Comp. Exam 2
The practical nurse (PN) is assisting the nurse with the care of a newborn immediately after delivery. Which action should the PN perform first?
A. Dry the infant and wrap in a warming blanket
A child is admitted for severe abdominal pain and possible appendicitis. Laboratory and x-ray studies are prescribed. During the diagnostic period, the practical nurse should implement which nursing actions? (Check all that apply.)
A. Maintain child's comfort. B. Relieve parent and child's anxiety. C. Prepare for surgery.
Which directions should the practical nurse (PN) provide to an unlicensed assistive personnel (UAP)?
A. Report the total urine output for the client on intake and output.
Which finding in a 4-month-old infant warrants further investigation by the practical nurse?
B. Grunts with expiration. Rationale: Grunting on expiration (B) is a sign of respiratory distress and requires immediate attention.
The practical nurse (PN) is reviewing the morning laboratory results for a group of assigned clients. Which finding should the PN report to the healthcare provider first?
C. An older client who has received heparin for two weeks with a platelet count of 15,500/mm3. Rationale: The client in with thrombocytopenia (normal platelets 150,000 to 400,000/mm3) (C) is likely experiencing a complication due to heparin therapy, and requires timely intervention to prevent bleeding.
A male child who hit his face on the sidewalk after falling off his bike presents in the school nurse's office with noticeable swelling around the mouth and nose and is carrying his front teeth in a tissue. Which action should the practical nurse (PN) take first?
B. Obtain the respiratory rate and effort. R
A male client is eating at his bedside table and suddenly starts gagging, is unable to talk, and places both hands over his throat. Which action should the practical nurse implement?
D. Apply successive abdominal thrusts. Rationale: Abdominal thrusts, also known as the Heimlich maneuver (D), should be performed to loosen the obstructing foreign body. The client's airway is obstructed and (A) is ineffective. Back blows
The practical nurse (PN) is caring for four clients. Which client's data requires further nursing action?
A. An adult with type 2 diabetes mellitus (DM) who has fasting glucose levels at 190 mg for 3 days. RATIONALE: The client with DM (A) who has fasting glucose levels of 190 mg for 3 days needs further action for the uncontrolled serum glucose. (d.
An infant receives an Apgar score of 9 at one minute following birth. Which deduction in the total score, based on the Apgar scoring system, generally results in a normal, healthy neonate receiving an Apgar score of 9 instead of 10?
A. Pink body with bluish discoloration of hands and feet. Rationale: The Apgar score is determined by evaluating the newborn infant's appearance (color), pulse (heart rate), grimace (reflex irritability), activity (muscle tone), and respirations. A score of 10 is highly unusual, and most newborns lose a point for the bluish coloring to their hands and feet, which will normalize to a pink coloring once their body temperatures have warmed up sufficiently (A). The findings described for heart rate (B), reflex irritability
A group of practical nurses (PNs) who work on a medical-surgical unit believe they are understaffed. Which data should the PNs consider when preparing the justification for additional staff?
B. Client acuity and census. Rationale: When presenting the need for increased staff, the PNs should present the request using staffing guidelines that consider client acuity, number of clients, and length of stay(B).
Which client who arrives at the urgent care clinic should be seen first by the practical nurse (PN)?
C. A thirteen-year-old with asthma who just vomited following a spell of coughing. Rationale: Particularly in pediatric clients with asthma, coughing until vomiting (C) can be a sign of an asthma exacerbation and requires further assessment. Diarrhea is a common side effect of amoxicillin (
An older male client who drove himself to the emergent care clinic with chest pain is placed on a cardiac monitor with oxygen per nasal cannula at 2 liters/minute as an IV access is obtained. Which intervention should the practical nurse implement first?
C. Apply telemetry electrodes to the client's chest.
Which action is most important for the practical nurse (PN) to implement for a client who has a Stage I pressure ulcer?
D. Monitor client's serum pre-albumin levels.
When reviewing the need to take warfarin sodium (Coumadin) with a male client who is recently diagnosed with chronic atrial fibrillation, what explanation should the practical nurse reinforce with the client?
