Examkin

Physiological Integrity

1313 soru

Tüm türler1,313Çoktan seçmeli672Çoklu seçim289Sayısal68Sıralama284
Soru 61Soru →

While providing care on a busy medical-surgical unit, a practical nurse performs several actions related to medication administration. Which of the following actions demonstrate adherence to safe pharmacological principles and the practical nurse scope of practice? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Declining a provider's order to administer a stat dose of intravenous push furosemide to a client with heart failure.; Withholding a scheduled oral antihypertensive medication when the client's systolic blood pressure is below the prescribed hold parameter.

Cevap

The safe and appropriate actions are declining to administer an intravenous push medication and withholding an antihypertensive medication when the blood pressure is below the hold parameter.
Practical nurses promote client safety and practice within their legal scope when they decline to perform tasks requiring RN-level certification (such as administering intravenous push medications) and when they appropriately withhold scheduled medications based on objective assessment data that falls outside safe or prescribed parameters.

Adım Adım Çözüm

1
Evaluate each action against the practical nurse scope of practice.
Declining intravenous push medications is correct as this route requires RN-level monitoring and assessment. Formulating initial teaching plans is incorrect as it is strictly an RN responsibility.
The practical nurse must understand the legal boundaries of their license and appropriately decline tasks outside their scope to ensure client safety.
2
Evaluate the remaining actions against fundamental medication administration safety principles.
Withholding medication for out-of-range vital signs is correct. Bypassing barcode scanners, estimating pediatric weights, and giving live vaccines to immunosuppressed clients are all severe safety violations.
Strict adherence to the rights of medication administration, precise dosage calculations, and recognizing drug contraindications prevents severe adverse events.

Anahtar Kavram

Safe Pharmacological Practices and Practical Nurse Scope of Practice
Soru 62Soru →

During a pediatric clinic follow-up, a practical nurse is collecting data from the caregiver of a child who weighs 32 kg (70.5 lb). The child has an active prescription for oral ibuprofen suspension 10 mg/kg/dose every 6 hours as needed for joint inflammation. The caregiver provides the medication bottle, which is labeled 'ibuprofen 100 mg/5 mL,' and states, 'I gave a 32 mL dose about 45 minutes ago because the joints looked very swollen.' Which action should the practical nurse take first?

Cevabı ve açıklamayı göster

Cevap: Immediately notify the supervising registered nurse and the healthcare provider regarding the medication overdose.

Cevap

The correct action is to immediately notify the supervising registered nurse and the healthcare provider regarding the medication overdose.
The correct action is to immediately notify the supervising registered nurse and healthcare provider. The child was prescribed 10 mg/kg10 \text{ mg/kg}, which equates to 320 mg320 \text{ mg} for a 32 kg32 \text{ kg} child. Using the concentration of 100 mg/5 mL100 \text{ mg}/5 \text{ mL} (20 mg/mL20 \text{ mg/mL}), the correct volume is 16 mL16 \text{ mL}. The caregiver administered 32 mL32 \text{ mL} (640 mg640 \text{ mg}), which is exactly double the correct dose. This significant medication error requires urgent escalation for potential toxicity management, which is the priority over routine assessment, and aligns perfectly with the practical nurse's scope to report critical findings.

Adım Adım Çözüm

1
Calculate the prescribed target dose in milligrams based on the child's weight.
32 kg×10 mg/kg=320 mg32 \text{ kg} \times 10 \text{ mg/kg} = 320 \text{ mg}.
To determine exactly how much active medication the child is supposed to receive per dose.
2
Calculate the correct volume in milliliters based on the supplied concentration.
The concentration is 100 mg/5 mL100 \text{ mg} / 5 \text{ mL}, which simplifies to 20 mg/mL20 \text{ mg/mL}. Volume needed = 320 mg÷20 mg/mL=16 mL320 \text{ mg} \div 20 \text{ mg/mL} = 16 \text{ mL}.
To compare the prescribed volume against what the caregiver actually administered.
3
Evaluate the caregiver's administered dose.
The caregiver administered 32 mL32 \text{ mL}. Using the concentration of 20 mg/mL20 \text{ mg/mL}, 32 mL×20 mg/mL=640 mg32 \text{ mL} \times 20 \text{ mg/mL} = 640 \text{ mg}.
To determine the clinical significance of the caregiver's action.
4
Determine the priority clinical action based on the LPN/LVN scope of practice.
Recognize that 640 mg640 \text{ mg} is exactly double the prescribed 320 mg320 \text{ mg} dose. This constitutes a severe medication error and overdose, requiring immediate escalation to the RN and provider.
Practical nurses must report critical safety events and cannot independently order or perform advanced interventions (like IV push reversals) for overdoses.

