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Tüm alıştırma soruları

2933 soru

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Soru 1441Soru →

While assigned to a medical unit, a practical nurse (PN) observes an unlicensed assistive personnel (UAP) preparing to enter the room of an older adult client with disseminated herpes zoster. The client, who has no documented history of cognitive impairment, has suddenly become severely agitated and is attempting to climb over the bed rails. The UAP has donned a surgical mask and gloves, stating they intend to quickly apply bilateral wrist restraints to prevent a traumatic fall. Which action by the PN demonstrates the highest priority for comprehensive error prevention and client safety?

Cevabı ve açıklamayı göster

Cevap: Halt the UAP from entering, require the use of an N95 respirator and isolation gown, and collaborate to provide direct bedside supervision rather than applying physical restraints.

Cevap

The practical nurse must stop the UAP, ensure the correct airborne and contact precautions (N95 respirator and gown) are worn, and use direct bedside supervision instead of physical restraints.
The correct action demonstrates a synthesis of safety protocols. It immediately prevents a transmission hazard by enforcing airborne/contact precautions (N95 and gown) for disseminated herpes zoster. Furthermore, it protects the client's rights and safety by utilizing the least restrictive alternative (direct bedside observation) rather than allowing the UAP to unlawfully apply physical restraints.

Adım Adım Çözüm

1
Analyze the infection control risk presented in the scenario.
Disseminated herpes zoster requires airborne and contact precautions. The UAP's surgical mask and gloves are insufficient; an N95 respirator and gown are required.
Preventing the spread of highly contagious airborne pathogens is a critical safety priority for the entire unit.
2
Evaluate the UAP's plan to apply physical restraints.
Applying restraints immediately is a safety violation. Restraints are a last resort and require a provider's order.
The standard of care mandates attempting the least restrictive alternative first, such as one-on-one bedside observation, to de-escalate agitation and prevent injury.
3
Assess the clinical significance of the client's sudden agitation.
Sudden agitation in an older adult with no cognitive history indicates acute delirium, a medical emergency requiring RN/provider evaluation.
Normalizing confusion leads to missed diagnoses of hypoxia, sepsis, or other life-threatening complications.
4
Synthesize findings to determine the priority action.
The PN must intervene immediately to stop the UAP, correct the PPE violation, and provide direct supervision to protect the client without using restraints.
This comprehensively addresses hazard prevention (infection control), error mitigation (avoiding illegal restraint application), and client safety (preventing a fall).

Anahtar Kavram

Comprehensive Error and Injury Prevention (Infection Control, Restraint Alternatives, and Safe Delegation)
Soru 1442Soru →

A client with acute confusion is repeatedly attempting to pull out their peripheral intravenous (IV) catheter. Which action should the practical nurse (PN) take first to ensure the client's safety?

Cevabı ve açıklamayı göster

Cevap: Cover the IV insertion site with a long sleeve or flexible tubular bandage

Cevap

Cover the IV insertion site with a long sleeve or flexible tubular bandage.
The correct action is to cover the IV site, which serves as a least restrictive alternative. By hiding the IV catheter from the client's view, the visual trigger to pull at it is removed, potentially eliminating the need for any type of physical or chemical restraint.

Adım Adım Çözüm

1
Identify the primary safety risk.
The client is at risk of dislodging their IV catheter due to acute confusion.
Recognizing the specific risk dictates the appropriate, targeted nursing intervention.
2
Determine the least restrictive intervention.
Concealing the IV line removes the visual stimulus that prompts the client to pull on it.
Nursing standards mandate that restraints must only be used after less restrictive measures have been attempted and proven ineffective.

Anahtar Kavram

Least Restrictive Environment and Restraint Alternatives
Soru 1443Soru →

A practical nurse (PN) is conducting a preoperative checklist for a client scheduled for a left below-the-knee amputation. The client has a peripheral intravenous (IV) line and received a prescribed sedative 30 minutes ago, but is currently becoming restless on the transport stretcher. The PN verifies that the signed informed consent form specifies a 'left below-the-knee amputation.' However, upon physical assessment, the PN observes the surgeon's initials marked in permanent ink on the client's right leg. Which action is the priority for the PN to prevent a sentinel event?

Cevabı ve açıklamayı göster

Cevap: Halt the preoperative process immediately and directly notify the surgeon of the site marking discrepancy.

Cevap

The PN must immediately halt the preoperative process and directly notify the surgeon of the site marking discrepancy.
Preventing wrong-site surgery is a critical safety priority. According to universal protocols, any discrepancy between the informed consent, the client's physical site marking, or the medical record requires an immediate halt to all preoperative procedures. The discrepancy must be reported directly to the surgeon, who is legally responsible for resolving the conflict and personally marking the correct site before any further action is taken.