A. Prevent emboli. Rationale: Atrial fibrillation is a condition in which the upper two chambers of the heart beat irregularly with the lower two chambers, which is a chaotic rhythm that causes the blood to pool and clot, which leads to stroke. Coumadin helps to prevent the formation of emboli (A) by blocking the action of vitamin K in the liver and reducing the amount of clotting factors in the blood. Coumadin does not stop the buildup of plaque
A healthcare provider begins screaming at the practical nurse (PN) who is standing at the nurses' station and demands that the laboratory results be made available immediately. Which action should the PN take first?
A. Suggest moving to a private area to discuss further. Rationale: Moving to a private area to discuss the issues away from public display is the first action (A), which may help de-escalate the situation. (B) may be indicated after the nursing supervisor is called to assist with resolving the incident. Although (C) is indicated, a setting that provides privacy should be used first to minimizing further disruptive interaction. The nursing supervisor (D) should be called to assist with the situation but privacy for further discussion should be suggested first
A male client who receives albuterol (Ventolin) nebulizing treatment PRN is asking the practical nurse (PN) for his breathing treatment. Which assessment should the PN implement before administering the PRN prescription? A. Incentive spirometer level. B. Breath sounds. C. Respiratory rate. D. Accessory respiratory muscles effort.
B. Breath sounds. Rationale: Albuterol (Ventolin), a bronchodilator, is indicated for wheezing caused by narrowing of the air passages, so the client's breath sounds (B) should be auscultated to determine if the albuterol breathing treatment is indicated. Incentive spirometer (A) is an inspiratory exercise used to inflate alveoli and prevent atelectasis, not treat reactive airway disease. (C and D) do not provide accurate information about bronchial airway patency
A client with "fever of undetermined origin" awakens with right periorbital swelling. Which action should the practical nurse take first? A. Apply warm moist compress to the right eye. B. Check for conjunctival erythemia and drainage. C. Determine if the client has nasal congestion. D. Ask the client about history of drug reactions.
B. Check for conjunctival erythemia and drainage. Rationale: Unilateral periorbital swelling is most likely a local infection, so the PN should assess the client for additional findings of eye infection, such as conjunctival erythemia and drainage (B) from the eye. The findings should be reported to the charge nurse for additional actions before (A) is implemented. Although (C and D) may provide additional information related to the client's swollen eye, a focused assessment of the eye should be completed first
A client who had a total knee arthroplasty (TKA) three days ago is being transferred to the rehabilitation center. The healthcare provider prescribes activity as tolerated. Which action should the practical nurse (PN) take? A. Ask someone to follow the client with a wheelchair. B. Obtain clarification of prescription about weight bearing. C. Inquire about routine physical therapy progression. D. Ask the client what he did yesterday for activity.
B. Obtain clarification of prescription about weight bearing. Rationale: The healthcare provider should indicate the amount of weight bearing the client should safely be able to tolerate after TKA, so the PN should clarify the prescription (B). (A) is a safety measure to prevent falls while the client begins mobilization. (C) may be helpful but does not provide individualized care for the client. (D) provides a comparison for the client's progression with activity as tolerated
A client is being discharged after repair of a retinal detachment. The practical nurse (PN) reviews the written discharge information with the client and family. Which instruction should the PN emphasize to the client when arriving at home?
B. Take a PRN antiemetic with early signs of nausea. Rationale: To minimize increased intraocular pressure, it is most important that the client take an antiemetic as soon as nausea is experienced
The practical nurse (PN) assigns the task of obtaining vital signs for all the clients on a 24-bed unit to an experienced unlicensed assistive personnel (UAP). What action should the PN take to ensure the clients are receiving safe care?
B. Take vital signs for any client with abnormal findings. Rationale: To ensure safe care, the PN should take the vital signs for any client with abnormal results to evaluate the client's condition (B). Trends should be evaluated on an ongoing basis, not just at the end of the shift
The practical nurse (PN) is caring for a client in a weight reduction program. Which client behavior is the best indicator to the PN that the client is applying the knowledge gained from the program about weight loss?
D. Loses five pounds in three weeks.
A female client reports to the practical nurse (PN) that she has had 10 watery diarrhea stools in the last 24 hours and is feeling dizzy. Which intervention should the PN implement first?