Anahtar Kavram

The practical nurse must accurately calculate weight-based dosages to identify medication errors made by caregivers and immediately escalate emergent toxicity risks to the supervising RN, adhering to the established scope of practice.
Tahmini Süre:2m 0s
Soru 63Soru →

A practical nurse is preparing to administer scheduled morning medications to an alert and oriented client. The unit's electronic barcode scanner is temporarily out of service. Which of the following actions should the practical nurse take to properly verify the client's identity?

Cevabı ve açıklamayı göster

Cevap: Ask the client to state their full name and date of birth while checking their identification band.

Cevap

Ask the client to state their full name and date of birth while checking their identification band.
When an electronic barcode scanner is malfunctioning, the practical nurse is legally and ethically bound to manually execute the 'Right Client' check. This requires asking the alert client to actively state two unique identifiers—most commonly their full name and date of birth—and comparing this information against both the client's physical identification band and the medication administration record.

Adım Adım Çözüm

1
Identify the clinical challenge presented in the scenario.
The nurse needs to safely identify the client for medication administration without the use of an electronic barcode scanner.
Technology failures require nurses to fall back on manual safety standards to prevent errors.
2
Recall the medication administration standard for client identification.
The standard requires using two distinct, acceptable identifiers (e.g., full name, date of birth, medical record number).
Relying on a single identifier or inappropriate identifiers increases the risk of a medication error.
3
Evaluate the options to find the one that meets the standard.
Asking the client to actively state their full name and date of birth while cross-referencing their ID band is the only option that utilizes two proper identifiers.
This guarantees the right medication is given to the right client.

Anahtar Kavram

Six Rights of Medication Administration: Right Client Verification
Tahmini Süre:45s
Soru 64Soru →

A client is on bed rest following a left-sided renal biopsy. The client verbalizes feeling lightheaded and reports a dull ache radiating to the left flank. Assessment reveals a pulse of 115 beats per minute and a blood pressure of 98/60 mm Hg. The most recent laboratory results indicate a 4% drop in hematocrit from the pre-procedure baseline. Which intervention should the practical nurse prioritize?

Cevabı ve açıklamayı göster

Cevap: Notify the charge nurse immediately regarding the current assessment data.

Cevap

Notify the charge nurse immediately regarding the current assessment data.
The correct action is to immediately report the findings to the charge nurse or provider. The combination of flank pain, lightheadedness, tachycardia, a lower-end blood pressure, and a drop in hematocrit strongly suggests internal bleeding (retroperitoneal hemorrhage) following the renal biopsy. Prompt escalation is necessary to reduce the risk of hypovolemic shock and ensure timely medical intervention.

Adım Adım Çözüm

1
Analyze the client's clinical cues, including flank pain, lightheadedness, a heart rate of 115/min, blood pressure of 98/60 mm Hg, and a dropping hematocrit.
These findings collectively indicate a high risk for retroperitoneal hemorrhage, a severe complication of a renal biopsy.
Recognizing the transition from stable to unstable is essential for reducing client risk.
2
Determine the appropriate scope of practice for the practical nurse in this emergency scenario.
The nurse must immediately escalate the findings to the charge nurse or healthcare provider rather than independently initiating advanced medical interventions or dismissing the signs.
Timely communication ensures the client receives rapid medical evaluation and necessary treatments to prevent hypovolemic shock.

Anahtar Kavram

Recognizing and escalating signs of post-procedure hemorrhage
Soru 65Soru →

A practical nurse (PN) is evaluating a client who is 6 hours postoperative following a total thyroidectomy. The client's current vital signs are: heart rate 114 beats/min, blood pressure 104/58 mm Hg, respiratory rate 18 breaths/min, and temperature 99.2°F (37.3°C). The morning laboratory results reveal a serum calcium level of 7.4 mg/dL (1.85 mmol/L). Which of the following actions should the PN take? (Select all that apply.)

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Notify the registered nurse (RN) immediately regarding the client's vital signs and laboratory results.; Assess the client for the presence of Chvostek's sign or perioral numbness.; Ensure that emergency suction equipment and a tracheostomy tray are at the bedside.

Cevap

The correct actions include notifying the RN immediately, assessing the client for signs of hypocalcemia (such as Chvostek's sign or numbness), and ensuring emergency airway equipment is kept at the bedside.
Following a total thyroidectomy, clients face immediate risks of hemorrhage, airway compromise, and hypocalcemia. The client's tachycardia and borderline hypotension may indicate early shock. The calcium level of 7.4 mg/dL is critically low. To reduce risk potential safely, the PN must escalate these findings to the RN immediately, assess for symptoms of tetany (such as Chvostek's sign), and ensure emergency airway equipment is physically present at the bedside.

