Examkin

Physiological Integrity

1313 soru

Tüm türler1,313Çoktan seçmeli672Çoklu seçim289Sayısal68Sıralama284
Soru 161Soru →

While providing morning hygiene and comfort measures for an individual recovering from a recent right posterior total hip arthroplasty, the practical nurse (PN) needs to change the soiled bottom bed linens. Which specific technique must the PN utilize to complete this task safely?

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Cevap: Secure an abduction device between the thighs and turn the client as a single unit onto their left lateral side.

Cevap

The correct action is to secure an abduction device between the thighs and turn the client as a single unit onto their left lateral side.
Following a posterior total hip arthroplasty, the client is at high risk for hip dislocation if the joint is subjected to adduction, internal rotation, or flexion greater than 90 degrees. Placing an abduction wedge or pillow between the legs prevents the affected leg from crossing the midline (adduction) while the client is safely turned onto their unoperated side to facilitate linen changes and back care.

Adım Adım Çözüm

1
Identify the client's surgical procedure and associated anatomical risks.
The client had a right posterior total hip arthroplasty, which carries a high risk of dislocation if specific joint movements are permitted.
Understanding surgical precautions is essential before initiating basic care and hygiene interventions.
2
Determine the specific movement restrictions for a posterior surgical approach.
The affected hip must not be flexed beyond 90 degrees, internally rotated, or adducted across the body's midline.
These specific positions force the femoral head out of the newly implanted acetabular cup.
3
Evaluate each proposed hygiene technique against the strict movement restrictions.
Raising the bed causes excessive flexion, removing the wedge causes adduction, and inward rotation is directly contraindicated. Only using an abduction device while turning maintains safety.
Basic care interventions must be fundamentally modified to strictly adhere to postoperative joint precautions.

Anahtar Kavram

Postoperative Positioning and Joint Precautions
Soru 162Soru →

During the morning shift, a practical nurse (PN) is reviewing the electronic health record for a client with pneumonia who recently developed peripheral edema. The new medication prescriptions include oral azithromycin and intravenous (IV) push bumetanide. The client's most recent basic metabolic panel reveals a serum potassium level of 2.82.8 mEq/L (2.82.8 mmol/L). Which is the most appropriate action for the PN to take?

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Cevap: Withhold the medications, immediately report the critical potassium level to the registered nurse (RN), and clarify that the IV push medication requires RN administration.

Cevap

Withhold the medications, immediately report the critical potassium level to the registered nurse (RN), and clarify that the IV push medication requires RN administration.
The client's serum potassium level of 2.82.8 mEq/L is critically low. Bumetanide is a potassium-wasting loop diuretic that would dangerously exacerbate this hypokalemia. Additionally, administering medications via the intravenous (IV) push route is outside the standard scope of practice for a practical nurse (PN). Therefore, the safest and most appropriate action is to withhold the medications and immediately escalate both the critical laboratory value and the administration of the IV push medication to the registered nurse (RN).

Adım Adım Çözüm

1
Analyze the client's laboratory results.
The serum potassium level is 2.8 mEq/L, which is critically low (normal range is typically 3.5 to 5.0 mEq/L).
Identifying critical abnormal values is required before administering medications that could worsen the condition or cause fatal dysrhythmias.
2
Evaluate the prescribed medications against the client's condition and the practical nurse (PN) scope of practice.
Bumetanide is a potassium-wasting loop diuretic that would further deplete the client's potassium. Additionally, IV push medications are generally outside the PN scope of practice.
Safe administration requires understanding drug mechanisms, contraindications, and adhering to legal practice boundaries.
3
Determine the priority nursing intervention.
The PN must withhold the medications and immediately escalate the critical laboratory value and the out-of-scope prescription to the RN.
Prompt communication of life-threatening abnormalities and strict adherence to the scope of practice ensures client safety.

Anahtar Kavram

Medication safety involves recognizing critical laboratory values (such as hypokalemia), withholding contraindicated drugs (like loop diuretics), and adhering to the legal scope of practice regarding intravenous push administration.
Soru 163Soru →

A practical nurse is caring for a 65-year-old client who underwent a total abdominal hysterectomy 4 hours ago. The client becomes restless, reports feeling dizzy, and states, "I am extremely thirsty." Baseline vital signs upon arrival to the unit were blood pressure 124/76 mm Hg, heart rate 82 beats/min, and respiratory rate 16 breaths/min. Current vital signs are blood pressure 104/66 mm Hg, heart rate 110 beats/min, and respiratory rate 22 breaths/min. The visible abdominal dressing is dry and intact. Which action should the practical nurse take first?

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Cevap: Inspect the perineal pad and the linens beneath the client for pooling blood.

Cevap

The practical nurse should first inspect the perineal pad and the linens beneath the client for pooling blood.
The client is exhibiting classic early signs of hypovolemic shock, including restlessness, dizziness, excessive thirst, tachycardia, and a narrowing pulse pressure with hypotension. Since the visible abdominal dressing is dry, the practical nurse must assess for dependent pooling of blood under the client and check the perineal pad for hidden vaginal bleeding. Gathering this complete data is essential before immediately escalating the findings to the registered nurse.