D. Obtain her vital signs lying and standing. Rationale: The client is experiencing fluid volume deficit related to diarrhea and dehydration evidenced by feeling dizzy, so the client's lying and standing vital signs (D)
The practical nurse (PN) is caring for a client who is receiving chemotherapy for cervical cancer who is scheduled to go for a chest xray. Current laboratory results include hemoglobin 10.0 grams/dl, absolute neutrophil count (ANC) of 500, platelets 120,000/mm3, and white blood cells 4,000/mm3. What action should the PN implement first?
D. Place a protective mask on the client for transport.
Which protocol regarding standard policies about prescriptions should the practical nurse (PN) question?
D. Preoperative prescriptions should be resumed after a client returns from surgery.
A male client who is paraplegic due to a diving accident is admitted to the rehabilitation unit. Which finding is most important for the practical nurse (PN) to report to the interdisciplinary team?
D. Repeated refusals to see any visitors.
The practical nurse (PN) administered furosemide (Lasix) 60 mg PO instead of the client's prescribed dose of 20 mg. What action is most important for the PN to implement? A. Complete an adverse occurrence report. B. Record dose on the medication administration record. C. Reinforce with the client about the side effects of Lasix. D. Take client's blood pressure in an hour.
D. Take client's blood pressure in an hour. Rationale: The onset of oral dosing of Lasix is 30-60 minutes, peaking 60-70 minutes after administration. Blood pressures should be monitored in an hour (D) to identify signs of hypovolemia during periods of diuresis. (A) is not indicated unless the client experiences a severe adverse response. Documentation (B) is implemented after drug administration. Although the client should be aware of side effects (C), the priority is assessment for adverse effects during the peak action of oral Lasix.
Which observation by the practical nurse (PN) indicates that a piece of medical equipment is not functioning properly? .
D. The sphygmomanometer's reading drops without a knob turn. Rationale: The blood pressure reading that is not controlled by the knob (D) on the cuff indicates a malfunction of the equipment.
The practical nurse is assisting with moving clients into semiprivate rooms so other rooms can be made available for the admission of victims of a community disaster. Which two clients should be placed in the same room?
D. Two clients on universal precautions, one for asthma exacerbation, the other with heart failure. Rationale: Two non-infectious clients on universal precautions should be placed in the same room (D).
Which individual should the practical nurse (PN) respond to first?
A. A visitor is lying still on the floor in the middle of the unit hallway. Rationale: The visitor who is unresponsive on the floor (A) requires immediate attention to determine if resuscitation is indicated. (B) can be contacted after the emergency situation is addressed. (C) can be delegated to the UAP to clean up the water spill and notify maintenance and housekeeping personnel. (D) can be addressed after the emergency or by another nursing team member.
A client with chronic kidney disease (CKD) begins to manifest Kussmaul respirations. What action should the practical nurse implement?
A. Administer prescribed sodium bicarbonate. Rationale: Kussmaul breathing occurs in an effort to compensate for metabolic acidosis, which results from kidneys inability to excrete acid products such as ammonia, which is normally buffered by bicarbonate. To help correct this imbalance, supplements such as sodium bicarbonate (A) are prescribed and should be administered promptly. Although
A client with type 2 diabetes mellitus is admitted to the hospital for an exacerbation of asthma. The practical nurse (PN) administers hydrocortisone (Solu-Cortef) 60 mg PO every 6 hours. What information should the PN to review the next day?
B. Serum glucose. Rationale: High doses of glucocorticoidsteriods can cause an elevation in the serum glucose level, so the PN should review the clients serum glucose(B)
A newborn with apnea is being discharged from the hospital with home monitoring. What information concerning the infant's care should the practical nurse review with the parents?
A. Cardiopulmonary resuscitation (CPR). Rationale: Apnea of infancy (AOI) engenders great anxiety in parents, and the initiation of home monitoring presents additional emotional stress. When home monitoring is required the parents should receive instructions that include cardiopulmonary resuscitation(A). (B) does not indicate Apnea
A client who sustained a C4 injury in a head-on automobile collision is admitted to the neurological unit. Which priority assessment should the practical nurse (PN) monitor?
