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Tüm alıştırma soruları

2933 soru

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Soru 1801Soru →

A practical nurse is preparing to administer cefdinir to a pediatric client who weighs 35.2 lb35.2\text{ lb} and has acute otitis media. The healthcare provider has prescribed 7 mg/kg7\text{ mg/kg} orally every 1212 hours. The medication available is cefdinir oral suspension labeled 125 mg/5 mL125\text{ mg}/5\text{ mL}. How many mL\text{mL} should the nurse administer per dose? (Record answer to the nearest tenth. Do not include units in answer.)

Cevabı ve açıklamayı göster

Cevap: 4.5

Cevap

4.5
To determine the correct dose, first convert the weight from pounds to kilograms (35.2÷2.2=16 kg35.2 \div 2.2 = 16\text{ kg}). Next, calculate the required dose by multiplying the weight by the prescribed amount (16 kg×7 mg/kg=112 mg16\text{ kg} \times 7\text{ mg/kg} = 112\text{ mg}). Then, calculate the liquid volume needed by dividing the desired dose by the available dose and multiplying by the available volume: (112 mg÷125 mg)×5 mL=4.48 mL(112\text{ mg} \div 125\text{ mg}) \times 5\text{ mL} = 4.48\text{ mL}. Finally, round to the nearest tenth as instructed, which results in 4.5 mL4.5\text{ mL}.

Adım Adım Çözüm

1
Convert the client's weight from pounds to kilograms.
35.2 lb÷2.2 lb/kg=16 kg35.2\text{ lb} \div 2.2\text{ lb/kg} = 16\text{ kg}
The medication dosage is prescribed based on the client's weight in kilograms, so the weight must be converted first.
2
Calculate the prescribed dose in milligrams.
16 kg×7 mg/kg=112 mg16\text{ kg} \times 7\text{ mg/kg} = 112\text{ mg}
This determines the exact amount of medication the client should receive for one dose.
3
Calculate the required volume in milliliters.
(112 mg÷125 mg)×5 mL=4.48 mL(112\text{ mg} \div 125\text{ mg}) \times 5\text{ mL} = 4.48\text{ mL}
Using the standard formula determines how much of the available liquid suspension is needed to deliver the prescribed dose.
4
Round the calculated volume to the nearest tenth.
4.5 mL4.5\text{ mL}
The question specifies recording the answer to the nearest tenth to ensure accurate measurement.

Anahtar Kavram

Weight-based pediatric dosage calculation and liquid medication volume conversion.
Soru 1802Soru →

While conducting morning rounds on the postpartum unit, a practical nurse observes a client crying softly in bed. The client's newborn was transferred to the neonatal intensive care unit for respiratory distress overnight. The client states, "I cannot stop thinking that this is my fault. I must have done something wrong during my pregnancy." Which of the following is the most therapeutic response by the nurse?

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Cevap: You are feeling responsible for your baby's transfer to the intensive care unit?

Cevap

The response utilizing reflection to address the client's feelings of responsibility.
The correct response utilizes the therapeutic technique of reflection. By restating the client's core message in a questioning, empathetic tone, the nurse validates the client's profound feelings of guilt and provides an open, non-judgmental space for the client to explore and verbalize their distress.

Adım Adım Çözüm

1
Analyze the client's statement and current situation to identify the primary emotional need.
The client is expressing deep guilt and anxiety regarding the newborn's unexpected transfer to the intensive care unit.
Identifying the core emotion is necessary to select a response that validates the client's feelings rather than dismissing them.
2
Evaluate the response choices to identify non-therapeutic communication blocks.
Three options utilize communication blocks: giving false reassurance, offering unwarranted advice, and asking an intimidating 'why' question.
Non-therapeutic techniques shut down dialogue, make the client feel defensive, or minimize their lived experience.
3
Identify the option that applies a validated therapeutic communication technique.
The option that restates the client's feeling of responsibility uses the therapeutic technique of reflection.
Reflection demonstrates active listening, validates the client's emotional state, and invites further exploration of their concerns without judgment.

Anahtar Kavram

Therapeutic Communication: Reflection and Active Listening
Soru 1803Soru →

A licensed practical nurse (LPN) is gathering supplies and reviewing a client's health record prior to administering routine morning medications. Which essential safety practices should the nurse implement? Select all that apply.

Geçerli olan tümünü seçin

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Cevap: Verify the client's identity using their full name and date of birth.; Confirm that the client does not have any documented medication allergies.; Compare the dispensed medication labels against the medication administration record (MAR).

Cevap

The correct practices are verifying the client's identity with two distinct identifiers, confirming allergy status, and comparing the medication labels to the medication administration record (MAR).
The correct practices adhere directly to the standard rights of medication administration. Checking two unique identifiers ensures the correct client receives the drug, reviewing allergies prevents adverse reactions, and comparing physical labels against the MAR ensures the correct medication and dose are given.