Adım Adım Çözüm

1
Analyze the client's vital signs and reported symptoms.
The client has developed tachycardia, mild hypotension, tachypnea, restlessness, dizziness, and extreme thirst compared to baseline.
Comparing current data to baseline is necessary to identify acute changes in condition.
2
Interpret the clinical significance of the changes.
These findings are classic early compensatory mechanisms for hypovolemic shock, likely due to postoperative hemorrhage.
Early recognition of shock is critical for preventing irreversible organ damage.
3
Determine the appropriate focused data collection.
Since the visible abdominal dressing is dry, the nurse must check for hidden bleeding by inspecting the perineal pad and underneath the client.
Blood follows gravity, so dependent pooling or vaginal bleeding are common sources of unseen hemorrhage after a hysterectomy.
4
Prioritize the immediate nursing action.
The practical nurse collects this critical data to complete the assessment before immediately escalating the findings to the registered nurse and provider.
The registered nurse needs complete assessment data to initiate emergency interventions.

Anahtar Kavram

Early recognition of hypovolemic shock and prioritization of data collection for hidden hemorrhage.
Soru 164Soru →

An outpatient clinic practical nurse (PN) is reviewing the health records of several clients scheduled to receive the live-attenuated measles, mumps, and rubella (MMR) vaccine. Which client findings require the PN to withhold the immunization and immediately consult the registered nurse (RN)? Select all that apply.

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Cevap: A 24-year-old client who states, "I just found out I am 8 weeks pregnant."; A 45-year-old client currently undergoing immunosuppressive chemotherapy for lymphoma.; A 6-year-old client with a documented severe anaphylactic reaction to a previous dose of the MMR vaccine.

Cevap

The findings that require withholding the live-attenuated MMR vaccine are the client who is 8 weeks pregnant, the client undergoing immunosuppressive chemotherapy, and the client with a documented anaphylactic reaction to a previous dose.
Live-attenuated vaccines, such as the MMR vaccine, contain a weakened form of the living virus. They are strictly contraindicated in pregnant clients due to the risk of fetal transmission and teratogenic effects. They are also contraindicated in severely immunocompromised clients (such as those on chemotherapy) because their weakened immune systems cannot safely handle the virus, risking a severe infection. A documented anaphylactic reaction to a previous dose is an absolute contraindication for any medication or vaccine due to the high risk of a life-threatening allergic response upon re-exposure.

Adım Adım Çözüm

1
Analyze the medication class.
The MMR vaccine is identified as a live-attenuated virus vaccine.
Different types of vaccines (live vs. inactivated) have distinct safety parameters and contraindications.
2
Recall absolute contraindications for live-attenuated vaccines.
Identified pregnancy, severe immunocompromise (e.g., active chemotherapy), and previous anaphylactic reactions as critical safety risks.
Live vaccines contain a weakened form of the virus that can cause harm in vulnerable or hypersensitive populations.
3
Evaluate the remaining scenarios to differentiate true contraindications from false contraindications.
Determined that mild acute illnesses, normal laboratory values, and normal pediatric vital signs are safe conditions for administration.
Recognizing false contraindications prevents unnecessary delays in vital immunizations.
4
Select the client scenarios that present true contraindications.
Selected the pregnant client, the chemotherapy client, and the client with a prior anaphylactic reaction as requiring immediate RN consultation.
The PN must practice within scope by identifying unsafe medication parameters and withholding administration until evaluated by the RN.

Anahtar Kavram

Live-attenuated vaccine contraindications and safe administration parameters.
Soru 165Soru →

An unresponsive client requires oral hygiene to maintain mucosal integrity. In which order should the practical nurse perform the following actions to complete this procedure safely? Arrange the steps in the correct chronological sequence.

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Cevap

The correct sequence is to first position the client side-lying, place protective linens and a basin, safely open the mouth with a padded tongue blade, perform the cleaning with simultaneous suctioning, and finally moisturize the lips.
When providing oral hygiene to an unresponsive client, safety—specifically airway protection—is the absolute highest priority. Therefore, the client must first be turned to a side-lying position to utilize gravity for drainage. Once positioned safely, the nurse prepares the area with a towel and basin to maintain cleanliness. Next, safe access to the oral cavity is secured using a padded tongue blade, preventing injury from reflex biting. The actual cleaning is then performed simultaneously with suctioning to ensure no fluid accumulates in the airway. Finally, the procedure concludes with a comfort measure, applying water-soluble lubricant to prevent the lips from drying and cracking.

Adım Adım Çözüm

1
Assist the client into a side-lying position.
The client is in a safe posture for oral care.
The side-lying position allows fluids to pool in the side of the mouth and drain out, significantly reducing the risk of aspiration.
2
Place a towel under the client's chin and an emesis basin against the cheek.
The physical environment is prepared.
This step protects the client's gown and linens from becoming soiled and provides a receptacle for the oral drainage.
3
Insert a padded tongue blade gently between the back molars to open the mouth.
The oral cavity is safely accessed.
An unresponsive client may bite down reflexively. Using a padded tongue blade protects both the client's teeth and the nurse's fingers.
4
Clean the teeth and oral mucosa using a moistened swab while applying suction.
The mouth is cleaned and secretions are removed.
Cleaning removes plaque and bacteria. Continuous or intermittent suctioning ensures that the fluid used for cleaning and any loosened secretions are not aspirated into the lungs.
5
Apply a water-soluble lubricant to the client's lips.
The client's lips are protected from cracking.
Unresponsive clients often breathe through their mouths, leading to dry lips. A water-soluble lubricant maintains tissue integrity without the flammability risk associated with petroleum-based products.