A. Depth of respirations.
The practical nurse (PN) assigns care of a client who is HIV positive to a newly employed PN who states, I can't take care of that client. How should the PN respond?
A. "I don't understand your response. Please explain what you mean." Rationale: The ethical principle of beneficence guides decisions based on the clients well being or dignity. The PN should first assess the rationale supporting the response (A) which may include an infection such as a "Cold" that places the immunosuppressed client at risk
After reviewing discharge instructions with a male client who has hepatitis C, what statement by the client indicates to the practical nurse that the client understands his disease?
A. "I will avoid taking any products with acetaminophen, such as Tylenol." Rationale: Tylenol is metabolized in the liver and should be avoided with clients with liver disease
The practical nurse (PN) is participating in a group interview of an applicant who will work in the clinic as a staff PN. Which question is best to ask the applicant?
A. "This position requires working on-call every fourth weekend. Can you do that?" Rationale: Job interview questions must be specifically job related (A)
A woman who is 32-weeks gestation arrives at the prenatal clinic and reports painless contractions and mucoid vaginal discharge. The fetal heart rate is 150 beats/minutes. What action should the practical nurse (PN) implement first?
A. Place in the left lateral recumbent position. Rationale: Preterm labors symptoms include contractions and mucoid vaginal discharge so the PN should place the client in the left lateral position
A client who is pregnant arrives at an urgent care clinic and complains of feeling very uncomfortable. The client states she feels a strong urge to have a bowel movement. Which action is most important for the practical nurse (PN) to implement?
A. Place the client in a room with a precipitous delivery tray. Rationale: The client is manifesting signs of an imminent delivery, which includes regular contractions that are very uncomfortable, a strong urge to defecate, and pushing, so she should be immediately placed in the room with a precipitous delivery tray (A) to ensure a safe, sterile environment for delivery.
An older client who takes digoxin (Lanoxin) daily calls the clinic about not feeling well. The new onset of which finding should the practical nurse advise the client to come for a visit with the healthcare provider?
A. Vomiting. Rationale: In older clients, nausea and vomiting (A) are early signs of digoxin toxicity, which can occur due to cumulative effects, even with subtoxic digoxin levels. Bradycardia, not tachycardia (B) is a sign of digoxin toxicity. Constipation (C) is not related to digoxin toxicity. Tinnitus (D) is a symptom of aspirin toxicity.
A client arrives in the clinic complaining of radiating back pain. Which finding related to a possible dissecting aneurysm should the practical nurse (PN) report to the healthcare provider?
A. Ripping chest pain and blood pressures of 150/90 in right arm and 120/70 in left arm. Rationale: A dissecting aneurysm is a tearing of the intima of a major artery, such as the ascending aorta, and classically presents with the onset of sudden, severe, ripping pain that moves. Depending on the location, as the intima of the artery tears, a difference in the extremity perfusion (A), deceased urine output, or petechiae on the feet occur. (ation
An older male client with a history of hypertension presents in the urgent care center with an elevated blood pressure and tachycardia. Which finding should the practical nurse report to the healthcare provider immediately?.
A. Tearing pain that has moved to his low back. Rationale: The client has classic findings, such as age and history of hypertension, for a possible dissecting aneurysm. Severe tearing pain that moves from the client's chest to the back (A) is symptomatic of this life threatening and requires immediate treatment and must be reported immediately. (
The practical nurse (PN) is using bag-mask device to administer artificial ventilation for a three-year-old child. Which method is best to use to create a seal while holding the mask in place?
B. Place the mask over nose and mouth using a c-e one-hand technique.
Which client should the practical nurse (PN) obtain a Glasgow Coma Scale (GCS) score?
B. An adolescent male who hit his head due to alcohol toxicity. Rationale: The GCS score evaluates a client's neurological responses after experiencing an acute head injury. Although alcohol toxicity may alter the adolescent's responses, the GCS score should be implemented during and after alcohol detoxification to screen for neurological changes characteristic of a head injury (B).
Which medication side effects should the practical nurse tell the client to report to the healthcare provider? A. Constipation occurs when taking hydrocodone/acetaminophen (Vicodin). B. Multiple diarrhea stools begins after starting Clindamycin (Cleocin). C. A weight loss of more than 5 pounds is identified with exenatide (Byetta). D. A headache occurs after taking the morning dose of nitroglycerin (Nitro-Dur).