Adım Adım Çözüm

1
Review the fundamental rights of safe medication administration.
Identify that standard safety protocols require verifying the right client, the right medication, and the client's allergy status.
Adhering strictly to established safety guidelines is necessary to prevent medication errors.
2
Evaluate each provided option based on established safety protocols.
Select the practices that involve using two client identifiers, checking allergies, and comparing labels directly to the MAR.
These actions actively prevent errors, whereas using unlabeled containers or bypassing scanners introduces severe risk.

Anahtar Kavram

Rights of Medication Administration and Client Safety
Soru 1804Soru →

A practical nurse arrives at the home of an 82-year-old client to conduct a routine health promotion visit and administer a scheduled pneumococcal vaccine. The client's spouse expresses concern, stating that the client woke up this morning unable to identify the current year and appears uncharacteristically restless. The client's baseline cognition is fully intact. Based on these findings, which action should the practical nurse take first?

Cevabı ve açıklamayı göster

Cevap: Withhold the vaccine administration and immediately contact the supervising registered nurse or provider.

Cevap

The correct action is to withhold the vaccine and promptly notify the supervising registered nurse or healthcare provider about the acute cognitive change.
The correct response addresses the sudden onset of disorientation and restlessness, which are classic signs of delirium. Delirium in older adults often points to an acute underlying medical issue such as a systemic infection. Because vaccines should generally be deferred in the presence of moderate to severe acute illness, the priority is to withhold the immunization and immediately notify the healthcare provider or registered nurse for a thorough medical evaluation.

Adım Adım Çözüm

1
Analyze the client's current clinical presentation compared to their baseline.
The client has a sudden, new onset of disorientation and restlessness.
Identifying acute changes is the first step in determining the priority of care.
2
Determine the clinical significance of new-onset confusion in an older adult.
Acute confusion represents delirium, which is often a symptom of an underlying moderate to severe acute illness (such as an infection).
Understanding that delirium is a medical emergency prevents the nurse from dismissing the symptom as normal aging.
3
Evaluate the appropriateness of the scheduled health promotion intervention (vaccination).
Vaccines are generally contraindicated or should be deferred during a moderate or severe acute illness.
Administering a vaccine during an acute illness can complicate the clinical picture and increase the risk of adverse reactions.
4
Select the safest, most immediate action within the practical nurse's scope of practice.
The nurse must withhold the vaccine and escalate the finding to the supervising nurse or provider.
The practical nurse is responsible for gathering data and reporting significant abnormal findings to ensure patient safety.

Anahtar Kavram

Prioritization of Care and Immunization Precautions in Older Adults
Soru 1805Soru →

While collecting morning vital signs on a surgical unit, the practical nurse observes a client polishing a pair of hiking boots. The client, who is scheduled for a below-the-knee amputation the following day due to peripheral vascular disease, states, "I have to get these ready for my mountain trip next month." Which statement by the practical nurse is the most therapeutic response?

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Cevap: You have a major surgery scheduled for tomorrow. Tell me what you are thinking about the procedure.

Cevap

The correct answer acknowledges the impending reality of the surgery while using open-ended communication to encourage the client to express their underlying feelings.
The correct response gently presents reality (the surgery scheduled for tomorrow) and uses an open-ended statement ('Tell me what you are thinking') to invite the client to explore their underlying fear and anxiety. This therapeutic approach addresses the client's denial without being overly aggressive or confrontational.

Adım Adım Çözüm

1
Analyze the client's behavior and statement.
The client is preparing for a future hiking trip despite an impending amputation, which indicates the use of denial as a defense mechanism to cope with extreme anxiety and impending loss.
Recognizing the defense mechanism is essential to formulating an appropriate therapeutic response.
2
Recall the principles of therapeutic communication when a client is in denial.
The nurse should not play into the denial, nor should they harshly confront the client. The goal is to gently present reality and encourage the exploration of feelings.
Direct confrontation increases anxiety, while playing along reinforces maladaptive coping.
3
Evaluate each option for therapeutic versus non-therapeutic techniques.
Options asking 'why', offering false reassurance, or changing the subject are non-therapeutic communication blocks. Only the option that states the reality of the surgery and asks for the client's thoughts is therapeutic.
Identifying communication blocks eliminates incorrect distractors on the NCLEX.

Anahtar Kavram

Therapeutic Communication for Denial
Soru 1806Soru →

A client diagnosed with bipolar disorder is in the dayroom. The client is experiencing an acute manic episode, speaking loudly, and intruding on the personal space of peers who are trying to watch television. Which action should the practical nurse take first?