Anahtar Kavram

Basic Care and Comfort: Oral Care for the Unresponsive Client
Soru 166Soru →

An elderly client is receiving care in a subacute rehabilitation facility following a recent lower respiratory tract infection. While completing evening rounds, the practical nurse (PN) collects data on the client's current physiological status. Which of the following assessment findings require immediate escalation to the registered nurse (RN) for suspected clinical deterioration? Select all that apply.

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Cevap: Sudden onset of agitation and disorientation to time and place.; Heart rate of 114 beats per minute with a blood pressure of 98/60 mm Hg.; Respiratory rate of 28 breaths per minute with the use of accessory muscles.

Cevap

The findings requiring immediate escalation are the sudden onset of agitation and disorientation, the heart rate of 114 beats per minute with a blood pressure of 98/60 mm Hg, and the respiratory rate of 28 breaths per minute with the use of accessory muscles.
The correct findings directly point to acute physiological decompensation. Tachypnea with accessory muscle use is a clear sign of respiratory distress (Breathing). Tachycardia with borderline hypotension suggests early shock or sepsis (Circulation). Sudden agitation and disorientation are classic early signs of hypoxia or poor cerebral perfusion in older adults. All of these require immediate RN notification to prevent further decline.

Adım Adım Çözüm

1
Analyze the client's clinical scenario.
The client is an older adult recovering from a respiratory infection, making them vulnerable to sepsis, hypoxia, and shock.
Understanding the baseline risk factors helps in identifying which signs represent acute complications.
2
Evaluate each finding using the Airway, Breathing, and Circulation (ABC) prioritization framework.
Respiratory rate of 28 with accessory muscle use affects Breathing. Heart rate of 114 with BP of 98/60 affects Circulation. Sudden agitation indicates altered brain perfusion, which is tied to ABCs.
ABCs take immediate precedence in physiological adaptation and emergency recognition.
3
Differentiate between acute deterioration and expected or stable findings.
Mild IV site pain, formed bowel movements, and a 95% oxygen saturation are stable, non-emergent findings.
Escalation to the RN is reserved for findings that indicate a life-threatening change in condition.

Anahtar Kavram

Acute Decompensation and ABC Prioritization
Soru 167Soru →

A practical nurse is collecting data from a client who was admitted with a pulmonary embolism and is currently receiving a continuous intravenous heparin infusion. Which of the following findings indicate a high risk for potential complications and require immediate notification of the supervising registered nurse? Select all that apply.

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Cevap: A platelet count of 88,000/mm388,000/\text{mm}^3; A resting heart rate of 115 beats per minute accompanied by a blood pressure of 98/62 mm Hg; The client reporting the sudden onset of a severe headache

Cevap

The correct findings that require immediate escalation are a platelet count of 88,000/mm388,000/\text{mm}^3, a resting heart rate of 115 beats per minute with a blood pressure of 98/62 mm Hg, and the sudden onset of a severe headache.
Clients on continuous intravenous heparin are at significant risk for hemorrhage and heparin-induced thrombocytopenia (HIT). A sudden, severe headache is a cardinal sign of intracranial bleeding. Tachycardia combined with borderline hypotension suggests early hypovolemic shock from internal blood loss. A platelet count of 88,000/mm388,000/\text{mm}^3 falls well below the normal range, indicating potential HIT, which can cause paradoxical life-threatening thrombosis. All three findings require immediate cessation of therapy and rapid RN/provider intervention.

Adım Adım Çözüm

1
Analyze the client's current clinical situation and treatment.
The client has a pulmonary embolism and is on continuous IV heparin, placing them at high risk for bleeding complications and heparin-induced thrombocytopenia (HIT).
Understanding the high-risk therapy guides the identification of life-threatening adverse effects.
2
Evaluate the laboratory values against therapeutic expectations.
A platelet count of 88,000/mm388,000/\text{mm}^3 is critically low (normal 150,000−400,000/mm3150,000-400,000/\text{mm}^3) indicating potential HIT. An aPTT of 64 seconds is therapeutic (1.5-2.5 times the control of 25-35 seconds). A positive D-dimer is expected given the PE diagnosis.
Differentiating between expected therapeutic effects and critical laboratory abnormalities is essential for safe care.
3
Assess the vital signs and subjective data for signs of shock or hemorrhage.
Tachycardia (115 bpm) with borderline hypotension (98/62 mm Hg) suggests early hemorrhagic shock. A sudden severe headache indicates possible intracranial bleeding. An SpO2 of 94% on 2L O2 is a stable finding for this respiratory condition.
Recognizing subtle signs of internal bleeding ensures timely escalation before hemodynamic collapse occurs.