Adım Adım Çözüm

1
Analyze the client's postoperative status and identify surgical risks.
The client is 6 hours post-thyroidectomy, placing them at high risk for hemorrhage, airway obstruction, and hypocalcemia (due to potential parathyroid gland removal).
Understanding the specific risks of the procedure guides focused data collection and safety preparation.
2
Evaluate the current assessment data against normal parameters.
The heart rate of 114 beats/min and blood pressure of 104/58 mm Hg suggest compensatory mechanisms for hypovolemia. The serum calcium level of 7.4 mg/dL is critically below the normal range (9.0-10.5 mg/dL).
Recognizing subtle signs of shock and identifying critical lab values are essential components of risk potential reduction.
3
Determine appropriate interventions within the PN scope of practice.
The PN must secure the bedside with emergency equipment, assess for tetany, and escalate the findings to the RN. The PN must avoid RN-level tasks, such as administering IV push medications.
Operating strictly within legal and professional scope ensures safe, effective, and coordinated client care.

Anahtar Kavram

Following a thyroidectomy, reduction of risk potential requires vigilant monitoring for hypovolemic shock, airway compromise, and hypocalcemia, combined with immediate escalation of critical findings and adherence to the PN scope of practice.
Soru 66Soru →

During the morning shift on a surgical unit, a nurse is assisting a postoperative client with daily hygiene and comfort needs. Which actions represent appropriate care for this client? (Select all that apply)

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Cevabı ve açıklamayı göster

Cevap: Offer a back massage using lotion to promote relaxation.; Place the call light and personal items within easy reach of the client's unaffected side.; Assist the client with oral hygiene using a soft-bristled toothbrush after breakfast.

Cevap

The appropriate actions are offering a back massage, keeping the call light within reach, and assisting with oral hygiene.
Appropriate basic care and comfort measures focus on promoting hygiene, ensuring a safe environment, and providing nonpharmacological relief. Assisting with oral care, offering a relaxing massage, and keeping essential items within reach directly fulfill these fundamental nursing responsibilities safely.

Adım Adım Çözüm

1
Identify the primary goal of the clinical scenario.
The goal is to provide safe and effective basic hygiene and comfort care to a postoperative client.
Understanding the goal helps filter out actions that are unsafe, outside the scope of practice, or non-therapeutic.
2
Evaluate each intervention for safety, efficacy, and scope of practice.
Massages, oral care, and environmental safety (keeping the call light near) are safe basic care actions. Flat positioning, false reassurance, and delegating evaluation are incorrect.
Each nursing action must align with evidence-based comfort measures and legal delegation rules.

Anahtar Kavram

Basic comfort measures include hygiene, environmental safety, and nonpharmacological relaxation, while avoiding improper positioning or inappropriate delegation.
Soru 67Soru →

During morning rounds, a practical nurse evaluates a client admitted with a severe urinary tract infection. The client was fully oriented yesterday but is now highly agitated, picking at their clothing, and unable to recognize family members. Which action should the nurse take first?

Cevabı ve açıklamayı göster

Cevap: Measure the client's current vital signs and oxygen saturation

Cevap

Measure the client's current vital signs and oxygen saturation
The correct answer addresses the immediate need to evaluate physiological stability. An acute change in mental status, such as sudden agitation and disorientation, is a primary indicator of a severe physiological complication like hypoxia, hypoglycemia, or sepsis. The practical nurse must immediately gather objective data (vital signs and oxygen saturation) to identify the underlying physiological cause before notifying the registered nurse or provider.

Adım Adım Çözüm

1
Analyze the clinical scenario
The client has experienced a sudden, acute change in mental status (agitation and disorientation) compared to their baseline.
Recognizing a sudden change in condition is the first step in clinical judgment.
2
Determine the potential underlying cause
Acute confusion (delirium) in a client with an infection often indicates systemic compromise, such as hypoxia, sepsis, or fluid imbalance.
Linking the symptom to potential physiological complications guides prioritization.
3
Select the highest priority nursing action
Obtaining vital signs and oxygen saturation must be done immediately.
According to the nursing process and ABC prioritization, objective physiological data must be collected first to ensure airway, breathing, and circulation are stable before implementing other interventions.

Anahtar Kavram

Early recognition of acute physiological deterioration requires immediate data collection (vital signs and oxygenation) before implementing secondary interventions.
Tahmini Süre:45s
Soru 68Soru →

A practical nurse (PN) is planning care and medication administration for a group of assigned clients. Which of the following actions by the PN demonstrate safe pharmacological practice within the practical nursing scope of practice? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Identifying a client by asking them to state their name and date of birth while verifying it against the medication administration record.; Withholding a scheduled dose of oral digoxin for an adult client with an apical pulse of 54 beats/minute and notifying the supervising registered nurse.; Reinforcing the registered nurse's teaching about the importance of reporting dark, tarry stools to a client prescribed warfarin.

Cevap

The correct actions are identifying the client using two identifiers, withholding digoxin for bradycardia and notifying the registered nurse, and reinforcing teaching about bleeding precautions for a client on warfarin.
The practical nurse demonstrates safe practice by always using two client identifiers before medication administration, which is a fundamental safety right. Withholding digoxin for an adult with an apical pulse below 60 beats/minute and notifying the registered nurse is the correct clinical protocol to prevent cardiac toxicity. Additionally, reinforcing previous teaching provided by the registered nurse regarding medication side effects, such as signs of internal bleeding with warfarin, is directly within the practical nursing scope of practice.