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Cevap: Suggest walking together to a quiet area and offer the client a high-protein snack.

Cevap

The practical nurse should redirect the client to a low-stimulus environment and offer a portable snack, as this addresses the acute symptoms of mania without confrontation.
Clients experiencing acute mania have poor impulse control, high distractibility, and elevated energy levels that can lead to exhaustion or altercations. The most effective initial action is to reduce environmental stimulation by gently redirecting the client to a quieter area. Offering a handheld, high-protein snack provides a constructive physical outlet and addresses the high risk of nutritional deficits common in manic episodes.

Adım Adım Çözüm

1
Analyze the client's current behavioral presentation within the milieu.
The client is exhibiting signs of acute mania, including hyperactivity, loud speech, and poor boundary control, which is disrupting other clients.
Accurately identifying the client's state dictates the priority of nursing interventions needed to maintain safety and therapeutic environment.
2
Determine the priority goal for a manic client exhibiting intrusive behavior.
The primary goals are to reduce environmental stimuli, protect peers from intrusion, and ensure the client's basic physiological needs are met.
Clients in acute mania are easily overstimulated, prone to physical exhaustion, and can inadvertently provoke altercations with others.
3
Select the least restrictive and most therapeutic nursing intervention.
Gently redirecting the client to a quiet area while providing a snack effectively de-escalates the situation and provides a safe outlet for their energy.
Physical or chemical restraints are a last resort. Furthermore, logical reasoning or probing questions are ineffective due to the client's impaired cognitive focus.

Anahtar Kavram

Crisis De-escalation and Milieu Management in Bipolar Disorder
Soru 1807Soru →

A practical nurse (PN) is reviewing the health history intake data for four pediatric clients who are scheduled to receive the live attenuated measles, mumps, and rubella (MMR) vaccine today. Which client's data indicates a contraindication that requires the PN to withhold the immunization and notify the healthcare provider?

Cevabı ve açıklamayı göster

Cevap: A 5-year-old client who is currently receiving systemic chemotherapy for acute lymphoblastic leukemia.

Cevap

The 5-year-old client who is currently receiving systemic chemotherapy for acute lymphoblastic leukemia.
Live attenuated vaccines, such as the MMR vaccine, contain a weakened form of the virus. In a healthy immune system, this safely stimulates an immune response. However, in clients who are severely immunocompromised, such as those receiving systemic chemotherapy for leukemia, the weakened virus can replicate uncontrollably and cause a severe, life-threatening infection. Recognizing this during data collection is critical, and the PN must withhold the vaccine and report the finding.

Adım Adım Çözüm

1
Identify the nature of the scheduled medication.
The MMR vaccine is a live attenuated virus vaccine.
Understanding the vaccine type is essential to identify specific contraindications.
2
Evaluate the clinical intake data of each client against known contraindications for live vaccines.
The client receiving systemic chemotherapy is severely immunocompromised.
Live vaccines carry a risk of causing severe, uncontrolled infection in clients with compromised immune systems.
3
Determine the appropriate nursing action based on the practical nurse's scope of practice.
The PN must recognize the contraindication, withhold the MMR vaccine for the immunocompromised client, and report this finding to the provider.
Administering a live vaccine to an immunocompromised client is a major safety risk that must be prevented.

Anahtar Kavram

Data collection for live vaccine contraindications
Soru 1808Soru →

A practical nurse (PN) is working in an outpatient endocrinology clinic. A client who received a therapeutic oral dose of radioactive iodine-131 one hour ago suddenly vomits on the floor in the main waiting area. Which of the following is the priority initial action for the PN to take?

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Cevap: Clear all other individuals from the immediate vicinity and physically block access to the spill.

Cevap

The priority initial action is to secure the area by clearing other individuals from the vicinity and restricting access to the spill.
When a hazardous radioactive spill occurs, the primary goal is to minimize radiation exposure based on the principles of time, distance, and shielding. Clearing the area and blocking access safely maximizes distance for bystanders and prevents the spread of contamination until the facility's Radiation Safety Officer can direct the specialized cleanup.

Adım Adım Çözüm

1
Identify the nature of the hazard.
The nurse recognizes that bodily fluids from a client recently treated with radioactive iodine-131 constitute a hazardous radioactive spill.
Accurate identification of the hazard dictates the required emergency response protocol.
2
Apply the principles of radiation safety.
The nurse prioritizes maximizing distance between the radioactive source and all bystanders.
Distance is the most immediate and effective way to reduce radiation exposure in a sudden spill.
3
Secure the contaminated environment.
The nurse evacuates the immediate area and blocks access to the hallway.
Securing the area prevents cross-contamination and unintended exposure while awaiting the facility's Radiation Safety Officer or specialized HazMat team.

