.
Informed consent requires the client to fully understand the procedure, its risks, benefits, and alternatives. The legal responsibility for explaining the medical procedure rests entirely with the healthcare provider performing it. The role of the licensed practical nurse is solely to witness the client's signature, confirm they are signing voluntarily, and verify they understand what they were told by the provider. Because the client explicitly stated a lack of understanding, the nurse must advocate for the client by stopping the consent process and notifying the provider to return and answer the client's questions.

Adım Adım Çözüm

1
Evaluate the client's statement regarding the surgery.
The client explicitly states a lack of understanding about the procedure.
Identifying the client's knowledge deficit is essential before a consent form can be legally signed.
2
Identify the licensed practical nurse's scope of practice regarding informed consent.
The nurse's role is strictly to witness the signature and verify that the client is signing voluntarily with an understanding of the provider's explanation.
It is outside the scope of nursing practice to provide the initial medical explanation of a surgical procedure.
3
Determine the appropriate intervention based on legal requirements.
The nurse must halt the consent process and notify the healthcare provider.
The provider who will perform the procedure is legally responsible for explaining the risks, benefits, and alternatives to ensure the consent is truly informed.

Anahtar Kavram

Informed Consent and Scope of Practice
Tahmini Süre:1m 0s
Soru 1370Soru →

A practical nurse (PN) is caring for a client with a high body mass index (BMI) who is hospitalized for severe pneumonia. During the night shift, the client becomes acutely disoriented, combative, and slides dangerously close to the foot of the bed, which severely compromises their respiratory expansion. The PN must move the client back up in bed. Which approach represents the safest application of ergonomic principles and equipment management?

Cevabı ve açıklamayı göster

Cevap: Recruit at least one additional healthcare worker, adjust the bed height to the waist level of the shortest team member, and utilize a friction-reducing slide device to move the client on a coordinated count.

Cevap

Recruit at least one additional healthcare worker, adjust the bed height to the waist level of the shortest team member, and utilize a friction-reducing slide device to move the client on a coordinated count.
The safest approach prioritizes both client stability and nurse ergonomics. By recruiting help, using a friction-reducing device, and setting the bed to the shortest worker's waist level, the nurses minimize musculoskeletal strain and prevent skin shear on the client.

Adım Adım Çözüm

1
Assess the client's size, combativeness, and the immediate risk to their respiratory status.
The nurse identifies the need for a multi-person lift using assistive equipment due to the client's BMI and agitation.
Safe patient handling algorithms dictate that bariatric or combative clients cannot be manually lifted by a single person.
2
Gather appropriate personnel and a friction-reducing slide device.
The necessary resources are assembled to perform the task safely.
Friction-reducing devices lower the physical exertion required by staff and protect the client's skin integrity from shear forces.
3
Adjust the bed height to the waist level of the shortest caregiver.
The environment is ergonomically optimized for the team.
Adjusting to the shortest worker prevents them from having to reach upward and overextend, while taller workers can widen their stance to accommodate the height safely.

Anahtar Kavram

Safe Patient Handling and Ergonomics
Soru 1371Soru →

A client with a documented history of mild cognitive impairment is hospitalized for the treatment of pneumonia. During the shift, the client becomes abruptly agitated, frequently attempts to climb out of bed, and pulls at the intravenous tubing. Which action should the practical nurse implement to ensure safety while minimizing the use of restrictive devices?

Cevabı ve açıklamayı göster

Cevap: Request that an unlicensed assistive personnel remain continuously at the bedside to provide direct observation.

Cevap

The most appropriate action is to request that an unlicensed assistive personnel remain continuously at the bedside to provide direct observation.
Providing continuous 1:1 observation utilizing an unlicensed assistive personnel (UAP) is a highly effective, non-restrictive alternative to physical restraints. This intervention immediately protects the client from injury, addresses the safety hazard, and strictly adheres to the UAP's legal scope of practice.

Adım Adım Çözüm

1
Identify the primary client safety risk presented in the scenario.
The client is at a high risk for falls and self-injury (such as pulling out intravenous lines) due to acute, sudden-onset agitation.
Abrupt changes in behavior compromise client safety and require immediate preventative nursing measures.
2
Evaluate the appropriateness of physical restraints for this client.
Physical restraints should be avoided until all less restrictive alternatives have been exhausted.
Restraints can increase agitation and carry significant physical and psychological risks; they are strictly regulated as a measure of last resort.
3
Determine the safest and most appropriate delegation of tasks to maintain observation.
Assigning an unlicensed assistive personnel to act as a 1:1 sitter provides continuous observation within their scope of practice, whereas assigning them to perform neurological assessments is legally out of scope.
Nurses must delegate tasks that directly match the competency and legal scope of the healthcare personnel.