Anahtar Kavram

Continuous heparin therapy requires vigilant monitoring for adverse effects, specifically systemic bleeding, intracranial hemorrhage (indicated by severe headache), and heparin-induced thrombocytopenia (indicated by a profound drop in platelets).
Soru 168Soru →

A practical nurse (PN) is preparing to administer scheduled oral digoxin to a 4-month-old infant diagnosed with a ventricular septal defect. Prior to administration, the PN assesses the sleeping infant's vital signs and notes an apical pulse of 84 beats/minute and a respiratory rate of 32 breaths/minute. Which action should the PN take first?

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Cevap: Withhold the dose of digoxin and immediately notify the registered nurse (RN).

Cevap

Withhold the dose of digoxin and immediately notify the registered nurse (RN).
For an infant (1 to 12 months of age), the typical threshold to withhold digoxin is an apical pulse of less than 90 to 110 beats/minute, depending on specific facility policy. An apical pulse of 84 beats/minute is definitively bradycardic for a 4-month-old. Because digoxin slows the heart rate, administering the medication could lead to severe bradycardia and decreased cardiac output. The practical nurse must withhold the dose and immediately notify the registered nurse or healthcare provider.

Adım Adım Çözüm

1
Assess the infant's vital signs and compare them to expected physiological norms.
The apical pulse is 84 beats/minute, which indicates bradycardia for a 4-month-old infant.
Normal infant heart rates range from 100 to 160 beats/minute. A rate of 84 is dangerously low and requires immediate clinical attention.
2
Evaluate the specific safety parameters for administering digoxin to a pediatric client.
The standard protocol requires withholding digoxin in infants if the apical pulse is less than 90 to 110 beats/minute.
Digoxin has a negative chronotropic effect, meaning it slows electrical conduction through the heart. Administering it to an already bradycardic infant could precipitate a life-threatening arrhythmia or cardiac arrest.
3
Determine the appropriate action within the practical nurse (PN) scope of practice.
The PN withholds the medication and immediately notifies the registered nurse (RN).
The PN is responsible for executing safe medication administration, recognizing critical deviations, and promptly escalating abnormal findings to the RN or provider for medical management.

Anahtar Kavram

Safe administration of digoxin in pediatric clients involves rigorous pre-administration pulse checks, with strict withholding parameters for bradycardia (typically less than 90 beats/minute for infants).
Soru 169Soru →

A client returns to the medical-surgical unit following a percutaneous liver biopsy. Which interventions should the practical nurse implement to reduce the risk of post-procedure complications? Select all that apply.

Geçerli olan tümünü seçin

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Cevap: Maintain the client in a right side-lying position.; Assess the client's respiratory status and breath sounds bilaterally.; Instruct the client to avoid forceful coughing or straining.

Cevap

The practical nurse should maintain the client in a right side-lying position, assess respiratory status and breath sounds bilaterally, and instruct the client to avoid forceful coughing or straining.
Following a percutaneous liver biopsy, the most significant risks are internal bleeding and accidental puncture of the lung (pneumothorax). The correct interventions actively mitigate these risks: positioning the client on the right side uses the body's weight to apply pressure to the liver capsule; monitoring breath sounds screens for lung injury; and avoiding coughing prevents spikes in intra-abdominal pressure that could disrupt clot formation.

Adım Adım Çözüm

1
Identify the primary risks associated with a percutaneous liver biopsy.
The major post-procedure risks are hemorrhage (due to the high vascularity of the liver) and pneumothorax (due to the needle's proximity to the diaphragm).
Understanding the anatomical risks directs the nurse toward the correct preventative and monitoring interventions.
2
Evaluate each action for its effectiveness in preventing or detecting bleeding.
Right side-lying positioning provides hemostasis via compression. Preventing coughing avoids dislodging clots. Tachycardia and low hemoglobin are signs of bleeding that require immediate escalation, not delay.
Prompt recognition and mechanical prevention of bleeding are core responsibilities within the practical nurse scope to reduce risk potential.
3
Evaluate each action for its effectiveness in detecting respiratory compromise.
Auscultating breath sounds bilaterally allows the nurse to detect diminished or absent sounds, which indicate a pneumothorax.
Early detection of airway or breathing complications prevents rapid physiological deterioration.
4
Review the scope of practice regarding delegation.
Delegating the evaluation of a surgical puncture site is inappropriate, as evaluating for a hematoma constitutes an assessment.
Maintaining client safety requires ensuring that tasks are delegated only to appropriately licensed or certified personnel.

Anahtar Kavram

Reduction of Risk Potential: Post-Procedural Complications
Soru 170Soru →

A pediatric client diagnosed with acute otitis media is receiving care in a clinic. The practical nurse (PN) reviews the electronic health record:

Vital Signs & Measurements:
Temperature: 101.4∘F101.4^\circ\text{F} (38.6∘C38.6^\circ\text{C})
Weight: 35.2 lb35.2\text{ lb}
Allergies: Penicillin (mild rash)

Provider Prescriptions:
Ceftriaxone 50 mg/kg/day50\text{ mg/kg/day} intramuscularly, divided into two equal doses.

Pharmacy Dispenses:
Ceftriaxone 1 g1\text{ g} vial of sterile powder.
Reconstitution instructions: Add 2.1 mL2.1\text{ mL} of sterile water for injection to yield a final concentration of 350 mg/mL350\text{ mg/mL}.

How many mL\text{mL} should the PN administer per dose? (Record the answer to the nearest tenth. Do not include units in the answer.)