Anahtar Kavram

In the event of a radioactive or hazardous material spill, the immediate priority is to ensure scene safety by maximizing distance from the source and restricting access to prevent exposure to others.
Tahmini Süre:1m 0s
Soru 1809Soru →

During morning rounds, the nurse evaluates the care plan for a client who is recovering from abdominal surgery and receiving a continuous nasogastric tube feeding. Which of the following basic care interventions should the nurse implement? (Select all that apply)

Geçerli olan tümünü seçin

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Cevap: Elevate the head of the bed to at least 30 degrees.; Provide oral hygiene with a soft toothbrush or swabs every 2 to 4 hours.; Assess the skin around the nostril where the tube is secured for any signs of redness.

Cevap

The correct actions include elevating the head of the bed to at least 30 degrees, providing oral hygiene every 2 to 4 hours, and assessing the skin around the nostril for redness.
Elevating the head of the bed to at least 30 degrees uses gravity to prevent regurgitation and aspiration of the feeding formula. Because clients with nasogastric tubes often breathe through their mouths, providing frequent oral hygiene is essential to prevent drying and cracking of the mucous membranes. Assessing the skin around the nares ensures that the medical device is not causing localized pressure injuries, maintaining overall skin integrity.

Adım Adım Çözüm

1
Identify the primary safety and comfort risks associated with a continuous nasogastric tube feeding.
The main risks are pulmonary aspiration, mucosal dryness, and skin breakdown around the insertion site.
Understanding these specific risks directly guides the selection of appropriate basic care interventions.
2
Evaluate each care option against safety standards and the practical nursing scope of practice.
Elevating the head of the bed, providing regular oral care, and monitoring skin integrity are safe, within-scope actions. Laying the client flat, altering feeding rates independently, and ignoring borderline vitals are unsafe or out of scope.
Ensuring that interventions promote patient safety and remain within legal boundaries is essential for proper nursing care.

Anahtar Kavram

Basic care and comfort for clients with enteral tubes involves preventing aspiration, maintaining skin and mucosal integrity, and practicing within the legal scope.
Tahmini Süre:1m 30s
Soru 1810Soru →

A client admitted to an orthopedic unit for a fractured tibia is exhibiting signs of escalating agitation. The client is pacing the room, speaking loudly, and aggressively pulling at their peripheral intravenous (IV) catheter. Arrange the following nursing interventions in the order they should be implemented, from the least restrictive to the most restrictive.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence follows the least restrictive alternative doctrine: attempt verbal de-escalation first, followed by decreasing environmental stimuli, offering voluntary oral medication, administering an intramuscular chemical restraint, and finally applying physical restraints as an absolute last resort.
The principle of least restrictive intervention mandates that nurses must exhaust all verbal, environmental, and voluntary pharmacological options before resorting to involuntary chemical or physical restraints. This sequential approach ensures client safety while preserving autonomy, dignity, and legal rights.

Adım Adım Çözüm

1
Assess the client's behavioral state and immediate safety risks.
Identifies escalating agitation without an immediate, life-threatening emergency.
Establishes a baseline to determine the appropriate starting point on the intervention hierarchy.
2
Implement non-pharmacological, non-physical interventions.
Uses verbal de-escalation and environmental modification.
Adheres to the legal and ethical requirement to exhaust the least restrictive, non-invasive measures first.
3
Utilize pharmacological interventions starting with the least invasive route.
Offers oral medications first, followed by IM medications only if necessary.
Chemical interventions are considered more restrictive than verbal or environmental ones; the oral route is less invasive than the intramuscular route.
4
Implement physical restraints only if all previous steps fail.
Applies soft extremity restraints to protect the IV line.
Physical restraints carry the highest risk of injury, loss of dignity, and psychological trauma, making them the ultimate last resort.

Anahtar Kavram

Least Restrictive Intervention Hierarchy
Tahmini Süre:1m 0s
Soru 1811Soru →

An adolescent diagnosed with type 1 diabetes mellitus is being seen at an outpatient endocrine center for a routine weight and glycemic check. While discussing recent dietary habits, the client quietly reveals intentionally omitting mealtime insulin doses over the past month to 'stay thin for the upcoming track season.' The client's current capillary blood glucose is 312 mg/dL312\text{ mg/dL}. Which action represents the most appropriate clinical judgment for the practical nurse?

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Cevap: Inform the client that insulin omission poses an immediate danger of ketoacidosis and promptly notify the supervising registered nurse.

Cevap

Inform the client that insulin omission poses an immediate danger of ketoacidosis and promptly notify the supervising registered nurse.
The correct action directly addresses the immediate life-threatening physiological risk (hyperglycemia and potential diabetic ketoacidosis) through patient education, while safely operating within the PN scope by immediately escalating the critical finding to the registered nurse.