B. Multiple diarrhea stools begins after starting Clindamycin (Cleocin). Rationale: Severe diarrhea is an indication of pseudomembranous colitis that can result from taking Clindamycin, and the client should promptly report this side effect to the healthcare provider (B). Vicodin, a narcotic analgesic, slows peristalsis and causes constipation (A), which is a common side effect managed with increased dietary intake of bulk, fluids, and ambulation. Byetta is known to cause transient nausea, feeling full, and weight loss (C). Up to 50% of all clients experience mild to severe transient headaches after taking nitroglycerin (D) related to the vasodilation
Which intervention is most important for the practical nurse to implement for a client with heart failure (HF)?e.
B. Obtain daily weights. Rationale: In heart failure, the inefficient pumping action of the heart causes fluid retention that is best evaluated by an increase in body weight. Obtaining daily weights (B) is the most important action in monitoring a client with HF. Although a record of intake and output
A child who is currently undergoing chemotherapy (CT) for leukemia is brought to the clinic for a possible broken ankle. What priority action should the practical nurse implement?
B. Place a mask on the child. Rationale: The child who is receiving CT for leukemia is immunosuppressed and should be protected from airborne pathogens and other sick children in the clinic. Placing a mask on the child
The practical nurse (PN) is caring for a newborn with a bluish discoloration of the hands and feet. What action should the PN implement? .
B. Record the finding on the medical record. Rationale: Acrocyanosis, a bluish discoloration of the hands and feet, is a normal variation of circulatory instability in the newborn. The finding should be documented (B). (
A male client's signed advance directive indicates that he wants no resuscitation measures, but the family disagrees and asks the practical nurse (PN) to try to change the client's mind regarding the decision. What action should the PN take?
B. Refer the family to the charge nurse to facilitate family discussion.
The practical nurse (PN) is caring for a client who had a total hip replacement yesterday. Which task should the PN assign to an unlicensed assistive personnel (UAP)?
B. Remind the client to use the incentive spirometer. Rationale: Reminding a client to use the incentive spirometer (B) can be assigned to the UAP, and the client's ability to effectively use IS should be evaluated by the PN. An abductor pillow is required during turning and this precautions must be included in the assignment
A client who is 39-weeks gestation arrives at the clinic asks the practical nurse if she is ready to have her baby soon. Which finding should the practical nurse (PN) respond to first?
B. Reports feeling wet and warm as if she is voiding involuntarily. Rationale: Rupture of the membranes that may leak at first and is often reported as a sensation of perineal wetness (B),
The practical nurse (PN) is assigned to assist with receiving clients in the Emergency Department (ED) following a community disaster. Which client finding should the PN recognize as the highest priority for care?
B. Sucking chest wound with protruding glass shard in chest Rationale: In any disaster, an immediate threat to life is the priority. The highest priority client is oxygenation, so the client with a sucking chest wound should receive immediate care. The care of the other clients (A, C, and D) should be imminently given, but do not have the priority of (B).
The practical nurse (PN) who is the charge nurse in an extended care facility works with two unlicensed assistive personnel (UAPs) who consistently do not take a lunch break. What action should the PN take?
C. Ask UAPs why they are not taking lunch breaks. Rationale: Legally, staff should take a break away from client responsibilities because staff who take lunch breaks can provide more effective and safe client care. The PN should first determine the reasons the UAPs are not taking a lunch break (C).
Following hip replacement surgery, an older male client tells the practical nurse (PN) that he lives alone in a second story apartment. What action is most important for the PN to take?
C. Contact a hospital case manager. Rationale: Living on a second floor apartment impacts the client's ability to return home. The PN should report the finding to the case manager (C), who can best assist the client by ensuring that a safe plan is in place for the care of the client after discharge.
The practical nurse (PN) stops to help an unconscious victim at the site of a motor vehicle collision. After Emergency Medical Services (EMS) arrive, the PN reports that first aid was rendered and then leaves. The victim dies on the scene from the injuries sustained. What is the PN's liability?