Adım Adım Çözüm

1
Identify the critical safety discrepancy between the legal consent document (left leg) and the physical site marking (right leg).
Recognition of an imminent sentinel event (potential wrong-site surgery).
The Universal Protocol requires exact agreement between the consent, site markings, and client records prior to any surgical procedure.
2
Evaluate the client's current cognitive state and the PN's scope of practice.
Determination that the client cannot self-verify due to sedation, and the PN cannot alter surgical markings or administer IV push medications.
Sedated clients cannot participate in a valid clinical time-out, and site marking is strictly the responsibility of the proceduralist.
3
Execute the priority safety intervention.
The transport is halted and the surgeon is notified.
A critical discrepancy requires an immediate hard stop to the preoperative process until the primary surgeon resolves the conflict.

Anahtar Kavram

Universal Protocol and Wrong-Site Surgery Prevention
Tahmini Süre:1m 30s
Soru 1444Soru →

During a morning shift on a surgical unit, a practical nurse receives a client assignment that includes preparing an individual for an upcoming elective procedure. The care team also includes a registered nurse and an assistive personnel. Which of the following actions by the practical nurse represent appropriate scope of practice and collaboration? (Select all that apply.)

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Delegating the assistive personnel to obtain and document the client's preoperative vital signs.; Signing the informed consent document solely as a witness to the client's voluntary signature.; Reinforcing the preoperative fasting instructions that were initially provided by the registered nurse.

Cevap

The correct actions include delegating the collection of preoperative vital signs to the assistive personnel, acting as a witness for the informed consent signature, and reinforcing the preoperative fasting instructions that were already taught by the registered nurse.
The practical nurse operates within a defined scope of practice that includes delegating stable, routine tasks (such as vital signs) to assistive personnel. The practical nurse may participate in the informed consent process by witnessing the client's signature, confirming it was given voluntarily. Furthermore, they are authorized to reinforce educational plans and instructions that have already been initiated by the registered nurse.

Adım Adım Çözüm

1
Analyze the practical nurse's role in delegation.
Determined that delegating routine, non-invasive tasks like vital signs to assistive personnel is appropriate.
Assistive personnel are trained to gather basic, stable clinical data without requiring nursing judgment.
2
Differentiate the practical nurse's role in the informed consent process.
Determined that the nurse acts only as a witness to the signature, while the provider must explain the actual risks and benefits.
Explaining surgical risks requires advanced medical knowledge and is strictly the responsibility of the performing provider.
3
Evaluate the scope of practice regarding medication administration and education.
Identified that IV push medications and initial comprehensive teaching are beyond the practical nurse scope, but reinforcing existing teaching is allowed.
Intravenous push medications and initial education require the comprehensive assessment skills of a registered nurse.
4
Apply confidentiality standards to clinical collaboration.
Recognized that discussing client details in a public cafeteria is inappropriate.
Patient privacy laws dictate that clinical discussions must occur in private areas to prevent unintentional disclosure.

Anahtar Kavram

Scope of practice for the practical nurse regarding delegation, informed consent, client education, and confidentiality.
Soru 1445Soru →

A practical nurse receives a report on a client admitted with a confirmed diagnosis of seasonal influenza. The unit currently has no private rooms available. The nurse should expect this client to share a room with which of the following clients?

Cevabı ve açıklamayı göster

Cevap: A client who has also been admitted with a confirmed diagnosis of seasonal influenza

Cevap

The safest option is to place the client in a room with another client who has the same confirmed diagnosis of seasonal influenza.
According to standard infection control guidelines, when private rooms are unavailable, it is acceptable to cohort (room together) clients who are infected with the exact same microorganism. Because both clients have a confirmed diagnosis of seasonal influenza, they pose no additional risk of cross-infecting each other with a new pathogen.

Adım Adım Çözüm

1
Identify the transmission-based precaution requirements for the newly admitted client.
Seasonal influenza is transmitted via large respiratory droplets and requires droplet precautions.
Understanding the mode of transmission is the first step in determining safe room placement.
2
Recall the Centers for Disease Control and Prevention (CDC) guidelines for cohorting clients when private rooms are unavailable.
CDC guidelines state that clients infected with the exact same pathogen can safely share a room.
Cohorting clients with identical active infections prevents the introduction of new pathogens to either client.
3
Evaluate the infectious status and vulnerability of each potential roommate.
Only the client who already has confirmed seasonal influenza is a safe match; the others are either vulnerable to infection or carry different pathogens.
Cross-contamination or exposing an immunocompromised client to an active infection violates core safety principles.

Anahtar Kavram

Cohorting Guidelines for Transmission-Based Precautions
Soru 1446Soru →

A practical nurse (PN) prepares to enter a client's room and correctly follows the sequence of applying an isolation gown, followed by an N95 respirator, and finally clean gloves. For which of the following assigned clients is this specific combination of personal protective equipment (PPE) strictly required by transmission-based precautions prior to room entry?