Adım Adım Çözüm

1
Identify the high-risk behavior being described.
The client is intentionally omitting insulin for weight control, a dangerous practice sometimes referred to as diabulimia, leading to severe hyperglycemia (312 mg/dL312\text{ mg/dL}).
Recognizing the specific behavior is essential to understanding the immediate physiological threat of diabetic ketoacidosis.
2
Evaluate communication and boundary guidelines.
The nurse must avoid making secret pacts about dangerous behaviors and avoid non-therapeutic communication blocks like asking 'why'.
Maintaining professional boundaries and open, non-judgmental communication ensures the client receives necessary life-saving care without alienation.
3
Determine the practical nurse's priority responsibility.
The nurse must address the acute safety risk via immediate patient education and communicate the findings to the supervising provider or registered nurse.
High-risk behaviors that cause immediate medical instability require collaborative intervention and comprehensive assessment beyond the independent scope of the PN.

Anahtar Kavram

Identifying and managing high-risk behaviors (insulin omission) within the practical nursing scope of practice.
Soru 1812Soru →

An older adult client with a history of mild dementia is receiving intravenous antibiotics for a severe lower respiratory tract infection. The client suddenly exhibits profound restlessness, fails to recognize familiar staff, and attempts to pull out the intravenous (IV) line while shouting, "Get away from me! You are trying to capture me!" Which action should the practical nurse (PN) take first?

Cevabı ve açıklamayı göster

Cevap: Maintain a calm presence at the bedside, gently redirect the client's hands away from the intravenous line, and use simple statements to present reality.

Cevap

Maintain a calm presence at the bedside, gently redirect the client's hands away from the intravenous line, and use simple statements to present reality.
The priority action is to ensure the client's immediate physical safety while employing the least restrictive intervention possible. Remaining at the bedside and gently redirecting the client's hands protects the intravenous line without the use of physical restraints. Furthermore, using a calm voice and simple statements helps to present reality and de-escalate the acute anxiety and perceptual disturbances associated with delirium.

Adım Adım Çözüm

1
Analyze the client's clinical presentation and medical history.
The client has a history of mild dementia but is experiencing a sudden, severe change in cognition and behavior while being treated for an infection.
Sudden onset of confusion and agitation in an older adult with an infection is a hallmark sign of acute delirium, not a typical progression of baseline dementia.
2
Identify the most immediate threat to the client.
The client is actively attempting to pull out their intravenous line, which poses an immediate safety risk and threatens their medical treatment.
Prioritization in nursing care always begins with immediate physical safety and the preservation of critical medical interventions.
3
Select the nursing intervention that addresses the threat using the least restrictive method.
The PN chooses to stay at the bedside, gently guide the client's hands away, and verbally reorient them.
Safe, ethical practice mandates utilizing the least restrictive environment. Physical redirection and therapeutic presence must be attempted before advancing to chemical or physical restraints.

Anahtar Kavram

Prioritizing least restrictive safety measures and recognizing acute delirium in older adults
Tahmini Süre:1m 15s
Soru 1813Soru →

A client who practices Tibetan Buddhism is receiving end-of-life care on a medical oncology unit. The client is entering the active phase of dying. Which actions are appropriate for the LPN/LVN to implement to support the client's spiritual and cultural needs? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Facilitate a quiet, peaceful environment by minimizing unnecessary alarms to allow for meditation and chanting; Minimize physical manipulation of the client's body during and immediately following death; Offer to contact the facility chaplain to arrange a visit from a Buddhist monk or spiritual leader

Cevap

The appropriate nursing actions include facilitating a quiet environment, minimizing physical manipulation of the body, and offering to contact a spiritual leader.
Appropriate end-of-life care for a Buddhist client includes maintaining a peaceful environment for meditation or chanting, minimizing physical contact with the body immediately after death to allow the spirit to transition, and facilitating visits from spiritual leaders like a monk or lama.

Adım Adım Çözüm

1
Analyze the client's cultural and spiritual background.
The client practices Tibetan Buddhism and is in the active phase of dying.
Understanding the specific spiritual tradition is necessary to provide culturally competent end-of-life care.
2
Evaluate each nursing action against Buddhist end-of-life practices.
Buddhist practices prioritize a peaceful death, chanting, minimal body disturbance after death, and often involve vegetarianism.
Ensures the selected interventions align with the client's faith and avoid cultural insensitivity.
3
Assess each action against the LPN/LVN scope of practice and therapeutic communication principles.
Obtaining consent and giving unwanted advice fall outside the LPN/LVN scope or violate therapeutic communication standards.
The LPN/LVN must only perform actions within their legal boundaries and use therapeutic techniques to support the family.