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Cevap: 1.1

Cevap

1.1
To administer the correct dose, the nurse must first convert the weight to kilograms, find the individual dose by dividing the daily total in half, and then use the final yield concentration (350 mg/mL350\text{ mg/mL}) to determine the volume to administer. The volume of diluent added (2.1 mL2.1\text{ mL}) is a distractor and is not used in the formula.

Adım Adım Çözüm

1
Convert pounds to kilograms.
16 kg16\text{ kg}
The medication is prescribed based on kilograms of body weight.
2
Calculate the total daily dose.
800 mg/day800\text{ mg/day}
Multiply the weight (16 kg16\text{ kg}) by the prescribed daily amount (50 mg/kg50\text{ mg/kg}).
3
Determine the single dose amount.
400 mg/dose400\text{ mg/dose}
The daily dose is divided into two equal doses (800 mg÷2=400 mg800\text{ mg} \div 2 = 400\text{ mg}).
4
Calculate the volume to administer.
1.1428... mL1.1428...\text{ mL}
Divide the desired single dose (400 mg400\text{ mg}) by the concentration (350 mg/mL350\text{ mg/mL}). The 2.1 mL2.1\text{ mL} of diluent is required for reconstitution but is irrelevant to the final volume calculation.
5
Round to the nearest tenth.
1.11.1
Follow the explicit rounding instructions provided in the question stem.

Anahtar Kavram

Weight-based pediatric dosage calculation and medication reconstitution
Soru 171Soru →

A practical nurse is caring for a client who is 24 hours postoperative following an abdominal surgery. The client is prescribed oral hydromorphone every 4 hours as needed for pain. Upon entering the room to administer a requested dose, the nurse observes that the client is difficult to arouse, with a respiratory rate of 8 breaths per minute and an oxygen saturation of 88% on room air. Which action should the nurse take first?

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Cevap: Withhold the hydromorphone, attempt to rouse the client, and immediately notify the registered nurse.

Cevap

The practical nurse should withhold the hydromorphone, attempt to rouse the client, and immediately notify the registered nurse.
The client is exhibiting signs of severe opioid-induced respiratory depression, as evidenced by a respiratory rate of 8 breaths per minute and hypoxia. The priority action is to ensure airway and breathing safety by withholding further central nervous system depressants, stimulating the client, and escalating the critical finding to the registered nurse for advanced intervention.

Adım Adım Çözüm

1
Assess the client's vital signs and clinical presentation.
The client is difficult to arouse with a respiratory rate of 8 breaths per minute and an oxygen saturation of 88%.
To identify signs of opioid-induced respiratory depression before medication administration.
2
Prioritize interventions based on the ABCs (Airway, Breathing, Circulation).
Further administration of the central nervous system depressant is withheld.
Administering an opioid would exacerbate the life-threatening respiratory depression.
3
Determine the appropriate action within the practical nurse scope of practice.
The nurse stimulates the client to encourage breathing and escalates the critical situation to the registered nurse.
Advanced interventions, such as administering intravenous naloxone, are outside the practical nurse scope of practice.

Anahtar Kavram

Opioid-Induced Respiratory Depression and PN Scope of Practice
Soru 172Soru →

A practical nurse is assessing an 8282-year-old client diagnosed with acute pyelonephritis who is receiving intravenous antibiotics. The client, who was previously oriented, suddenly exhibits marked restlessness and confusion. Vital signs reveal a blood pressure of 92/6092/60 mm Hg (baseline was 136/82136/82 mm Hg), a heart rate of 118118 beats/minute, and a respiratory rate of 2424 breaths/minute. Which action should the practical nurse implement first?

Cevabı ve açıklamayı göster

Cevap: Notify the registered nurse immediately to report the acute changes in condition.

Cevap

The correct action is to notify the registered nurse immediately regarding the acute changes in the client's condition.
The correct answer identifies the need for immediate escalation. The client's presentation of a known infection accompanied by sudden confusion, a significant drop in blood pressure, and tachycardia indicates early septic shock. Within the practical nurse's scope of practice, recognizing these critical cues and immediately notifying the registered nurse is the highest priority to ensure the client receives life-saving interventions.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
The client has a severe infection and is exhibiting new-onset confusion, restlessness, significant hypotension (92/6092/60 mm Hg from a baseline of 136/82136/82 mm Hg), tachycardia (118118 beats/minute), and tachypnea.
Identifying abnormal assessment data is the first step in clinical reasoning.
2
Correlate the findings to potential complications.
The combination of infection, altered mental status, and deteriorating vital signs points strongly to systemic inflammatory response syndrome (SIRS) or early septic shock.
Recognizing patterns of physiological decompensation ensures timely intervention.
3
Determine the priority nursing action based on scope of practice.
The practical nurse must urgently escalate these critical findings to the registered nurse or provider for immediate medical intervention.
Initiating advanced shock management requires the RN and provider, making immediate communication the highest priority.

Anahtar Kavram

Early recognition of shock and acute physiological decompensation requires immediate escalation to the registered nurse.
Soru 173Soru →

A practical nurse is evaluating an older adult resident in a long-term care setting who has been receiving oral antibiotics for the past three days to treat a lower extremity soft tissue infection. During an evening check, the resident appears unusually drowsy, is unable to identify a visiting family member, and has a blood pressure of 104/60 mm Hg with a resting pulse of 102 beats per minute. The resident's documented baseline blood pressure is 138/78 mm Hg. Which conclusion should guide the nurse's immediate response?