Adım Adım Çözüm

1
Analyze each action to determine if it falls within the practical nurse (PN) scope of practice.
The PN scope of practice includes administering oral medications, reinforcing teaching, and reporting abnormal findings, but generally excludes administering high-risk IV push medications.
Ensuring actions are within scope prevents legal violations and protects client safety.
2
Evaluate the medication safety principles and clinical judgment for each scenario.
Identifying clients with two identifiers, checking an apical pulse before digoxin, and recognizing bleeding risks with warfarin are standard safe practices.
These actions adhere to the rights of medication administration and prevent severe adverse outcomes.
3
Identify contraindicated or unsafe pharmacological actions.
Giving live vaccines to immunosuppressed clients and estimating pediatric weight-based doses are highly unsafe practices.
These actions ignore critical contraindications and mathematical safety standards, potentially causing fatal harm.

Anahtar Kavram

Safe Medication Administration and Practical Nurse Scope of Practice
Soru 69Soru →

While working in a skilled nursing facility, a practical nurse receives a report from an assistive personnel regarding an older adult resident with a healing stage 3 sacral pressure injury. The resident is described as unusually difficult to awaken and suddenly disoriented to place. Current vital signs reveal a blood pressure of 94/58 mmHg, a heart rate of 114 beats/min, a respiratory rate of 24 breaths/min, and a tympanic temperature of 96.2°F (35.7°C). Based on these assessment data, what is the most appropriate initial action for the practical nurse to take?

Cevabı ve açıklamayı göster

Cevap: Communicate the clinical changes to the supervising registered nurse for urgent evaluation.

Cevap

Communicate the clinical changes to the supervising registered nurse for urgent evaluation.
The client's presentation of sudden confusion, hypothermia, tachycardia, and borderline hypotension strongly suggests the onset of sepsis, likely originating from the sacral pressure injury. In older adults, infection often presents atypically with hypothermia and altered mental status rather than a fever. Because these vital signs indicate impending hemodynamic instability and distributive shock, the practical nurse must prioritize communicating these changes to the supervising registered nurse immediately to initiate life-saving interventions.

Adım Adım Çözüm

1
Analyze the client's current clinical presentation and vital signs.
The resident exhibits sudden confusion, hypothermia (96.2°F), tachycardia (114 beats/min), tachypnea (24 breaths/min), and borderline hypotension (94/58 mmHg).
Identifying abnormal data is the first step in recognizing a change in client condition.
2
Correlate the physical findings with the client's medical history.
The presence of a stage 3 sacral pressure injury provides a high-risk source for systemic infection. The combined signs strongly suggest systemic inflammatory response syndrome (SIRS) or septic shock.
Older adults frequently present with atypical signs of infection, such as hypothermia and acute delirium, rather than classic high fevers.
3
Determine the priority nursing intervention within the practical nurse scope of practice.
The client is experiencing a life-threatening acute decompensation that requires advanced hemodynamic support and medical orders.
The practical nurse must recognize the instability and immediately escalate the findings to the supervising registered nurse or provider for urgent intervention.

Anahtar Kavram

Recognition of Sepsis and Shock in Older Adults
Tahmini Süre:1m 15s
Soru 70Soru →

A newly licensed practical nurse (PN) is reviewing safety protocols and scope of practice during clinical orientation on a progressive care unit. Which of the following actions indicate that the PN is correctly applying risk reduction principles? (Select all that apply)

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Verifying a client's identity by checking the name and date of birth on the wristband before administering treatments.; Immediately escalating a newly reported serum potassium level of 2.8 mEq/L to the supervising registered nurse (RN).; Withholding a scheduled dose of oral digoxin and notifying the RN when the client's apical pulse is 52 beats/minute.

Cevap

The correct actions include verifying client identity using two identifiers, immediately escalating critical potassium levels, and withholding digoxin for bradycardia while notifying the RN.
Verifying two client identifiers directly reduces the risk of medication errors. Escalating a critical potassium level of 2.8 mEq/L ensures prompt treatment of hypokalemia, preventing cardiac arrhythmias. Withholding digoxin when the apical pulse is less than 60 beats/minute is a standard risk reduction action to prevent medication toxicity.

Adım Adım Çözüm

1
Evaluate each nursing action against the established practical nurse (PN) scope of practice and basic safety protocols.
Identify safe versus unsafe actions in clinical scenarios.
Risk reduction requires acting within scope and prioritizing immediate client safety over routine tasks.
2
Identify the correct applications of risk reduction.
Verifying identity, escalating a critical hypokalemia lab (2.8 mEq/L), and holding digoxin for a heart rate below 60 beats/minute are identified as correct safety measures.
These actions directly prevent medication errors and address physiological deterioration.
3
Identify and exclude unsafe actions.
Ignoring hypotensive tachycardia, giving IV push medications, and delaying critical lab reporting are excluded.
These represent severe breaches of safety principles and fall outside the appropriate LPN scope.