Anahtar Kavram

Culturally competent end-of-life care for Buddhist clients and LPN/LVN scope of practice.
Soru 1814Soru →

A client receiving hospice care at home begins to exhibit loud, rattling respirations. The client's family members are crying and express concern that the client is choking. In which order should the practical nurse implement the following actions? Arrange the steps from first (highest priority) to last.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence is to first reposition the client, then administer the anticholinergic medication, gently clear oral secretions, provide oral hygiene, and finally educate the family.
When managing terminal secretions (often referred to as a 'death rattle'), the nurse must prioritize interventions from least invasive physical measures to pharmacological treatments, followed by hygiene and psychosocial support. Repositioning uses gravity to immediately clear the airway without causing distress. Administering an anticholinergic medication treats the root cause by drying up ongoing secretions. Gentle oral clearing removes already pooled fluids, followed by oral care for mucosal comfort. Once the client's physical comfort is stabilized, the nurse must educate the distressed family to reduce their anxiety, as the sound is often more distressing to loved ones than to the dying client.

Adım Adım Çözüm

1
Reposition the client into a side-lying position with the head of the bed elevated.
Secretions drain passively via gravity.
Airway patency must be addressed first using the least invasive, fastest non-pharmacological method.
2
Administer the prescribed as-needed anticholinergic medication.
The production of new respiratory secretions decreases.
Pharmacological intervention targets the underlying physiological cause of the 'death rattle'.
3
Perform gentle, shallow clearing of pooled secretions from the oral cavity.
Existing secretions that are causing the rattling sound are removed.
Gentle clearance removes the immediate physical blockage without stimulating the gag reflex or causing the distress of deep suctioning.
4
Provide oral hygiene and apply a water-soluble lubricant to the lips.
The client's mucous membranes remain moist and intact.
Oral care promotes dignity and physical comfort after the airway has been stabilized.
5
Explain to the family that the noisy breathing is a natural part of the dying process and does not cause pain.
The family's anxiety and fear are reduced.
Once the client's physical needs are met, the nurse must address the family's psychosocial distress through therapeutic education.

Anahtar Kavram

Prioritization of Terminal Secretions (Death Rattle) Management
Soru 1815Soru →

An LPN/LVN is conducting a morning assessment on a client with type 1 diabetes mellitus. The medication administration record indicates scheduled doses of subcutaneous NPH and regular insulin are due. The client informs the nurse, 'I am observing a holy month and will strictly abstain from all food and fluids from dawn until sunset. However, you may proceed with the injection if it is required for my treatment.' Which action is the priority for the nurse?

Cevabı ve açıklamayı göster

Cevap: Hold the prescribed insulin medications and immediately report the client's fasting intentions to the registered nurse.

Cevap

Hold the prescribed insulin medications and immediately report the client's fasting intentions to the registered nurse.
The priority action is to prevent life-threatening hypoglycemia while respecting the client's spiritual practices. Because NPH and regular insulin require subsequent caloric intake to prevent dangerous drops in blood glucose, administering them to a fasting client would cause profound harm, even if the client consents to the injection. The LPN/LVN must recognize this physiological risk, withhold the medication, and collaborate with the registered nurse or provider to adjust the treatment schedule safely.

Adım Adım Çözüm

1
Analyze the physiological effect of the scheduled medications in the context of the client's fasting state.
Recognize that administering NPH and regular insulin without subsequent caloric intake will lead to severe, potentially life-threatening hypoglycemia.
Patient safety and physiological integrity are always the highest priorities in nursing care.
2
Evaluate the client's statement regarding their religious fasting.
Acknowledge the client's right to maintain their spiritual practices while hospitalized, even if they mistakenly consent to a dangerous intervention.
Culturally competent care requires respecting and accommodating religious dietary restrictions without imposing personal or medical judgments.
3
Determine the appropriate intervention within the LPN/LVN scope of practice.
Withhold the insulin and notify the supervising registered nurse or provider immediately.
The LPN/LVN cannot independently adjust medication dosages or schedules; collaboration is required to safely modify the treatment plan (e.g., shifting insulin administration to after sunset).

Anahtar Kavram

Balancing physiological safety with cultural/spiritual accommodations within the LPN/LVN scope of practice.
Soru 1816Soru →

A 76-year-old client with a history of congestive heart failure and osteoarthritis attends an adult day health program. The client's baseline cognitive status is intact, and they are typically highly conversational. Today, the practical nurse (PN) notes the client is uncharacteristically withdrawn, profoundly lethargic, and experienced an unassisted fall while attempting to ambulate to the restroom. Which action should the PN take first based on an understanding of the aging process?

Cevabı ve açıklamayı göster

Cevap: Evaluate oxygen saturation and vital signs to investigate for an underlying acute systemic illness.