Cevabı ve açıklamayı göster

Cevap: A client with disseminated varicella-zoster virus who requires assistance with daily hygiene

Cevap

The client with disseminated varicella-zoster virus is the correct answer because this condition uniquely requires the combination of Airborne (N95 respirator) and Contact (gown and gloves) precautions prior to room entry.
Disseminated varicella-zoster virus requires both Airborne and Contact precautions. Airborne precautions require the nurse to don an N95 respirator before entry, and Contact precautions mandate an isolation gown and clean gloves prior to entering the room. The stem correctly describes the donning sequence for this specific combination of required PPE.

Adım Adım Çözüm

1
Analyze the PPE combination listed in the stem.
The nurse is donning an isolation gown, an N95 respirator, and clean gloves prior to room entry.
Identifying the specific PPE helps determine which isolation precaution categories are being implemented.
2
Map the PPE to specific transmission-based precaution categories.
An N95 respirator indicates Airborne precautions. A gown and gloves required prior to entry indicates Contact precautions.
Understanding what each PPE item is used for allows you to filter the client diagnoses based on their required precautions.
3
Evaluate the transmission-based precaution requirements for each client option.
Bacterial meningitis requires Droplet; TB requires Airborne; C. diff and RSV require Contact and Droplet; Disseminated varicella-zoster requires Airborne and Contact.
This systematic evaluation ensures the correct pathogen is matched to the PPE.
4
Select the client that requires both Airborne and Contact precautions.
The client with disseminated varicella-zoster virus is the only match.
Disseminated shingles can be transmitted through both airborne aerosols and direct contact with blister fluid, necessitating the full PPE combination described.

Anahtar Kavram

Standard and Transmission-Based Precautions
Soru 1447Soru →

A practical nurse (PN) is providing care for a client who was recently diagnosed with a terminal illness and is now preparing for palliative surgery. The multidisciplinary care team includes a registered nurse (RN), a healthcare provider (HCP), and an assistive personnel (AP). Which action by the PN demonstrates appropriate interprofessional collaboration and adherence to legal practice boundaries?

Cevabı ve açıklamayı göster

Cevap: Requesting the RN to administer a prescribed intravenous (IV) push analgesic for breakthrough pain while the PN reinforces the HCP's prior preoperative teaching.

Cevap

The action that demonstrates appropriate interprofessional collaboration and scope of practice is requesting the RN to administer the prescribed intravenous (IV) push analgesic while the PN reinforces the HCP's prior preoperative teaching.
The correct action involves the PN accurately identifying tasks that exceed their scope (administering an IV push medication) and properly escalating those to the RN. Concurrently, the PN performs a task safely within their scope by reinforcing preoperative education that was already initiated by the HCP. This demonstrates excellent interprofessional collaboration and strict adherence to safe practice boundaries.

Adım Adım Çözüm

1
Analyze the scope of practice limits for a practical nurse (PN) regarding medication administration and client education.
Identified that IV push medications and initial client teaching are generally outside the PN's legal scope, but reinforcing previous teaching is permitted.
Understanding the precise boundaries of PN practice is necessary to evaluate the safety and legality of the proposed actions.
2
Evaluate the collaborative roles regarding the informed consent process.
Determined that the HCP must explain the procedure, risks, and alternatives; the nurse only acts as a witness to the signature.
Clarifies the difference between the provider's duty to inform and the nurse's duty to witness, preventing illegal assumption of provider responsibilities.
3
Assess the boundaries of nursing assessment and care planning.
Recognized that the RN must perform the initial comprehensive assessment and develop the care plan, a task that cannot be safely delegated to the PN.
Protects the client by ensuring that tasks requiring complex, independent clinical judgment remain with the appropriately licensed team member.
4
Review the principles of client confidentiality in collaborative communication.
Identified that sharing client information with team members must occur in private, secure areas to avoid unauthorized disclosure.
Ensures compliance with federal privacy regulations while coordinating care with assistive personnel.

Anahtar Kavram

Scope of Practice and Interprofessional Collaboration
Soru 1448Soru →

A client receiving intravenous antibiotics for a severe skin infection unplugs their infusion pump, puts on street clothes, and states, 'I am going home right now.' Arrange the following actions the practical nurse (PN) should take in the correct chronological order.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

First, inquire about the client's reasons. Second, notify the charge nurse and provider. Third, reinforce the provider's explanation of risks. Fourth, witness the AMA signature. Finally, document the event.
The correct sequence prioritizes the nursing process and client advocacy. Gathering data by asking the client why they want to leave comes first. Communication with the healthcare team follows so the provider can address medical risks. The PN then reinforces the provider's teaching. If the client still wishes to leave, witnessing the AMA form ensures legal compliance, followed by comprehensive documentation of the entire event.