C. Good Samaritan immunity. Rationale: Based on the good Samaritan act (C) the PN rendered emergency care in good faith at the scene of the accident and is immune from civil liability for actions while providing care. The PN did not violate the status of Nurse practice act
When monitoring a newborn, which observation should the practical nurse report to the healthcare provider?
C. Heart rate of 110 beats per minute Rationale: The normal range for a heart beat for an infant is 120-160 so a heart rate of 110 should be reported to the healthcare provider. Newborn temperature ranges from 97.7,99.4,36.5,37.5 and normal respiratory rate is 30-60
An unemployed female client who is receiving chemotherapy shares with the practical nurse (PN) that it has been devastating for her to become bald. What action should the PN take?
C. Investigate potential resources to help obtain a wig.
The practical nurse (PN) enters a client's room at 0900 to administer a heparin injection that is prescribed BID. The physical therapist is in the middle of providing bedside therapy. What action should the PN take?
C. Leave with the medication and come back after the therapist is finished.
What client behavior illustrates to the practical nurse that a male client is adapting to the effects of his recent surgery for laryngeal cancer?
C. Looks at surgical site during care. Rationale: Surgical intervention for cancer of the larynx includes laryngectomy and radial neck dissection. The willingness to touch or look at the affected area (C) is the best indication that the client acknowledges and accepts the change in appearance. Lack of facial tension
Which early finding for a client with a new cast for a fractured leg should the practical nurse report to the charge nurse?
C. Paresthesia of affected leg.
What finding is most important for the practical nurse to consider before ambulating an older client?
C. Use of assistive devices. Rationale: To ensure the client's safety,
What is the first action the practical nurse (PN) should take when assisting with the care of a healthy newborn immediately after birth?
C. Verify the establishment of respirations. Rationale: The first action is to verify that respirations are established (C).
The practical nurse (PN) is visiting a client with a colostomy and notes excoriated skin around the stoma opening. What information should the PN provide?
D. Cut a smaller opening in the adhesive. Rationale: The most common cause of skin excoriation is from the adhesive appliance opening that is cut too large and allows fecal matter to come in contact with the skin (D). Excoriated skin is not related to diet intake (
A client who is receiving continuous oxygen is going home after discharge from the hospital. The practical nurse (PN) discovers that oxygen has not been delivered to the client's home. What priority action should the PN implement?
D. Delay the time of the client's discharge. Rationale: The client should not be released until the necessary equipment or supplies are delivered to the client's home to safely continue the client's necessary treatment (D). Sending the client home with a hospital tank
Which action should the practical nurse implement when administering an 8 ounce can of a concentrated nutritional formula via a client's gastrostomy tube (GT)?
D. Give 30 ml of tap water after administration of formula. Rationale: After administering formula additional water should be given to prevent obstruction of the GT and provide the client with additional hydration
The practical nurse (PN) is preparing to administer azithromycin (Zithromax) 500 mg PO for a client with pneumonia. The medication is available as a suspension that is labeled, 200 mg/5 ml. How many ml should the PN administer? (Enter numeric value only. If rounding is required, round to the nearest tenth
•12.5 Using ratio and proportion calculation, 200 mg : 5 ml :: 500 mg : X 200X = 2500 X = 12.5 ml
Which information should the practical nurse (PN) provide to an unlicensed assistive personnel (UAP) who is newly assigned to the unit?
A. Keep head-of-bed elevated 45 degrees for clients with an infusing enteral pump. Rationale: Information about the basic care clients such as positioning (A) should be specific to a common intervention or treatment and should focus on task within the scope of the UAP's assignment
Which action should the practical nurse perform first for a child who is injured on the school grounds and has an obvious mis-alignment of the lower forearm?
A. Remove the child's finger rings. Rationale: The child is a risk for swelling in the distal areas of the affected arm and hand. Removal of finger rings (A) should be implemented first to remove any potential constriction that may occur after tissue injury or fracture of the lower arm
A male client with recurrent angina is receiving oxygen at 2 liters/minute and begins to complain that he feels funny in his chest. The telemetry monitor reveals a rapid narrow QRS complex at 170 beats/minute. Which action is most important for the practical nurse to implement?