Anahtar Kavram

Restraint Alternatives and Safe Delegation
Soru 1372Soru →

An ambulatory care practical nurse (PN) is evaluating an older adult client who was brought to the clinic by a family caregiver. During a private portion of the examination, the PN notes bilateral, fading contusions on the client's upper arms that resemble grip marks. The client tearfully admits that the caregiver sometimes forcibly restrains them during arguments. The client begs, "Please keep this a secret; I do not want to be sent to a facility." Moments later, the caregiver enters the examination room and insists on reading the clinical documentation. What is the PN's mandatory legal course of action?

Cevabı ve açıklamayı göster

Cevap: Report the suspected mistreatment to the designated state protective agency despite the client's plea for secrecy.

Cevap

The practical nurse must report the suspected mistreatment to the designated state protective agency despite the client's plea for secrecy.
The correct answer accurately reflects the legal responsibilities of the practical nurse. Practical nurses are legally designated as mandated reporters in all jurisdictions. When elder abuse, neglect, or mistreatment is suspected based on physical evidence and client admission, the nurse has an immediate legal obligation to report the situation to the appropriate state agency (such as Adult Protective Services). This legal mandate supersedes the client's right to confidentiality, their request for secrecy, and the caregiver's demands.

Adım Adım Çözüm

1
Analyze the clinical findings and the client's statement.
The client has physical signs (contusions) and provided a verbal admission of being forcibly restrained by their caregiver.
Establishing the presence of a 'reasonable suspicion' of elder abuse is the first step in determining legal obligations.
2
Evaluate the client's request for confidentiality against legal statutes.
The client requested secrecy out of fear of placement in a facility.
Standard confidentiality rules apply to most health information, but state laws provide specific exemptions for vulnerable populations.
3
Apply the principle of mandatory reporting.
The legal mandate to report suspected elder abuse supersedes the client's right to privacy and HIPAA protections.
Protecting a vulnerable adult from immediate harm takes legal precedence over their request to keep the abuse hidden.
4
Determine the practical nurse's specific role in the reporting process.
The practical nurse must personally ensure the report is made.
The duty to report is an individual licensure obligation that cannot be delegated to an RN or delayed while waiting for a physician's definitive proof.

Anahtar Kavram

Mandatory Reporting of Abuse
Soru 1373Soru →

During a follow-up visit at an outpatient clinic, a practical nurse (PN) evaluates a frail adult client who requires assistance with activities of daily living. The client is accompanied by their primary caregiver. The PN observes multiple unexplained bruises on the client's back and notes that the client flinches and remains silent when the caregiver speaks sharply. To advocate for the client's right to a safe environment, what is the most appropriate action for the PN to take?

Cevabı ve açıklamayı göster

Cevap: Notify the clinic supervisor and initiate a report to the designated adult protective services agency regarding the suspected abuse.

Cevap

The most appropriate action is to notify the clinic supervisor and report the suspected abuse to adult protective services.
As a client advocate, the practical nurse is legally mandated to report any suspicion of abuse, neglect, or exploitation to the appropriate state authorities and facility management immediately. The nurse does not need definitive proof to make a report; a reasonable index of suspicion based on physical findings and behavioral indicators is sufficient to trigger a protective investigation.

Adım Adım Çözüm

1
Identify the clinical and behavioral indicators of potential abuse.
The unexplained bruising, combined with the client's flinching and silence around the harsh caregiver, indicates a high suspicion of physical abuse and intimidation.
Recognizing signs of abuse is the first step in advocating for vulnerable populations.
2
Determine the practical nurse's legal and ethical responsibility in this scenario.
The PN recognizes their role as a mandated reporter under state and federal law.
Nurses are legally required to advocate for client safety by reporting suspected abuse immediately, rather than waiting for proof.
3
Select the action that aligns with mandated reporting protocols and maintains client confidentiality.
Notifying the supervisor and protective services is chosen as the correct priority action.
This action ensures the client is protected through proper legal channels without inappropriately delegating tasks or breaching privacy laws.

Anahtar Kavram

Mandated Reporting and Client Advocacy
Tahmini Süre:1m 0s
Soru 1374Soru →

A practical nurse (PN) at a long-term care facility is preparing to obtain a resident's signature on a consent document for a palliative thoracentesis. The healthcare provider previously discussed the procedure with the resident. The resident has a documented "Do Not Resuscitate" (DNR) order on their chart. When the PN presents the consent document, the resident states, "I know the doctor explained the benefits, but I forgot what they said about the risk of my lung collapsing. Also, I've decided I want to cancel my DNR order starting today." Which of the following actions by the PN are legally and professionally required? (Select all that apply.)