Adım Adım Çözüm

1
Determine the first action based on the nursing process.
Inquiring about the client's reasons for wanting to leave.
Gathering data is always the initial step. Understanding why the client wants to leave may reveal a problem that the nursing staff can resolve, such as uncontrolled pain or anxiety.
2
Identify the need for collaboration and escalation.
Notifying the charge nurse and healthcare provider.
Leaving against medical advice is a significant safety risk. The healthcare provider must be informed so they can evaluate the client and legally disclose the specific medical consequences of leaving.
3
Determine the practical nurse's role in client education.
Reinforcing the provider's explanation of the health risks.
While the healthcare provider is responsible for the initial disclosure of medical risks, the PN acts as an advocate by reinforcing this information and ensuring the client fully comprehends the consequences.
4
Address the legal requirements if the client refuses to stay.
Witnessing the client's signature on the Against Medical Advice (AMA) form.
If the client remains resolute in their decision to leave, the facility must have legal documentation proving that the client was informed of the risks and chose to leave anyway.
5
Complete the nursing responsibilities for the encounter.
Documenting the entire event in the medical record.
Accurate, factual, and objective documentation of the client's statements, notifications made, education reinforced, and forms signed is legally required.

Anahtar Kavram

Client Rights and Advocacy during Refusal of Care
Soru 1449Soru →

During the morning shift, a vocational nurse is assigned to care for a client who was admitted with bacterial meningitis. The client has subsequently developed profuse diarrhea that tested positive for Clostridioides difficile. Which interventions should the nurse include when organizing care for this client? (Select all that apply)

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Don a surgical mask, an isolation gown, and clean gloves prior to entering the client's room.; Perform hand hygiene using soap and water rather than an alcohol-based hand rub after providing care.; Apply a standard surgical mask to the client when transport outside of the isolation room is necessary.

Cevap

The correct interventions are to don a surgical mask, gown, and gloves prior to entry; use soap and water for hand hygiene; and place a surgical mask on the client during necessary transport.
Bacterial meningitis is transmitted via large respiratory droplets, requiring a surgical mask when within 3 feet of the client. Clostridioides difficile is an enteric pathogen transmitted via contact, requiring a gown and gloves. Therefore, the nurse must don a mask, gown, and gloves before entering. C. difficile spores resist alcohol, making soap and water mandatory for hand hygiene. Finally, clients on droplet precautions must wear a standard surgical mask when transported to contain their own respiratory secretions.

Adım Adım Çözüm

1
Analyze the client's diagnoses to determine the required transmission-based precautions.
Bacterial meningitis requires droplet precautions. C. difficile requires contact precautions.
Identifying the transmission route dictates which infection control protocols and personal protective equipment (PPE) are necessary.
2
Determine the necessary PPE and procedural rules for combined droplet and contact precautions.
The nurse must use a surgical mask (droplet) alongside a gown and gloves (contact). C. difficile specifically mandates handwashing with soap and water.
Combined precautions mean the strictest rules of both must be followed simultaneously to ensure safety.
3
Evaluate each option against safe delegation, confidentiality, and proper PPE sequence.
The options involving UAP assessment, posting the diagnosis on the door, and removing the mask first are identified as incorrect actions.
Assessments cannot be delegated, diagnoses cannot be displayed publicly, and masks should be removed last to prevent facial contamination.

Anahtar Kavram

Standard and Transmission-Based Precautions: Synthesizing Droplet and Contact Precautions
Soru 1450Soru →

A severe weather event has disrupted normal staffing matrixes at an acute care facility, requiring the interdisciplinary team to restructure client care delivery on a busy telemetry unit. A practical nurse (PN) is reviewing directives delegated by the shift director. Which specific task must the PN decline as exceeding the practical nursing scope of practice, thereby escalating it to a registered nurse (RN)?

Cevabı ve açıklamayı göster

Cevap: Synthesizing collected clinical data to formulate an initial, comprehensive discharge teaching plan for a client newly diagnosed with congestive heart failure.

Cevap

The task of synthesizing collected clinical data to formulate an initial, comprehensive discharge teaching plan for a newly diagnosed client exceeds the practical nursing scope of practice and must be escalated to a registered nurse.
The correct answer identifies that formulating an initial, comprehensive teaching plan requires the synthesis of clinical data and complex educational planning. Under national scope of practice guidelines, the Registered Nurse (RN) is solely responsible for creating the initial care and teaching plans. The Practical Nurse (PN) is legally restricted to reinforcing education that has already been initiated and planned by the RN.