A. Report the findings to the charge nurse.
After a large scale community disaster occurs, many seriously injured victims need to be hospitalized. Which client who is currently hospitalized should the practical nurse most likely prepare for discharge? A. An older male who was admitted with heart failure (HF) and a troponin level of 3 ng/ml. B. A young adult male with a serum INR of 2 who was admitted for deep vein thrombosis. C. An older female client who is admitted after experiencing numbness of the left side of face. D. An adult female with acute abdominal pain who has a hemoglobin of 10 grams/dl.
B. A young adult male with a serum INR of 2 who was admitted for deep vein thrombosis.
What action is most important for the practical nurse (PN) implement to help control pain for a client who is two days post-laminectomy?
B. Determine the client's pain level at regular intervals.
The practical nurse (PN) is changing the ileostomy collection bag on a client who is 6-days postoperative for a total colectomy. Which finding requires additional action by the PN?
B. Skin maceration around stoma. Rationale: Maceration around the stoma (B) may indicate that the ileostomy bag is leaking and the peristomal skin is irritated by liquid stool from the ileum.
The practical nurse (PN) observes a family member accidentally stumble over the three-compartment drainage system (Pleur-evac®) for a client with a chest tube to suction. The PN sees that the drainage system container is cracked and the chest tube is disconnected. What action should the PN implement?
B. Submerge the end of the chest tube in a bottle of sterile water Rationale: The disconnected chest tube allows air into the chest cavity, which causes pneumothorax. The water seal should be reestablished by quickly placing the end of the tube in a bottle of sterile water (B) until a new apparatus can be prepared. A gloved hand
The practical nurse (PN) is visiting an older male client in his home. Which observation requires intervention by the PN?
B. There are piles of papers laying on the floor. Rationale: Papers cluttering the floor increases the client's risk for falls
A client in a nursing home becomes violent and verbally threatens an unlicensed assistive personnel (UAP). Which is the best way for the practical nurse (PN) in charge during the shift to handle the staff's reaction to the incident?
B.Offer a group discussion session so staff can share their thoughts and feelings Rationale: A critical incident stress debriefing evolves expression of personal feelings, discussion, and working on unresolved emotional issues to minimize post traumatic stress for the staff member. A CISD is the best action for the PN in charge to take (B) in conjunction with the guidance and assistance of the nursing supervisor in the facility
A female client who is waiting for the results of her breast biopsy tells the practical nurse (PN) that she fears it is cancer. How should the PN respond?
C. "This must be a difficult time for you." Rationale: The PN should acknowledge the client's feelings (C). Although this respond attempts to express empathy, unless the nurse has had the same experience, (A) may not be perceived as supportive. (B) offers false reassurance. (D) ignores the client's feeling and closes the topic
After a community disaster, two clients must be placed in the same room. Which client should the practical nurse select for placement in a room with a client with systemic lupus erythematosus (SLE)? .
C. A client scheduled for an emergency appendectomy. Rationale: A client with SLE is immunosuppressed and is susceptible to infections, so the client with appendicitis (C), which is an intra-abdominal inflammation of the appendix, is the best option to place in the same room.
The practical nurse (PN) is assisting the nurse with the care of a client with end stage emphysema who is on a mechanical ventilator. The PN auscultates decreased breath sounds in the right lung fields and notices that the client's neck veins are distended. Which additional assessment should the PN implement to report a tension pnuemothorax to the nurse?
C. Inspect the trachea to see if it is midline. Rationale: Tension pnuemothorax can occur when an emphysematic bullae or blebs ruptures causing air to accumulate in the pleural space and collapsing the lung. Additional findings are needed to differentiate the onset of right sided heart failure versus tension pneumothorax, which is manifested by worsening respiratory status, decreased breath sounds on the affected side, distended neck veins, and tracheal deviation from midline (C). The client's findings are due to a pneumothorax, not resisting the ventilator
The practical nurse (PN) is monitoring a client who is 3 hours post-cardiac catheterization of the right femoral artery. Which client finding requires further action by the PN?
C. Loss of right pedal pulse.
At the beginning of the shift, the practical nurse (PN) is reconciling a client's medication administration record, the prescriptions, and the dispensed drugs. Which available medication should the PN give?