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Contact the healthcare provider to clarify the resident's question regarding the risk of a collapsed lung.; Withhold the consent document until the healthcare provider has directly addressed the resident's questions about the procedure.; Inform the healthcare provider and the supervising registered nurse (RN) of the resident's verbal request to revoke the DNR order.

Cevap

The correct actions are to contact the provider to clarify the risk, withhold the consent document until questions are answered, and inform the provider and RN of the DNR revocation request.
The practical nurse's role in informed consent is limited to witnessing the signature and verifying that the client gave consent voluntarily. Because the resident has questions about the specific risks of the procedure (a collapsed lung), the PN must withhold the consent form and contact the healthcare provider, who retains the sole responsibility for explaining surgical risks. Furthermore, a competent client has the legal right to revoke a DNR order at any time, including verbally. The PN must honor this right by immediately notifying the provider and supervising RN so the medical record and care plan can be legally updated to reflect the new code status.

Adım Adım Çözüm

1
Analyze the resident's statement regarding the procedure.
The resident has expressed uncertainty and asked a specific question about a procedural risk (lung collapse).
Identifying that the resident lacks full understanding is critical because it directly impacts the validity of the informed consent process.
2
Determine the PN's scope of practice regarding informed consent.
The PN cannot explain procedural risks or obtain a signature from an uninformed client; the provider must be contacted.
The PN's legal role is strictly limited to witnessing a voluntary signature from a fully informed client, not providing the primary education.
3
Analyze the resident's statement regarding the DNR order.
The resident has verbally requested to revoke their DNR status.
Clients have the right to revoke advance directives at any time, and this change must be acted upon immediately to ensure safe care.
4
Determine the appropriate PN action for the DNR revocation.
The PN must report this verbal revocation to the supervising RN and the healthcare provider.
While the PN cannot independently alter medical orders, they have a professional duty to communicate the client's wishes so the provider can legally update the code status.

Anahtar Kavram

The practical nurse's role in informed consent is strictly to act as a witness; the PN must defer risk explanations to the provider. Additionally, the PN must promptly report a client's request to revoke an advance directive to ensure legal documentation is updated.
Soru 1375Soru →

A practical nurse is preparing to safely transfer a client with left-sided hemiparesis (weakness) from the bed to a wheelchair. To prevent injury to both the client and the nurse, arrange the following steps in the correct chronological order. (Place the first action at the top and the final action at the bottom).

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence requires prioritizing environmental safety first, preparing the client physiologically, applying safety equipment, prompting the client to stand using their strong side, and finally pivoting safely into the chair.
Safe transfer protocols dictate that the wheelchair must be placed on the client's unaffected (strong) side so the client can lead with their strength. Environmental safety, such as locking the wheels, must always precede physical movement. The client is then brought to a seated position to stabilize blood pressure and equipped with non-skid footwear and a gait belt. During the physical transfer, the client pushes up using their own strength to minimize the lifting strain on the nurse, followed by a controlled pivot to safely lower into the seat.

Adım Adım Çözüm

1
Prepare the environment.
The wheelchair is locked and positioned on the client's strong side.
Ensures the destination is secure before attempting to move the client.
2
Position the client and apply footwear.
The client is dangling at the bedside wearing non-skid socks or shoes.
Prevents orthostatic hypotension and ensures traction to prevent falls.
3
Apply the gait belt.
A transfer belt is secured around the client's waist.
Provides a designated, secure hold for the nurse to safely control the transfer.
4
Assist to stand.
The client pushes up and bears weight on the unaffected right leg.
Promotes client independence and prevents back injury to the nurse.
5
Pivot and sit.
The client is safely seated in the wheelchair.
Completes the transfer smoothly without unsafe twisting motions.

Anahtar Kavram

Safe Client Transfer and Fall Prevention
Soru 1376Soru →

A resident in a long-term care facility has a methicillin-resistant Staphylococcus aureus (MRSA) infection in a sacral pressure injury. The practical nurse is preparing to change the resident's soiled bed linens. Which of the following combinations of personal protective equipment (PPE) must the nurse wear?