Adım Adım Çözüm

1
Analyze the legal scope of practice for a Practical Nurse (PN) regarding the nursing process.
The PN is authorized to collect data, participate in care planning, and implement interventions, but the Registered Nurse (RN) retains sole responsibility for comprehensive assessment, nursing diagnosis, and the initial formulation of the care plan.
Identifying the boundaries of the PN's role within the nursing process is the fundamental step in safe delegation and assignment acceptance.
2
Evaluate the task of formulating an initial, comprehensive discharge teaching plan.
This task requires synthesizing complex clinical data to identify learning needs and create a novel educational strategy.
Initial teaching and the creation of the teaching plan fall strictly under the RN's scope of practice; the PN's role is limited to reinforcing this previously established teaching.
3
Evaluate the remaining tasks for scope compliance.
Witnessing consent, reporting critical laboratory values to providers, and applying prescribed restraints after alternative measures fail are all safely within the established legal and clinical scope of the PN.
Eliminating tasks that are within the PN's scope confirms the single inappropriate assignment that must be refused.

Anahtar Kavram

The Registered Nurse (RN) is exclusively responsible for the initial comprehensive assessment, formulation of the nursing care plan, and initial client education. The Practical Nurse (PN) may only reinforce established teaching and contribute data to the assessment.
Tahmini Süre:1m 30s
Soru 1451Soru →

A practical nurse (PN) and an assistive personnel (AP) are providing care for a stable client in a rehabilitation facility. The client is recovering from a total knee arthroplasty and is scheduled for a morning physical therapy session. Which of the following tasks can the PN safely delegate to the AP? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Assisting the client with applying anti-embolism stockings; Emptying the urinary catheter drainage bag and recording the output volume; Helping the client complete morning oral hygiene at the bedside sink

Cevap

The tasks that can be safely delegated to the AP are assisting with anti-embolism stockings, emptying the urinary drainage bag, and helping with oral hygiene.
The correct tasks involve standard, unchanging procedures that have predictable outcomes (applying stockings, emptying drainage bags, and assisting with hygiene). These activities of daily living (ADLs) and basic data collection tasks do not require nursing judgment, making them legally and safely delegable to an AP.

Adım Adım Çözüm

1
Identify the client's condition and the role of the assistive personnel (AP).
The client is stable, and the AP is qualified to perform routine, non-invasive care tasks.
Delegation decisions must be based on client stability and the legal scope of practice for the team member.
2
Evaluate each task against the Five Rights of Delegation.
Routine ADLs and measurement tasks (stockings, oral hygiene, emptying a catheter) are appropriate. Evaluation, education, and discussing clinical data are not appropriate.
Tasks requiring clinical judgment, nursing assessment, or specialized knowledge must remain with the licensed nurse.

Anahtar Kavram

Delegation of Routine Tasks to Assistive Personnel
Tahmini Süre:1m 0s
Soru 1452Soru →

A practical nurse (PN) is preparing to administer a scheduled investigational medication to a client participating in a clinical trial. The client refuses the dose, stating, "I changed my mind. I do not want to be in this study anymore, but I am terrified the hospital will stop treating my cancer if I quit." In which order should the PN perform the following actions to advocate for this client's rights? Arrange the actions in the correct chronological sequence.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence is to first withhold the medication, then reassure the client, next notify the healthcare team, and finally document the event.
The nursing process and prioritization frameworks dictate that immediate physical safety (withholding unwanted treatment) comes first. This is followed by immediate psychosocial intervention (reassuring a terrified client). Once the client is stabilized physically and emotionally, the nurse communicates with the team (chain of command) to update the care plan. Finally, the nurse documents the events as a retrospective administrative task.

Adım Adım Çözüm

1
Withhold the administration of the investigational medication.
The unwanted treatment is prevented.
Protects the client's immediate right to refuse treatment and withdraw informed consent at any time.
2
Reassure the client that withdrawing from the study will not compromise their standard medical care.
The client's fear of abandonment is alleviated.
Advocacy requires addressing immediate psychological distress and supporting the client's autonomous decisions without coercion.
3
Notify the charge nurse and the healthcare provider of the client's decision.
The interdisciplinary team is made aware of the status change.
Facilitates the prompt transition back to the standard therapeutic regimen.
4
Document the client's exact statements and the refusal in the health record.
A formal legal and medical record is created.
Fulfills professional and legal standards of nursing practice after immediate clinical needs are met.

Anahtar Kavram

Client right to refuse treatment and withdraw informed consent without penalty
Soru 1453Soru →

A practical nurse (PN) on a medical-surgical unit is admitting a 67-year-old client for severe dehydration. The PN notes that the client has matted hair, soiled clothing, and multiple fading contusions on the upper arms. The client's adult child is present and aggressively attempts to answer all questions for the client. Which of the following actions should the PN take? (Select all that apply.)