Cevap

The practical nurse should prioritize evaluating oxygen saturation and vital signs to investigate for an underlying acute systemic illness.
In the older adult population, acute illnesses (such as pneumonia, urinary tract infections, or myocardial infarctions) frequently present atypically. Instead of classic symptoms, these clients may exhibit sudden functional decline, lethargy, acute confusion, or unexplained falls. By immediately evaluating vital signs and oxygen saturation, the practical nurse correctly recognizes this atypical presentation and prioritizes a critical physiological assessment to identify the underlying cause.

Adım Adım Çözüm

1
Analyze the client's clinical presentation against their known baseline.
The client is experiencing a sudden, acute change from an intact, conversational baseline to being profoundly lethargic and suffering a fall.
Identifying acute deviations from a client's baseline is the first step in recognizing a potential medical emergency.
2
Apply knowledge of the aging process to interpret the symptoms.
Recognize that older adults frequently exhibit atypical presentations of illnesses. Instead of a fever or localized pain, an infection, hypoxic event, or cardiac issue may present simply as acute confusion, lethargy, or sudden falls.
Failure to recognize atypical presentation can lead to missed diagnoses and delayed treatment in the geriatric population.
3
Determine the highest priority nursing intervention.
Gathering objective physiological data (vital signs and oxygen saturation) is the immediate priority to identify potential airway, breathing, or circulation compromises before any other interventions are implemented.
The nursing process dictates that assessment must occur prior to intervention, and ABC priorities must govern the sequence of care.

Anahtar Kavram

Atypical Presentation of Illness in Older Adults
Soru 1817Soru →

During morning rounds, a client's laboratory report indicates a serum potassium level of 3.1 mEq/L3.1\text{ mEq/L}. The client's vital signs include a blood pressure of 118/76 mmHg118/76\text{ mmHg} and an apical pulse of 56 beats/min56\text{ beats/min}. The medication administration record shows a scheduled dose of oral digoxin 0.25 mg0.25\text{ mg}. Based on these findings, which of the following actions is most appropriate for the practical nurse to perform?

Cevabı ve açıklamayı göster

Cevap: Withhold the medication and immediately report the clinical findings to the registered nurse.

Cevap

Withhold the medication and immediately report the clinical findings to the registered nurse.
The client is exhibiting bradycardia (an apical pulse less than 60 beats/min60\text{ beats/min}) and hypokalemia (a serum potassium level less than 3.5 mEq/L3.5\text{ mEq/L}). Both conditions are contraindications or high-risk factors for administering digoxin, as low potassium significantly increases the risk of digoxin toxicity. The appropriate action within the practical nurse scope of practice is to withhold the medication and escalate these critical findings to the registered nurse or healthcare provider.

Adım Adım Çözüm

1
Evaluate the client's vital signs and laboratory values against established normal parameters.
The apical pulse of 56 beats/min56\text{ beats/min} is below the normal threshold (60 beats/min60\text{ beats/min}) for digoxin administration, and the potassium level of 3.1 mEq/L3.1\text{ mEq/L} indicates hypokalemia.
Safe medication administration requires ensuring that the client's current physiological status does not contraindicate the ordered pharmacological therapy.
2
Determine the relationship between the abnormal clinical findings and the scheduled medication.
Hypokalemia significantly increases the risk of digoxin toxicity, making the administration of the medication unsafe in the presence of a low heart rate.
Understanding drug-laboratory interactions is essential to prevent severe adverse pharmacological events.
3
Identify the correct nursing intervention within the practical nurse's scope of practice.
The medication must be withheld and the abnormal clinical findings promptly reported to the registered nurse for further medical evaluation.
Practical nurses must escalate critical abnormal findings and withhold potentially harmful medications to ensure client safety.

Anahtar Kavram

Pharmacological therapies require the practical nurse to evaluate pertinent laboratory values and vital signs prior to administration, withholding the medication and notifying the registered nurse when findings suggest a heightened risk for adverse effects or toxicity.
Soru 1818Soru →

Following an intentional medication overdose, a client is transferred from the emergency department to the inpatient behavioral health facility. The primary healthcare provider prescribes continuous one-to-one suicide precautions. Which interventions should the practical nurse (PN) incorporate into the client's care? (Select all that apply.)

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Inventory the client's personal belongings and confiscate items such as belts, shoelaces, and glass objects.; Maintain an arm's-length distance and uninterrupted visual contact with the client, including during toileting and showering.; Serve meals using exclusively paper or plastic service items and verify that all utensils are returned when removing the tray.

Cevap

The appropriate interventions for a client on continuous one-to-one suicide precautions include inventorying belongings to remove hazards, maintaining uninterrupted visual contact (even during hygiene), and ensuring meal trays have safe utensils that are counted upon return.
For a client on strict one-to-one suicide precautions, the highest priority is maintaining a safe environment and preventing self-harm. This requires continuous, uninterrupted visual observation at all times (including during hygiene), removing any potentially hazardous personal belongings, and strictly controlling and counting safe meal utensils.