Cevabı ve açıklamayı göster

Cevap: A disposable isolation gown and non-sterile gloves

Cevap

The correct combination of PPE is a disposable isolation gown and non-sterile gloves.
The correct answer identifies the fundamental requirements of contact precautions. MRSA is transmitted by direct contact with the client or indirect contact with their environment, such as bed linens. Therefore, the nurse must wear a disposable isolation gown and non-sterile gloves to create a physical barrier against the pathogen.

Adım Adım Çözüm

1
Identify the transmission mode of the stated pathogen.
Methicillin-resistant Staphylococcus aureus (MRSA) is primarily transmitted through direct physical contact with the client or indirect contact with their contaminated environment.
Understanding how a specific microorganism spreads determines the type of transmission-based precautions required.
2
Determine the required isolation category based on the transmission mode.
Contact precautions must be implemented for this resident.
Contact precautions are the standard safety protocol for epidemiologically significant microorganisms that spread by touching.
3
Select the specific PPE components mandated for that isolation category.
A gown and gloves are required upon entry into the resident's room.
Gloves prevent direct transfer of MRSA to the nurse's hands, and a gown protects the uniform from becoming contaminated when leaning over the bed to change soiled linens.

Anahtar Kavram

Contact Precautions for MRSA
Soru 1377Soru →

The healthcare team on an acute care medical-surgical unit is organizing client care for the shift. Match each specific clinical task to the interprofessional team member most qualified and legally authorized to perform it.

Soldaki öğeye tıklayın, sonra eşleşen sağdaki öğeye tıklayın

Öğeler

Administering a continuous intravenous (IV) heparin infusion for a client with deep vein thrombosis
Performing tracheostomy care and suctioning for a client with a stable, well-established airway
Reporting a client's decreased oral fluid intake and dry mucous membranes to the primary nurse
Facilitating home health services and securing durable medical equipment for a client nearing discharge

Eşleşmeler

Cevabı ve açıklamayı göster

Cevap

The RN administers the continuous IV heparin; the LPN/VN performs tracheostomy care on the stable airway; the UAP reports the oral intake and dry mucous membranes; and the Case Manager facilitates home health services.
Each task is appropriately delegated according to the principles of safe client care. The RN handles unstable, high-risk interventions requiring advanced assessment (IV heparin). The LPN/VN manages stable clients with predictable outcomes (established tracheostomy). The UAP handles basic care and reporting without making clinical judgments. The Case Manager coordinates resources across the continuum of care.

Adım Adım Çözüm

1
Evaluate the IV heparin task.
Matched with the RN.
Heparin is a high-alert medication requiring independent clinical judgment, continuous lab monitoring, and IV dose titration, which exceeds the scope of the LPN/VN and UAP.
2
Evaluate the tracheostomy care task.
Matched with the LPN/VN.
While it is a sterile procedure, the airway is stable and established. The LPN/VN is legally authorized and educationally prepared to safely perform this predictable task.
3
Evaluate the reporting of fluid intake.
Matched with the UAP.
The UAP can observe and report findings to the nurse. This does not involve independent nursing assessment or clinical decision-making.
4
Evaluate the discharge coordination task.
Matched with the Case Manager.
Securing home services and durable medical equipment is a collaborative administrative and coordination function best suited for the Case Manager.

Anahtar Kavram

Interprofessional collaboration and delegation based on legal scope of practice and the NCSBN National Guidelines for Nursing Delegation.
Soru 1378Soru →

A practical nurse enters a client's room and discovers a small fire in the bedside wastebasket. The client is in bed and receiving supplemental oxygen. In what order should the nurse perform the following actions? Arrange the actions from first to last.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence follows the RACE acronym: Rescue the client, Alarm the facility, Confine the fire, and Extinguish the fire.
The RACE acronym (Rescue, Alarm, Confine, Extinguish) dictates the exact sequence of mandatory actions during a fire. Client safety (Rescue) is always the first priority. Only after the client is out of immediate danger should the nurse alert others (Alarm), contain the hazard (Confine), and attempt to fight the fire (Extinguish).

Adım Adım Çözüm

1
Rescue the client
The client is removed from immediate danger.
Life safety is always the highest priority during a fire emergency, particularly when oxygen is in use in the immediate vicinity.
2
Alarm the facility
Emergency responders and other facility staff are notified.
Activating the alarm ensures that help is on the way to manage the emergency and initiate facility-wide protocols.
3
Confine the fire
The fire and smoke are contained to the room of origin.
Closing doors and windows minimizes airflow, reducing the fire's oxygen supply and protecting the rest of the facility from smoke inhalation hazards.
4
Extinguish the fire
The small fire is put out if it is safe to do so.
Once people are safe, the alarm is sounding, and the area is secured, a fire extinguisher can be used on small, manageable fires.