C. Prescribed albuterol (Proventil); dispensed albuterol (Ventolin). Rationale: Albuterol (Ventolin and Proventil) are the same drug, and should be administered as prescribed. (
A client who is receiving oxygen (O2) at 35% per mask receives a prescription for a trial weaning of O2 to 4 liters/minute per nasal cannula. The practical nurse (PN) notes the client's pulse oximeter reading goes from 96% to 90% after two minutes with the change in O2 administration. What action should the PN take?
C. Reapply the O2 at 35% per mask.
Which task could the practical nurse assign to an unlicensed assistive personnel (UAP)?
C. Verify identification arm bands when infant is left in mom's room. Rationale: Delivering an infant from the nursery to the mother's room and verifying the identification on both arm bands is a task that could be assigned to a UAP (C). The task is a predictable, routine task on a unit. Reinforcing teaching about infant sleeping positions
Which technique should the practical nurse implement when providing care to a pediatric client? A. Weigh the mother and infant together then subtract the mother's weight. B. Tell a 5-year-old child to blow bubbles during an invasive painful procedure. C. Pinch the child's nose shut to encourage child to swallow oral medications. D. Administer intramuscular injections in the vastus lateralis for a 9-month-old.
D. Administer intramuscular injections in the vastus lateralis for a 9-month-old. Rationale: The vastus lateralis site should be used for an infant (D) until other intramuscular sites develop, which occurs as the child learns to walk.
The practical nurse (PN) arrives at the scene of a mass casualty community disaster. Which victim should the PN triage for immediate transport to the hospital for additional care? .
D. An adolescent male with mouth burns and singed nasal hairs. Rationale: The victim with singed nasal hairs (D) has inhaled flames or hot smoke and is at risk for swelling of the airways, which requires preemptive intubation to avert an expected possible life-threatening respiratory closure and arrest. (A) can be transported about the possible closed fracture site is splinted. (B) is not manifesting signs of impending delivery, and lacerations can be repaired up to 12 hours after the injury. (C) is not a priority for immediate transport.
The healthcare provider prescribes ketorolac (Toradol) 15 mg IM for a client in pain. The available concentration is 30 mg/ml. How many ml should the practical nurse (PN) administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)
•0.5 Using ratio and proportion, 30 mg : 1 ml :: 15 mg : X 30X = 15 X = 0.5 ml
A client receives a prescription for diltiazem (Cardizem) at 5 mg/hour. The drug is dispensed as 125 mg in 100 ml D5W. How many ml/hour should the practical nurse (PN) program the infusion pump?
•4 125 mg divided by 100 ml = 1.25 mg/ml = concentration of the Cardizem solution Using the formula, D/H x Q, 5 mg/1.25 mg x 1 ml = 4 ml/hour
When reviewing the safety precautions regarding newborns, what information should the practical nurse communicate to the parents? .
A. Position the infant to sleep on the baby's back. Rationale: The incident of sudden infant death syndrome (SIDS) declines when infants are positioned on their backs
A 14-year-old female arrives in the school nurse's office seeking information about healthcare agencies in the community. The practical nurse (PN) understands the client can make an autonomous healthcare decision if she has which circumstance?
A. Pregnancy. Rationale: According to the supreme court a minor who is pregnant (A) can make an autonomous healthcare decision
The practical nurse (PN) is caring for a client with angina pectoris. Which assessment finding is most important for the PN to report to the health care provider?.
A. Premature ventricular beats (PVC) at 8 per minute.
A female client recently diagnosed with colon cancer is admitted for surgery. When the practical nurse (PN) asks the woman how she is feeling, the client starts to cry. How should the PN respond?
A. Sit in silence with the client as she cries. Rationale: Sitting down with the client in silence (A) is an effective form of therapeutic communication that allows the client to express herself with tears. Since the client has not asked to be left alone,
A client who was struck by a baseball on the right temple is admitted for 24-hour observation. What finding should the practical nurse (PN) report to the nurse immediately?
D. Right pupil size 9 mm; left pupil size 6 mm. Rationale: Anisocoria, or unequal pupil size (D), is a sign of intracranial compression after head injury and should be reported immediately for follow-up management.