Anahtar Kavram

Reduction of Risk Potential through adherence to safety protocols, timely escalation of critical findings, and operating within the LPN scope of practice.
Soru 71Soru →

During bedside handoff, a practical nurse assumes care for a client who underwent an open bowel resection 4 hours ago. The client is receiving continuous intravenous fluids. Upon initial assessment, the client reports incisional pain of 7 on a 0 to 10 scale. The electronic health record displays the following recent vital signs: blood pressure 98/62 mm Hg, heart rate 118/min, respirations 20/min, and oxygen saturation 95% on room air.

Which of the following actions should the practical nurse take? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Alert the supervising registered nurse about the current heart rate and blood pressure values.; Examine the client's surgical dressing and the dependent linens for evidence of active hemorrhage.; Utilize the electronic barcode scanner to match the client's wristband with the medication packaging before giving oral antibiotics.

Cevap

The correct actions are to alert the registered nurse about the vital signs, examine the dressing and linens for hemorrhage, and utilize the barcode scanner for medication administration.
The correct actions prioritize client safety by recognizing and responding to early signs of hypovolemic shock. A heart rate of 118/min with a blood pressure of 98/62 mm Hg warrants immediate escalation to the registered nurse and targeted data collection for bleeding (inspecting the dressing and dependent linens). Additionally, using barcode scanning for all medication administration is a fundamental risk-reduction strategy.

Adım Adım Çözüm

1
Analyze the client's postoperative vital signs.
The heart rate of 118/min and blood pressure of 98/62 mm Hg indicate tachycardia and borderline hypotension.
These findings are early compensatory mechanisms for hypovolemia or active hemorrhage, which require immediate clinical attention rather than routine monitoring.
2
Determine the appropriate practical nursing interventions for the identified risk.
The practical nurse must escalate the findings to the registered nurse and gather focused data by checking the surgical site and dependent linens for bleeding.
Timely communication and targeted data collection reduce the risk of severe complications from delayed treatment.
3
Evaluate other standard care actions against the practical nurse scope of practice and safety protocols.
Intravenous push medications must be avoided, knee flexion must be minimized to prevent deep vein thrombosis, and barcode scanning must be used for oral medications.
Adhering strictly to the legal scope of practice and evidence-based safety guidelines minimizes the potential for adverse events.

Anahtar Kavram

Early recognition of postoperative complications and adherence to the practical nurse scope of practice are essential to risk reduction.
Soru 72Soru →

A practical nurse is participating in the care of a client admitted with a suspected upper gastrointestinal bleed. Which action by the nurse demonstrates the appropriate application of risk reduction principles?

Cevabı ve açıklamayı göster

Cevap: Promptly notifying the registered nurse about a client blood pressure of 100/64 mm Hg and a heart rate of 108 beats/min

Cevap

Promptly notifying the registered nurse about a client blood pressure of 100/64 mm Hg and a heart rate of 108 beats/min.
The client is at high risk for hypovolemic shock due to a gastrointestinal bleed. A slight drop in blood pressure paired with a rising heart rate (tachycardia) are early, subtle indicators that the body is attempting to compensate for blood loss. Prompt escalation to the registered nurse allows for early intervention, directly reducing the risk of severe cardiovascular collapse.

Adım Adım Çözüm

1
Analyze the clinical scenario and the client's primary risk factor.
The client has a suspected upper gastrointestinal bleed, placing them at high risk for hypovolemia and hemorrhagic shock.
Understanding the client's diagnosis highlights the need to monitor for signs of active bleeding and impaired perfusion.
2
Evaluate each nursing action against safety guidelines and the practical nurse scope of practice.
Delaying critical lab reports, bypassing proper medication identifiers, and accepting IV push delegations are unsafe practices. Escalating borderline vital signs is a safe and required practice.
Risk reduction requires identifying early signs of deterioration and adhering strictly to safety protocols and scope of practice.
3
Select the action that best mitigates risk for the client.
Reporting the borderline low blood pressure and elevated heart rate directly addresses the immediate risk of shock.
Tachycardia and borderline hypotension are often the first physiological signs of significant blood loss.

Anahtar Kavram

Early recognition and escalation of subtle signs of shock (borderline vital signs) in clients with active bleeding risk.
Soru 73Soru →

An adult client on a medical-surgical unit is due for a scheduled dose of oral amlodipine. When the practical nurse attempts to scan the client's identification wristband, the barcode is unreadable due to water damage. Which action is the most appropriate method for the practical nurse to verify the client's identity?

Cevabı ve açıklamayı göster

Cevap: Ask the client to state their full name and date of birth while comparing the response to the medication administration record.

Cevap

The practical nurse should ask the client to explicitly state their full name and date of birth, comparing these details to the medication administration record.
When automated safety systems like barcode scanners fail, the nurse must manually verify the client's identity using two approved identifiers (typically full name and date of birth). Asking the client to state this information requires active participation, ensuring accurate identification and fulfilling the 'right client' parameter of safe medication administration.