Adım Adım Çözüm

1
Analyze the client's clinical situation and the provider's prescription.
The client has a recent history of an intentional overdose and requires strict one-to-one suicide precautions.
Identifying the prescribed safety level is essential to determine the necessary stringency of the nursing interventions.
2
Evaluate each proposed action against environmental safety protocols for high-risk psychiatric clients.
Removing hazardous belongings, observing the client continuously without exception, and controlling meal utensils directly support the goal of preventing self-harm.
Environmental safety and constant monitoring are the highest priorities for a actively suicidal client.
3
Identify and eliminate actions that violate safety requirements or therapeutic communication standards.
Asking 'why' questions, offering false reassurance, and prioritizing privacy over direct observation are incorrect actions.
Non-therapeutic communication hinders trust and rapport, while compromising visual observation places the client at immediate risk of fatal harm.

Anahtar Kavram

Suicide Precautions and Environmental Safety
Soru 1819Soru →

A practical nurse is preparing to administer prescribed ear drops to an adult client. Arrange the steps of this procedure in the correct chronological order.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence is: perform hand hygiene and verify identity; position the client on their side; pull the pinna up and back; instill the drops; and instruct the client to remain in position.
The correct sequence ensures medication safety, proper anatomical alignment, and effective drug absorption. Hand hygiene and patient identification are universally the first steps. Positioning the client prepares the treatment area. Because the client is an adult, the pinna must be pulled up and back to straighten the ear canal. Instilling the medication without touching the ear maintains sterility, and having the client remain in position ensures the drops effectively reach their target.

Adım Adım Çözüm

1
Perform hand hygiene and verify the client using two identifiers.
The nurse confirms the right client and maintains infection control.
This is the mandatory foundational safety check for all nursing interventions.
2
Place the client in a lateral position with the affected ear exposed.
The ear canal is positioned to receive the medication.
Gravity facilitates the flow of the liquid medication into the ear.
3
Grasp the pinna and pull it up and back.
The adult ear canal is straightened.
Straightening the canal ensures the medication reaches the tympanic membrane rather than resting in the outer curvature of the canal.
4
Squeeze the dropper to instill the correct number of drops without making physical contact.
Medication is administered safely and cleanly.
Hovering the dropper without touching the skin or ear canal prevents microbial contamination.
5
Ask the client to remain still for approximately 2 to 3 minutes.
The medication is fully absorbed and dispersed.
It prevents the drops from rolling out of the ear canal prematurely.

Anahtar Kavram

Safe and effective administration of otic medications in adult clients
Tahmini Süre:1m 0s
Soru 1820Soru →

An adult client is admitted to the surgical unit the evening before a scheduled total abdominal hysterectomy. The practical nurse observes the client pacing the hallway. The client suddenly stops and states, 'My sister had this exact procedure two years ago and ended up with a life-threatening infection. I should just get dressed and leave right now.' Which response by the practical nurse is the most therapeutic?

Cevabı ve açıklamayı göster

Cevap: It sounds as though you are very frightened about the possibility of developing a severe complication from your surgery.

Cevap

The most therapeutic response is the one that reflects and validates the client's underlying emotions: 'It sounds as though you are very frightened about the possibility of developing a severe complication from your surgery.'
The correct answer utilizes the therapeutic technique of reflection. By stating, 'It sounds as though you are very frightened...', the nurse accurately identifies the client's underlying emotion (fear) and content (surgical complication). This validates the client's feelings, demonstrates empathy, and encourages the client to verbalize their anxiety further, which is the necessary first step in de-escalating the situation.

Adım Adım Çözüm

1
Analyze the client's statement and nonverbal behavior to identify the core emotion.
The pacing, loud speech, and threat to leave indicate severe acute anxiety and fear related to the upcoming surgery.
Accurate assessment of the client's emotional state is required before selecting a therapeutic communication technique.
2
Evaluate the options for therapeutic versus non-therapeutic communication techniques.
Defending the hospital, shifting focus to the sister, and challenging the client's logic are non-therapeutic blocks. Reflecting the client's fear is a therapeutic technique.
Therapeutic communication should focus on the client's current feelings, validate their concerns, and encourage further expression without judgment.
3
Select the response that best applies therapeutic reflection.
The option acknowledging the client is 'very frightened' directly addresses the emotional context of the situation.
Reflection demonstrates empathy, helps the client feel heard, and opens the door to de-escalation.

Anahtar Kavram

Therapeutic Communication - Reflecting and Validating Client Fears
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Tüm alıştırma soruları — NCLEX-PN | Examkin