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Cevap: The current data indicates potential systemic hypoperfusion, necessitating urgent escalation of medical care.

Cevap

The correct conclusion is that the data indicates potential systemic hypoperfusion, requiring urgent medical escalation.
The correct answer identifies that the combination of a significant drop in baseline blood pressure, tachycardia, and a sudden change in mental status in a client with an active infection strongly suggests early sepsis and systemic hypoperfusion. This represents an acute failure of physiological adaptation, requiring immediate intervention to restore adequate circulation and tissue oxygenation.

Adım Adım Çözüm

1
Analyze the client's vital signs by comparing the current readings to the documented baseline parameters.
The blood pressure has dropped significantly from a baseline of 138/78 mm Hg to 104/60 mm Hg, which is accompanied by a resting pulse of 102 beats per minute.
Recognizing relative hypotension (a significant drop from baseline, even if the absolute number does not meet strict hypotensive criteria) and tachycardia is crucial for identifying early hemodynamic instability.
2
Correlate the objective physical data with the new onset of neurological changes and the active infection diagnosis.
The combination of relative hypotension, tachycardia, new-onset lethargy, and a pre-existing soft tissue infection points directly to a severe systemic complication.
Acute confusion or uncharacteristic drowsiness in an older adult, especially alongside an active infection and vital sign changes, is frequently the earliest indicator of sepsis and inadequate cerebral perfusion.
3
Prioritize the nursing response based on the severity and acuity of the identified condition.
The nurse must determine that the client is experiencing impending shock and initiate an urgent emergency response.
Systemic hypoperfusion is a life-threatening airway, breathing, and circulation (ABC) emergency that takes absolute precedence over routine monitoring, comfort measures, or psychosocial interventions.

Anahtar Kavram

Recognizing early signs of systemic hypoperfusion and sepsis in older adults
Tahmini Süre:1m 15s
Soru 174Soru →

A practical nurse enters the room of a client who has a central venous catheter. The nurse discovers that the intravenous tubing has disconnected from the catheter hub. The client suddenly reports sharp chest pain, is gasping for air, and appears cyanotic. In what order should the nurse perform the following actions to reduce the client's risk of further harm? Arrange the steps in the correct sequence from first to last.

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Cevap

The correct sequence for managing a suspected central line air embolism is to first clamp the catheter to stop air entry, then position the client in a left lateral Trendelenburg position to trap the air, followed by administering high-flow oxygen, activating the Rapid Response Team, and finally obtaining vital signs.
The sequence reflects the fundamental principles of risk reduction during an acute central line complication: stop the source of the injury (clamp), mitigate the immediate pathophysiological risk (position to trap air), treat the physiological symptoms (oxygen), escalate care (call for help), and evaluate the client's status (vital signs).

Adım Adım Çözüm

1
Clamp the disconnected central venous catheter.
Stops further air from entering the circulatory system.
The most critical initial action in any mechanical hazard is to eliminate the source of the harm before addressing the consequences.
2
Place the client in a left lateral Trendelenburg position.
Traps the air embolus in the right ventricle.
This specific gravitational positioning prevents the air bubble from moving forward into the pulmonary circulation, which would cause an acute right ventricular outflow obstruction.
3
Administer high-flow oxygen.
Treats systemic hypoxia and reduces the size of the embolus.
Administering 100% oxygen addresses the respiratory distress and creates a diffusion gradient that helps the body resorb the nitrogen-rich air bubble.
4
Activate the Rapid Response Team.
Summons advanced medical and critical care support.
An air embolism is a profound systemic emergency requiring interventions and continuous monitoring beyond the practical nurse's scope of practice.
5
Obtain vital signs.
Establishes a baseline of the client's current physiological status.
Vital signs provide essential, objective data regarding cardiac output and respiratory effort for the Rapid Response Team upon their arrival.

Anahtar Kavram

Prioritization of interventions for a central venous catheter air embolism requires stopping the source of air first, followed by mechanical positioning to trap the air, and then supportive oxygen therapy.
Soru 175Soru →

A 55-year-old individual is recovering on the surgical unit 24 hours after a right-sided modified radical mastectomy with axillary lymph node dissection. As the practical nurse organizes basic care and comfort measures for the shift, which of the following actions should be included in the plan of care? Select all that apply.

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Cevap: Elevate the client's right arm on a pillow while resting in bed.; Encourage the client to perform finger-flexion and wrist-rotation exercises with the right hand.

Cevap

The correct actions are to elevate the client's right arm on a pillow while resting and to encourage finger-flexion and wrist-rotation exercises with the right hand.
The correct answers involve elevating the affected right arm on a pillow and encouraging simple distal movements like finger-flexion and wrist-rotation. Following an axillary lymph node dissection, normal lymphatic drainage is disrupted, predisposing the client to lymphedema (swelling) and severe discomfort. Elevating the arm uses gravity to facilitate fluid return, thereby reducing edema and pain. Additionally, gentle distal exercises such as hand squeezing or wrist rotation promote circulation and prevent joint stiffness without placing undue stress on the fresh chest wall incision.