Adım Adım Çözüm

1
Recognize that barcode scanning is a primary safety tool, but manual verification is required when technology fails.
The nurse must actively identify the client using alternative, approved methods.
Bypassing identification protocols due to equipment failure is a leading cause of medication errors.
2
Identify the most reliable manual method for patient verification according to standard safety guidelines.
Asking the client to state two acceptable identifiers (such as name and date of birth) provides active confirmation.
Active confirmation prevents false identification that can occur if a client simply nods or answers 'yes' to a closed-ended question.

Anahtar Kavram

Medication Safety and Patient Identification
Soru 74Soru →

While working on a medical-surgical unit, a practical nurse evaluates an older adult client who is two days postoperative following percutaneous endoscopic gastrostomy (PEG) tube placement. The client is receiving continuous enteral nutrition. Suddenly, the individual becomes restless, complains of severe nausea, and demonstrates tachypnea. Which interventions should the practical nurse implement? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Stop the enteral feeding infusion pump immediately.; Raise the head of the bed to an angle of 45 degrees or higher.; Obtain a current set of vital signs and oxygen saturation levels.

Cevap

The correct actions are to stop the enteral feeding infusion pump, raise the head of the bed to 45 degrees or higher, and obtain a current set of vital signs.
The client's presentation of restlessness, nausea, and tachypnea strongly suggests aspiration, hypoxia, or feeding intolerance. The immediate nursing priorities are to protect the airway by halting the continuous enteral feeding and elevating the head of the bed to maximize chest expansion. Collecting vital signs is a safe, within-scope action that provides critical objective data for the RN or provider.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
The client is showing sudden signs of respiratory distress (tachypnea), gastrointestinal distress (severe nausea), and hypoxia (restlessness) while receiving continuous enteral feeding.
Recognizing the combination of these symptoms indicates a high risk for aspiration or acute feeding intolerance.
2
Identify the immediate priority interventions.
The most urgent actions are related to airway protection and breathing (ABCs).
Stopping the source of potential aspiration (the feeding pump) and using gravity to protect the airway and expand the lungs (elevating the head of the bed) address the most life-threatening risks.
3
Determine appropriate data collection and scope of practice constraints.
Gathering vital signs is within the practical nurse scope and provides necessary data; administering IVP medications is out of scope.
The practical nurse must collect objective data to report to the RN while safely avoiding delegated tasks that exceed licensure bounds.

Anahtar Kavram

Prioritizing airway protection, recognizing acute status changes, and adhering to the legal scope of practice during basic care and enteral feeding management.
Tahmini Süre:2m 0s
Soru 75Soru →

A practical nurse is caring for a client who had a cardiac catheterization through the right femoral artery 6 hours ago. The client reports a new, continuous lower backache. During data collection, the nurse notes the right pedal pulse is palpable but weaker than the left, a heart rate of 104 beats per minute, and a blood pressure of 102/60 mm Hg. What is the priority action for the practical nurse?

Cevabı ve açıklamayı göster

Cevap: Alert the registered nurse immediately about the client's changing condition.

Cevap

The correct action is to alert the registered nurse immediately about the client's changing condition.
The client is exhibiting classic signs of retroperitoneal bleeding, a severe complication of a femoral artery cardiac catheterization. The new onset of continuous backache occurs because blood is accumulating in the retroperitoneal space, causing pressure. The diminished distal pulse and borderline vital signs (tachycardia and mild hypotension) indicate early hemorrhagic shock. The practical nurse must immediately escalate this critical circulatory emergency to the registered nurse for rapid medical intervention.

Adım Adım Çözüm

1
Analyze the client's procedure and current symptoms.
The client had a right femoral cardiac catheterization and now presents with new back pain, a weaker distal pulse, and borderline tachycardia and hypotension.
Identifying the combination of symptoms following this specific invasive procedure is crucial for recognizing early complications.
2
Correlate the clinical findings with potential postoperative complications.
These findings strongly indicate retroperitoneal bleeding.
Blood pooling in the retroperitoneal space causes referred back pain, while active volume loss leads to a compensatory increase in heart rate and a drop in blood pressure.
3
Determine the priority nursing action based on the practical nurse scope of practice.
The nurse must immediately escalate the findings to the registered nurse or provider.
A retroperitoneal hemorrhage is a critical circulatory emergency that requires immediate medical intervention and fluid resuscitation beyond the independent scope of a practical nurse.

Anahtar Kavram

Recognition of retroperitoneal bleeding following femoral artery procedures
Soru 76Soru →

A practical nurse is reviewing morning laboratory results for an adult client with a history of heart failure who is receiving a daily loop diuretic. The client's serum potassium level is 2.8 mEq/L (2.8 mmol/L). Which action should the nurse take first?