Anahtar Kavram

Emergency Fire Response (RACE Protocol)
Soru 1379Soru →

A practical nurse (PN) is coordinating client care with a registered nurse (RN) and an assistive personnel (AP) on a medical-surgical unit. Which of the following decisions by the PN demonstrates the most appropriate application of scope of practice, delegation, and collaborative care principles?

Cevabı ve açıklamayı göster

Cevap: Monitoring a client receiving a packed red blood cell transfusion and collecting subsequent vital signs 15 minutes after the RN has initiated the infusion and completed the initial assessment.

Cevap

The correct decision is to monitor a client receiving a packed red blood cell transfusion and collect subsequent vital signs 15 minutes after the RN has initiated the infusion and completed the initial assessment.
The correct decision is to accept the assignment to monitor the client receiving a blood transfusion after the first 15 minutes. While registered nurses must initiate blood products and complete the critical initial 15-minute assessment, practical nurses are legally permitted to monitor the client and collect subsequent vital signs once the client is deemed stable and free of initial transfusion reactions.

Adım Adım Çözüm

1
Analyze the practical nurse's legal scope of practice regarding blood transfusions.
Registered nurses must initiate blood products and perform the critical 15-minute assessment. Practical nurses may monitor stable clients and collect vital signs after this initial period.
Identifying boundaries ensures safe care and prevents working outside the legal scope of practice.
2
Evaluate the appropriateness of delegating tasks to assistive personnel (AP).
APs can take vital signs on stable clients, but clients exhibiting new symptoms of instability (like post-operative lightheadedness) require assessment by a licensed nurse.
Delegation requires the client to be medically stable with a predictable outcome.
3
Determine the practical nurse's role in informed consent and discharge teaching.
Practical nurses can only witness consent signatures, not explain procedure risks. They can reinforce teaching, but cannot initiate primary discharge education or perform medication reconciliation.
These tasks require comprehensive assessment and clinical judgment, which are RN and provider responsibilities.
4
Select the option that aligns with safe and legal practice.
Monitoring the blood transfusion after the initial 15-minute RN assessment is the only legally and clinically appropriate action for the PN.
This correctly applies delegation and collaborative care principles within the PN scope.

Anahtar Kavram

LPN/VN Scope of Practice, Delegation, and Collaboration
Soru 1380Soru →

Connect the following routine healthcare encounters with the appropriate security protocol required to safeguard protected health information (PHI).

Soldaki öğeye tıklayın, sonra eşleşen sağdaki öğeye tıklayın

Öğeler

A relative calls the nursing unit requesting the latest laboratory results for an admitted client.
A nurse is urgently called to assist another staff member while actively charting in a client's electronic file.
At the conclusion of the shift, a nurse needs to discard a personal assignment sheet containing client vital signs.
A community member approaches the desk asking if a well-known local official is currently a patient on the floor.

Eşleşmeler

Cevabı ve açıklamayı göster

Cevap

The proper security protocols are: phone inquiries require privacy codes, unattended computer charts require logging off, physical notes require shredding, and public inquiries regarding patient presence require a refusal to confirm or deny.
Each correct pairing represents the fundamental, required nursing protocol for safeguarding different forms of protected health information (verbal communications, electronic records, physical paperwork, and general admission status) in compliance with standard privacy laws.

Adım Adım Çözüm

1
Evaluate the protocol for telephone inquiries regarding client data.
Match the phone call scenario with the requirement to verify the caller's identity using a privacy code.
Nurses must ensure they are speaking to an authorized individual before disclosing protected health information verbally.
2
Evaluate the protocol for maintaining electronic health record security during an interruption.
Match the urgent interruption scenario with locking the screen or logging out.
Leaving a charted screen open allows opportunistic viewing by unauthorized individuals, violating information security standards.
3
Evaluate the protocol for disposing of written health information.
Match the assignment sheet scenario with using a secure shredding receptacle.
Placing documents with patient identifiers in standard trash bins is a violation of federal privacy laws.
4
Evaluate the protocol for responding to unauthorized questions about facility admissions.
Match the public inquiry scenario with the statement refusing to confirm or deny.
Simply confirming a client's presence in a healthcare facility is considered a disclosure of protected health information.

Anahtar Kavram

Maintaining client confidentiality and information security requires specific, consistent daily actions to protect verbal, electronic, physical, and public relations data.
Tahmini Süre:1m 0s
ÖncekiSayfa 69 / 147Sonraki
Tüm alıştırma soruları — NCLEX-PN | Examkin