Adım Adım Çözüm

1
Analyze the client's surgical procedure.
The client had a right-sided mastectomy with axillary lymph node removal.
Lymph node removal disrupts normal lymphatic drainage pathways, increasing the client's risk for lymphedema and significant discomfort in the affected upper extremity.
2
Evaluate positioning and mobility options for comfort and safety.
Elevating the right arm and encouraging distal joint exercises are appropriate interventions.
Elevation uses gravity to assist lymphatic fluid return away from the hand and arm, while simple distal exercises promote circulation without straining the chest wall suture lines.
3
Identify contraindicated actions that compromise safety or comfort.
Dependent positioning, lying on the operative side, and delegating assessments to UAP are incorrect.
Dependent positions and direct pressure on the operative side worsen tissue edema and pain. Furthermore, wound assessment falls outside the UAP's legal scope of practice.

Anahtar Kavram

Post-mastectomy basic care and comfort focuses on preventing lymphedema and pain by elevating the affected arm and promoting circulation through gentle, distal range-of-motion exercises.
Soru 176Soru →

A practical nurse is preparing to collect a sterile urine specimen for culture and sensitivity from a client's indwelling urinary catheter. To reduce the risk of sample contamination and client infection, in what order should the nurse perform the following actions? (Arrange the steps in the correct sequence from first to last.)

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Cevabı ve açıklamayı göster

Cevap

The correct sequence is to first clamp the tubing to collect urine, clean the port, withdraw the sample with a syringe, transfer it to a sterile cup, and finally unclamp the tubing.
The collection of a sterile urine specimen from a closed urinary drainage system requires strict aseptic technique to prevent introducing bacteria into the client's bladder and to ensure the laboratory results are accurate. First, the tubing is clamped to collect freshly produced urine. Next, the port must be disinfected before access. A sterile syringe is then used to withdraw the sample from the clean port. The sample is transferred to a sterile cup, and finally, the tubing must be unclamped to prevent urinary retention and potential kidney damage from backflow.

Adım Adım Çözüm

1
Clamp the drainage tubing.
Fresh urine collects above the clamp.
Urine from the drainage bag is not sterile; fresh urine must be collected to ensure an accurate culture.
2
Scrub the aspiration port.
The surface of the port is disinfected.
Prevents the introduction of surface pathogens into the urinary tract when the syringe is attached.
3
Aspirate the urine.
A sterile sample is obtained.
Safely extracts the accumulated urine using a closed-system approach.
4
Transfer the sample.
The urine is secured in a sterile container.
Prepares the specimen for transport to the laboratory without environmental contamination.
5
Remove the clamp.
Continuous bladder drainage is restored.
Prevents urinary retention, bladder spasms, and potential kidney damage from urine backflow.

Anahtar Kavram

Sterile Specimen Collection from a Closed Drainage System
Soru 177Soru →

A practical nurse (PN) is preparing to administer prescribed timolol eye drops to a client diagnosed with glaucoma. Assuming hand hygiene has been performed and clean gloves are applied, in what order should the PN perform the following steps?

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Cevap

The correct sequence is to first cleanse the eye, position the client looking upward, expose the conjunctival sac, instill the medication into the sac, and finally apply pressure to the nasolacrimal duct.
The proper sequence for ophthalmic administration prioritizes infection control, client safety, and the prevention of systemic absorption. Cleansing the eye first prevents the introduction of debris. Proper positioning and exposing the conjunctival sac protect the highly sensitive cornea from injury. Instilling the medication into the sac ensures even distribution. Finally, applying pressure to the nasolacrimal duct is a critical safety step to prevent systemic effects of the medication.

Adım Adım Çözüm

1
Cleanse the client's eyelid and eyelashes, wiping from the inner to the outer canthus.
Debris is removed from the eye area.
Prevents the introduction of external contaminants into the eye during administration.
2
Instruct the client to tilt their head back slightly and look up at the ceiling.
The cornea is rotated upward and away.
Reduces the risk of stimulating the blink reflex and protects the cornea from injury.
3
Gently pull down the client's lower eyelid using a thumb or index finger to expose the conjunctival sac.
The conjunctival sac is exposed.
Creates a pouch to safely receive the medication without dropping it directly onto the sensitive cornea.
4
Instill the prescribed number of drops into the center of the lower conjunctival sac.
Medication is delivered evenly without touching the eye.
Prevents injury to the cornea and maintains the sterility of the medication dropper.
5
Apply gentle pressure to the client's nasolacrimal duct for 30 to 60 seconds.
The nasolacrimal duct is occluded.
Prevents systemic absorption of the medication, which is critical when administering beta-blockers like timolol.

Anahtar Kavram

Safe Administration of Ophthalmic Medications
Soru 178Soru →

A practical nurse is assessing a client who underwent an open bowel resection 1212 hours ago. Which clinical finding should the nurse identify as the highest priority to report to the registered nurse?