Cevabı ve açıklamayı göster

Cevap: Promptly notify the registered nurse and the healthcare provider about the laboratory result.

Cevap

Promptly notify the registered nurse and the healthcare provider about the laboratory result.
The correct answer addresses the urgent need to report a critically low serum potassium level. Normal serum potassium ranges from 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Severe hypokalemia can lead to life-threatening cardiac dysrhythmias. Immediate escalation ensures that the client receives prompt medical intervention, such as intravenous potassium replacement and the temporary discontinuation of the potassium-wasting diuretic.

Adım Adım Çözüm

1
Identify the normal reference range for serum potassium.
The expected normal range is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L).
This establishes a baseline to evaluate the significance of the client's laboratory results.
2
Evaluate the client's specific laboratory value.
A value of 2.8 mEq/L (2.8 mmol/L) indicates severe hypokalemia.
Loop diuretics commonly cause potassium wasting, leading to this expected but dangerous imbalance.
3
Determine the priority nursing intervention based on the practical nurse's scope of practice.
The nurse must immediately escalate this critical finding to the registered nurse or healthcare provider.
Severe hypokalemia can cause fatal cardiac dysrhythmias, making this a time-sensitive physiological emergency that requires immediate medical intervention.

Anahtar Kavram

Electrolyte Imbalances (Hypokalemia) and Critical Value Escalation
Soru 77Soru →

A client with a history of type 2 diabetes mellitus activates the call light at 07:15. Upon entering the room, the practical nurse observes that the client is fully conscious but visibly diaphoretic and experiencing hand tremors. A point-of-care capillary blood glucose test reveals a level of 5858 mg/dL (3.23.2 mmol/L). A scheduled dose of oral glipizide is due at 07:30. Which action should the practical nurse take next?

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Cevap: Withhold the glipizide, provide 1515 grams of a fast-acting oral carbohydrate, and alert the registered nurse.

Cevap

Withhold the glipizide, provide 15 grams of a fast-acting oral carbohydrate, and alert the registered nurse.
The client is experiencing symptomatic hypoglycemia (blood glucose less than 70 mg/dL). Because the client is fully conscious and able to swallow, the safest and most appropriate immediate action is to provide 15 grams of a fast-acting oral carbohydrate (such as 4 ounces of fruit juice). The practical nurse must withhold the glipizide, as its mechanism of action is to stimulate insulin release, which would further lower the blood glucose level. After initiating treatment, the practical nurse must promptly report the client's condition to the registered nurse for further evaluation.

Adım Adım Çözüm

1
Analyze the client's assessment data.
The client has a blood glucose level of 58 mg/dL and is exhibiting diaphoresis and tremors.
Identifying the clinical signs and laboratory confirmation of hypoglycemia is required to determine the appropriate intervention.
2
Evaluate the scheduled medication.
Glipizide is a sulfonylurea that stimulates insulin secretion and lowers blood glucose.
Understanding the medication's mechanism reveals that administering it would dangerously exacerbate the hypoglycemia.
3
Determine the practical nurse's scope of practice and prioritize actions.
The nurse must provide an oral carbohydrate (since the client is conscious), withhold the contraindicated medication, and escalate the critical findings to the RN.
This sequence ensures immediate patient safety, adheres to the LPN/LVN scope of practice, and maintains effective interdisciplinary communication.

Anahtar Kavram

Management of hypoglycemia and practical nurse scope of practice in medication administration
Tahmini Süre:1m 30s
Soru 78Soru →

A practical nurse (PN) is performing focused assessments on a group of assigned clients. Which of the following client situations are considered expected or stable, allowing the nurse to safely document the data and continue routine care WITHOUT immediately notifying the registered nurse (RN)? Select all that apply.

Geçerli olan tümünü seçin

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Cevap: A client with a new left forearm arteriovenous (AV) fistula who has a continuous palpable thrill and an audible bruit at the access site.; A client 12 hours post-laparoscopic cholecystectomy who reports mild right shoulder pain and has hypoactive bowel sounds.; A client with an indwelling urinary catheter whose total urine output over the previous 4 hours is 160 mL.

Cevap

The correct selections are the client with the functioning AV fistula, the client with expected post-laparoscopic cholecystectomy findings, and the client with adequate urinary output.
The practical nurse must apply risk reduction principles by filtering benign, expected data from clinical emergencies. A palpable thrill and audible bruit prove that an AV fistula is patent and functioning properly. Right shoulder pain after a laparoscopic procedure is a common, non-emergent consequence of the carbon dioxide gas used to inflate the abdomen, and bowel sounds naturally remain sluggish after anesthesia. A urine output averaging 40 mL/hour comfortably exceeds the minimum safety threshold of 30 mL/hour. All of these situations reflect stable clients progressing as expected, allowing the PN to document the findings and proceed with routine care.