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Document objective characteristics of the contusions, including size, color, and location.; Ensure the client is interviewed privately by asking the adult child to step out of the room.; Report the suspected abuse and neglect immediately to the nursing supervisor and adult protective services.

Cevap

The nurse should document objective findings of the injuries, arrange to interview the client privately without the family member present, and immediately report the suspected abuse to the appropriate authorities.
Appropriate nursing actions for suspected abuse involve ensuring client safety through private assessment, meticulously documenting objective physical evidence, and fulfilling the legal obligation of mandated reporting immediately based on reasonable suspicion.

Adım Adım Çözüm

1
Analyze the clinical findings and family dynamics.
The client displays signs of physical neglect (poor hygiene, dehydration) and physical abuse (fading contusions), while the caregiver exhibits controlling behavior.
Recognizing clustered indicators of abuse or neglect is the first step in initiating protective measures for vulnerable adults.
2
Determine immediate safety and assessment priorities.
The nurse must separate the client from the potential abuser to safely gather an accurate history.
Victims of abuse often fear retaliation and will rarely disclose trauma if the suspected abuser is present in the room.
3
Identify legal and documentation responsibilities.
The nurse must document all physical findings objectively and immediately report the suspicion.
Practical nurses are mandated reporters who must act on reasonable suspicion to ensure client safety, and objective documentation provides critical evidentiary support.

Anahtar Kavram

Prioritizing client safety, objective documentation, and immediate mandated reporting when elder abuse or neglect is suspected.
Soru 1454Soru →

The interprofessional healthcare team is coordinating care on a busy medical-surgical unit. To ensure safe and effective care, match each clinical task with the team member whose scope of practice or professional role is most appropriate for the assignment.

Soldaki öğeye tıklayın, sonra eşleşen sağdaki öğeye tıklayın

Öğeler

Completing the initial comprehensive admission assessment and establishing the nursing care plan.
Administering scheduled enteral tube feedings and reinforcing previous ostomy care teaching.
Assisting a stable, two-day postoperative client with morning hygiene and transferring to a chair.
Evaluating a client's specific mobility deficits and designing a customized progressive ambulation program.

Eşleşmeler

Cevabı ve açıklamayı göster

Cevap

Clinical tasks must be assigned according to the legal scope of practice: comprehensive assessments to the RN, routine medication and teaching reinforcement to the PN, basic care to the AP, and mobility evaluation to the PT.
Delegation and interprofessional collaboration require assigning tasks to team members based on their legal scope of practice and specialized training. The RN must handle initial assessments and care planning. The PN manages stable clients, performs routine procedures, and reinforces teaching. The AP handles basic care for stable clients. The PT evaluates and prescribes interventions for mobility and rehabilitation.

Adım Adım Çözüm

1
Identify the task requiring comprehensive assessment and initial care planning.
Matched with the Registered Nurse (RN).
Initial assessments and the creation of a care plan require advanced clinical judgment and fall exclusively within the RN scope of practice.
2
Identify the task involving enteral feedings and reinforcing teaching.
Matched with the Practical Nurse (PN).
The PN is qualified to administer enteral feedings for stable clients and can reinforce education that was originally provided by the RN.
3
Identify the task involving basic hygiene and transferring a stable client.
Matched with Assistive Personnel (AP).
Routine, standard care tasks with predictable outcomes can be safely delegated to the AP.
4
Identify the task involving evaluating mobility needs and designing an exercise program.
Matched with the Physical Therapist (PT).
Evaluating musculoskeletal function and prescribing physical rehabilitation programs are the specific expertise of the PT.

Anahtar Kavram

Client care assignments must be delegated based on the legal scope of practice, team member competency, and client stability.
Soru 1455Soru →

A vocational nurse is assigned to care for a resident in a long-term care facility who has been placed on droplet and contact precautions due to a confirmed adenovirus infection. The nurse is preparing to enter the room to assist with morning hygiene and feeding. Arrange the following steps for donning the required personal protective equipment (PPE) in the correct chronological sequence.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence for donning personal protective equipment is: gown, mask, goggles or face shield, and finally gloves.
According to standardized infection control guidelines, the proper sequence for donning personal protective equipment is to start with the gown, followed by the mask or respirator, then goggles or a face shield, and finally the gloves. This sequence ensures that all clothing and mucous membranes are protected systematically and allows the gloves to form a continuous barrier by overlapping the gown cuffs.

Adım Adım Çözüm

1
Put on the isolation gown.
The torso and arms are covered.
The gown is large and bulky, making it the most logical first step before applying facial protection.
2
Apply the surgical mask.
The airway and mucous membranes of the nose and mouth are protected.
The mask is placed before eye protection so the mask edges do not interfere with the placement of goggles or a face shield.
3
Don the eye protection.
The eyes are shielded from potential splashes or respiratory droplets.
Goggles or a face shield are placed over the mask to seal the facial area.
4
Put on clean gloves.
The hands are protected and the gown cuffs are secured.
Gloves are applied last to ensure they can be pulled over the gown sleeves for complete continuous coverage.