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Cevap: A resting heart rate of 114114 beats per minute and a blood pressure of 98/6298/62 mm Hg

Cevap

The correct answer is the finding of a resting heart rate of 114 beats per minute and a blood pressure of 98/62 mm Hg.
The correct answer is the elevated heart rate and lowered blood pressure, as these are classic signs of early hypovolemic shock. In a client who is 1212 hours postoperative, these borderline vital signs strongly suggest internal hemorrhage or severe fluid volume deficit. This is a life-threatening complication requiring immediate escalation to the registered nurse for assessment, fluid resuscitation, and provider notification.

Adım Adım Çözüm

1
Analyze the client's timeframe and surgical procedure.
The client is 1212 hours post-open bowel resection, placing them in a critical window for postoperative hemorrhage and fluid shifts.
Identifying the postoperative timeframe highlights the most likely physiological risks.
2
Evaluate the vital signs option against baseline expectations.
Tachycardia (heart rate of 114114) combined with borderline hypotension (blood pressure of 98/6298/62) are classic indicators of early hypovolemic shock.
Vital signs provide objective data about the client's circulatory status.
3
Apply the ABC (Airway, Breathing, Circulation) prioritization framework to compare the options.
Circulatory compromise (shock) takes priority over expected postoperative pain (comfort), slightly abnormal but stable labs, and scope of practice limitations regarding medication administration.
The ABC framework ensures life-threatening physiological needs are addressed first.
4
Select the most life-threatening finding.
The vital signs indicating early shock require immediate registered nurse notification for prompt fluid resuscitation.
Delaying treatment for shock can result in irreversible organ damage or death.

Anahtar Kavram

Reduction of Risk Potential: Prioritization of Postoperative Complications
Tahmini Süre:1m 0s
Soru 179Soru →

A practical nurse (PN) is assigned to care for a client with bipolar disorder who is receiving scheduled oral lithium carbonate. The PN reviews the client's morning electronic health record and notes a serum lithium level of 2.2 mEq/L2.2 \text{ mEq/L}. The next dose of lithium is due in 30 minutes. Which of the following actions should the PN take?

Cevabı ve açıklamayı göster

Cevap: Withhold the scheduled medication and immediately notify the registered nurse (RN).

Cevap

Withhold the scheduled medication and immediately notify the registered nurse (RN).
The client's serum lithium level of 2.2 mEq/L2.2 \text{ mEq/L} indicates toxicity, as the normal therapeutic range is typically 0.60.6 to 1.2 mEq/L1.2 \text{ mEq/L}. The safest and most appropriate action within the practical nurse's scope of practice is to withhold the scheduled dose to prevent further harm and immediately notify the registered nurse or healthcare provider so that the treatment plan can be medically evaluated.

Adım Adım Çözüm

1
Evaluate the client's laboratory results against normal therapeutic ranges.
The serum lithium level is 2.2 mEq/L2.2 \text{ mEq/L}, which is significantly above the expected therapeutic range of 0.60.6 to 1.2 mEq/L1.2 \text{ mEq/L}.
Recognizing critical laboratory values is essential before administering narrow-therapeutic-index medications.
2
Determine the appropriate nursing intervention for a toxic medication level.
The scheduled dose of lithium must be withheld to prevent further central nervous system and renal toxicity.
Administering the medication would exacerbate the existing toxicity and cause patient harm.
3
Apply the practical nurse (PN) scope of practice regarding abnormal findings.
The PN must report the critical lab value to the supervising registered nurse (RN) or healthcare provider.
The PN is responsible for gathering data and reporting significant deviations from normal to the RN for further assessment and collaborative management.

Anahtar Kavram

Lithium toxicity recognition and the practical nurse's role in withholding medication and escalating critical findings.
Soru 180Soru →

The practical nurse (PN) is providing care for a client who recently returned to the surgical unit following a subtotal thyroidectomy. Which positioning technique should the PN implement to maintain client comfort and safety?

Cevabı ve açıklamayı göster

Cevap: Elevate the head of the bed to a semi-Fowler's position and support the client's head and neck.

Cevap

Elevate the head of the bed to a semi-Fowler's position and support the client's head and neck.
Following a thyroidectomy, placing the client in a semi-Fowler's position (30 to 45 degrees) with the head and neck carefully supported by pillows is the optimal intervention. This position utilizes gravity to reduce swelling and edema in the neck area. Furthermore, keeping the head in a neutral, supported position decreases tension on the surgical suture line, minimizes discomfort, and crucially helps maintain a patent airway, which is the absolute primary postoperative priority for this specific surgery.

Adım Adım Çözüm

1
Analyze the client's surgical procedure (subtotal thyroidectomy).
Identify that the surgical incision is on the anterior neck.
Understanding the surgical site is essential for determining the safest and most comfortable postoperative position.
2
Determine the primary postoperative risks for this procedure.
Recognize that edema, bleeding, and hematoma formation in the neck can lead to life-threatening airway obstruction.
Anticipating complications guides the prioritization of nursing interventions.
3
Select the positioning technique that mitigates these risks.
Choose a semi-Fowler's position with the head and neck carefully supported by pillows.
Gravity helps reduce edema in the head and neck, while firm support prevents hyperextension or hyperflexion, protecting the airway and the integrity of the suture line.

Anahtar Kavram

Basic Care and Comfort: Postoperative Positioning for Airway Protection
ÖncekiSayfa 9 / 66Sonraki
Physiological Integrity Alıştırma Soruları — NCLEX-PN — Sayfa 9 | Examkin