Adım Adım Çözüm

1
Evaluate the assessment data for the client with the AV fistula.
A thrill and bruit are identified at the site.
These findings confirm normal, healthy blood flow through a newly created fistula and do not require escalation.
2
Analyze the post-operative findings for the client who underwent a laparoscopic cholecystectomy.
Right shoulder pain and hypoactive bowel sounds are present 12 hours post-surgery.
Both findings are expected physiological responses to abdominal insufflation and general anesthesia, respectively.
3
Calculate the hourly urine output for the client with the catheter.
160 mL divided by 4 hours equals 40 mL/hour.
This is above the critical minimum threshold of 30 mL/hour, demonstrating adequate organ perfusion and stability.
4
Identify the complications and scope-of-practice issues in the remaining scenarios.
The platelet count is critically low, the thoracentesis client is showing early shock/hypoxia signs, and the diltiazem titration is beyond PN scope.
These three situations carry high risk potential and mandate immediate notification of the RN to ensure client safety.

Anahtar Kavram

Distinguishing between expected clinical progression and subtle indicators of complications to determine when RN escalation is required.
Soru 79Soru →

A practical nurse is preparing to transfer a client who has left-sided weakness from the edge of the bed to a wheelchair. In what order should the nurse perform the following actions?

Öğeleri doğru sıraya koymak için sürükleyin

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Cevap

The nurse must first secure the environment by placing the wheelchair on the client's strong side and locking all brakes. Next, the nurse prepares the client with non-slip footwear and a transfer belt. Finally, the nurse executes the transfer by bracing the weak leg, assisting the client to stand, pivoting on the strong leg, and having the client reach for the armrests before sitting.
Safe transfer mechanics require setting up the environment first (wheelchair placement on the unaffected side with brakes locked), followed by client preparation (non-slip footwear and a transfer belt). During execution, the nurse must brace the weak side while the client bears weight and pivots on the strong side. Finally, the client secures their balance by reaching for the armrests before lowering into the seat.

Adım Adım Çözüm

1
Position the wheelchair on the client's right side and lock all brakes.
The environment is safe and ready for the transfer.
Setting up the destination on the strong side prevents the client from having to cross over their weak side.
2
Apply non-slip footwear and check foot placement.
The client has a stable base of support.
Prevents slipping when weight-bearing begins.
3
Fasten the transfer belt around the waist.
A secure gripping point is established.
Ensures the nurse can lift safely without pulling on the client's arms or shoulders.
4
Brace the left knee and foot, then assist to stand.
The client achieves a standing position without collapsing.
The left side is weak and prone to buckling under body weight; bracing it provides necessary artificial support.
5
Pivot the client on their right leg.
The client is aligned squarely with the wheelchair.
Turning on the strong leg provides the necessary biomechanical stability.
6
Instruct the client to reach back for the armrests before sitting.
The client lowers safely into the chair.
Provides sensory feedback regarding the chair's location and allows for a controlled lowering motion.

Anahtar Kavram

Safe Client Transfer and Mobility
Soru 80Soru →

A 4-year-old child is receiving inpatient treatment for a severe asthma exacerbation and is currently prescribed high-dose oral prednisone. The practical nurse (PN) notes that a routine measles, mumps, and rubella (MMR) vaccine is scheduled to be administered prior to discharge. Which action should the PN take?

Cevabı ve açıklamayı göster

Cevap: Withhold the MMR vaccine and report the child's current prednisone therapy to the supervising registered nurse.

Cevap

The nurse should withhold the MMR vaccine and report the current prednisone therapy to the supervising registered nurse.
The measles, mumps, and rubella (MMR) vaccine is a live attenuated virus. High-dose systemic corticosteroids, such as prednisone, cause significant immunosuppression. Administering a live vaccine to an immunocompromised client places them at high risk for developing a severe, disseminated infection from the vaccine virus itself. The appropriate and safe action within the practical nurse's scope of practice is to recognize this critical safety hazard, withhold the contraindicated medication, and notify the supervising registered nurse or healthcare provider.

Adım Adım Çözüm

1
Identify the classification of the scheduled medication.
The MMR vaccine is a live attenuated virus vaccine.
Understanding the vaccine type is essential to identify potential contraindications.
2
Evaluate the client's current medication regimen for interactions.
The client is receiving high-dose oral prednisone, a systemic corticosteroid that causes immunosuppression.
Immunosuppressants alter the body's ability to handle live vaccines safely.
3
Apply pharmacological safety principles.
Live vaccines are strictly contraindicated in immunocompromised clients due to the risk of severe infection from the vaccine strain.
Preventing medication-induced harm is a primary nursing responsibility.
4
Determine the appropriate nursing action within the PN scope of practice.
The PN must safely withhold the contraindicated medication and immediately communicate the finding to the RN or provider.
The PN is responsible for recognizing safety hazards and reporting them up the chain of command.

Anahtar Kavram

Immunization Contraindications and Scope of Practice
Tahmini Süre:1m 30s
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Physiological Integrity Alıştırma Soruları — NCLEX-PN — Sayfa 4 | Examkin