Anahtar Kavram

Donning sequence for Personal Protective Equipment (PPE)
Soru 1456Soru →

An 80-year-old client admitted with pneumonia becomes acutely restless, disoriented, and repeatedly attempts to pull out their peripheral intravenous (IV) catheter. Which action should the practical nurse (PN) take first?

Cevabı ve açıklamayı göster

Cevap: Conceal the intravenous insertion site by covering it with a long-sleeved gown or stockinette bandage.

Cevap

The practical nurse should first attempt to conceal the intravenous site by covering it, utilizing a least restrictive alternative before considering physical or chemical restraints.
The correct action is to conceal the intravenous site with a long-sleeved gown or stockinette bandage. This is a recognized, evidence-based, least restrictive alternative to physical restraints. According to safety protocols, nurses must always attempt and document less restrictive measures (such as reorientation, camouflage of tubes, or placing the client closer to the nurses' station) before resorting to restraints.

Adım Adım Çözüm

1
Assess the situation and identify the client's behavior as a risk for dislodging essential medical equipment.
The client is at risk for harming themselves by pulling out the IV line due to acute disorientation.
Accurate situational assessment is the first step in clinical decision-making and prioritizing patient safety.
2
Recognize the legal and ethical standard of care regarding restraints.
The nurse identifies that the least restrictive interventions must be implemented before resorting to any form of restraint.
Federal guidelines and nursing standards mandate the use of alternatives to physical restraints whenever possible to protect client rights and prevent restraint-related injuries.
3
Implement a non-restrictive alternative intervention.
The nurse covers the IV site with a stockinette or long sleeve to remove the visual trigger.
If the client cannot see the IV catheter, they are significantly less likely to pick at or pull it, effectively solving the safety issue without restricting their movement.

Anahtar Kavram

Least Restrictive Alternatives to Restraints
Soru 1457Soru →

A client is recovering from surgery on a medical-surgical unit. A person approaches the practical nurse (PN) at the nursing station, states they are the client's sibling, and requests an update on the client's condition. The PN verifies in the medical record that this individual is not listed on the client's authorized information release form. Which action by the PN is appropriate?

Cevabı ve açıklamayı göster

Cevap: Inform the sibling that no information can be provided without the client's explicit consent.

Cevap

Inform the sibling that no information can be provided without the client's explicit consent.
Under confidentiality regulations (such as HIPAA), nurses must protect the privacy of personal health information. Information can only be disclosed to individuals who are explicitly authorized by the client. Because the sibling is not on the approved list, the nurse must respectfully decline to share any information to maintain legal and ethical standards.

Adım Adım Çözüm

1
Identify the legal requirements regarding client confidentiality.
Protected health information (PHI) can only be shared with authorized individuals.
To protect the client's privacy and comply with regulations like HIPAA.
2
Verify the requester's authorization status.
The sibling is not listed on the client's authorized release form.
To determine if disclosure to this specific person is legally permissible.
3
Determine the appropriate nursing response.
Respectfully decline to provide any information regarding the client.
Sharing any client information with an unauthorized person, even a family member, is a breach of confidentiality.

Anahtar Kavram

Client Confidentiality and Authorized Disclosure
Tahmini Süre:45s
Soru 1458Soru →

A healthcare team in a rehabilitation unit is tasked with moving an immobile, bariatric client from a standard hospital bed to a reinforced cardiac chair using a ceiling-mounted mechanical lift. The client's medical history includes a right total hip arthroplasty (THA) performed 48 hours ago, a continuous intravenous (IV) infusion, and intermittent agitation. To ensure optimal biomechanics and equipment safety during this high-risk maneuver, which interventions must the assigned practical nurse (PN) implement? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Adjust the bed height to the practical nurse's waist level and lower the head of the bed as flat as the client tolerates before positioning the sling.; Maintain an abduction wedge between the client's lower extremities while attaching the uncrossed leg straps of the sling to the lift's spreader bar.; Verify that both the ceiling lift motor and the specific fabric sling being used have a safe working load (SWL) that exceeds the client's current documented weight.

Cevap

The correct actions are adjusting the bed to waist height while flattening it, maintaining an abduction wedge with uncrossed sling straps, and verifying the safe working load of all lift components.
Safe mechanical transfers for complex clients require a multi-faceted approach. Adjusting the bed height and angle optimizes caregiver biomechanics. Using uncrossed straps with an abduction wedge adheres to vital total hip arthroplasty (THA) precautions while using the equipment. Finally, verifying the safe working load (SWL) for both the motor and the sling is a mandatory safety check for bariatric clients to prevent equipment failure.

Adım Adım Çözüm

1
Evaluate the environmental and equipment safety requirements.
The nurse confirms the lift and sling weight capacities exceed the bariatric client's weight.
Preventing equipment failure is the first step in a safe mechanical transfer.
2
Prepare the environment for optimal ergonomics.
The bed is raised to waist level and the head of the bed is flattened.
This minimizes lumbar flexion and rotational strain on the nursing staff during the manual rolling phase of sling placement.
3
Integrate post-operative precautions into the equipment use.
An abduction wedge is maintained, the hip is not flexed past 90 degrees, and the sling straps remain uncrossed.
Standard lifting techniques must be modified to protect the recent total hip arthroplasty from dislocation.
4
Manage client behavior using least restrictive measures.
The nurse remains at the bedside to monitor the IV and redirect the agitated client without using restraints.
Nursing presence ensures continuous safety monitoring, prohibiting the delegation of this complex transfer.

Anahtar Kavram

Safe operation of mechanical lifting equipment requires integrating principles of body mechanics, surgical precautions, equipment load verification, and continuous nursing supervision.
Soru 1459Soru →

A practical nurse (PN) working in a subacute care facility observes a colleague exhibiting an unsteady gait, slurred speech, and an odor of alcohol while preparing oral medications. The colleague states, 'I just need to finish passing these medications.' Arrange the following actions the PN should take in the correct order of priority.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct priority sequence is to first intervene to prevent the administration of medications, then notify the nursing supervisor, followed by verifying that another nurse has assumed client care, and finally documenting the objective observations in an incident report.
The correct sequence follows standard nursing prioritization frameworks: immediate physiological safety of the client comes first (stopping the medication administration). Once safety is secured, the nurse must utilize the chain of command to manage the impaired staff member. Following this, the unit must ensure safe continuity of care (reassigning clients). Finally, detailed legal documentation is completed once the clinical situation is stabilized.

Adım Adım Çözüm

1
Assess the immediate risk to clients and intervene directly with the colleague.
The colleague is prevented from interacting with clients or administering potentially fatal incorrect medications.
According to Maslow's hierarchy of needs and basic safety principles, protecting clients from immediate physical harm is always the absolute highest priority.
2
Escalate the situation through the appropriate chain of command.
The nursing supervisor is alerted to the impaired nurse.
Facility management must be involved immediately to formally remove the impaired nurse from the premises and arrange for mandatory drug/alcohol screening.
3
Ensure continuity of care for the affected clients on the unit.
Medication administration and treatments are reassigned to a competent nurse.
Clients cannot be left without care; ensuring a safe handoff prevents legal liability for client abandonment.
4
Complete formal administrative documentation.
An objective, factual incident or variance report is filed.
Legal and ethical guidelines require non-judgmental documentation of the event for internal investigation and potential mandatory reporting to the State Board of Nursing.

Anahtar Kavram

Prioritization in Mandatory Reporting of Impaired Practice
Soru 1460Soru →

During the evening shift at a long-term care facility, a client with a history of Alzheimer's disease becomes increasingly restless and repeatedly attempts to walk out the main exit doors. A visiting family member asks the practical nurse to secure the client in a wheelchair with a lap belt to prevent elopement and potential injury. Which action should the practical nurse take first?

Cevabı ve açıklamayı göster

Cevap: Assess the client for unexpressed physical needs, such as pain or a full bladder.

Cevap

The practical nurse should first assess the client for unexpressed physical needs, such as pain, hunger, or a full bladder.
The correct action is to assess the client for unexpressed physical needs. Clients with dementia often lack the verbal ability to communicate pain, hunger, or the need to eliminate. Wandering and restlessness are frequently manifestations of these unmet needs. Assessing and addressing the root cause is the most effective and least restrictive way to prevent injury.

Adım Adım Çözüm

1
Analyze the client's behavior and the family's request.
The client is restless and attempting to elope; the family is requesting a physical restraint (lap belt).
Understanding the clinical situation is necessary to prioritize safety interventions.
2
Evaluate the appropriateness of using a restraint.
Applying a lap belt or giving a sedative before trying other measures violates the principle of using the least restrictive alternative.
Restraints (physical or chemical) are a last resort and can increase the risk of injury, agitation, and physical decline.
3
Determine the first line of intervention for new or increasing agitation in a client with dementia.
The nurse must act as a detective to identify unmet physiological needs.
Clients with cognitive impairment often express physical discomfort (such as pain, urinary retention, or infection) through behavioral changes like wandering or restlessness.

Anahtar Kavram

Accident, Error, and Injury Prevention: Restraint Alternatives
Tahmini Süre:1m 0s
ÖncekiSayfa 73 / 147Sonraki
Tüm alıştırma soruları — NCLEX-PN | Examkin