2.A client with end stage chronic obstructive pulmonary disease (COPD) is anxious with labored respirations, increasing dyspnea when attempting to talk, and reports a painful cough. Which intervention should the practical nurse (PN) implement?
- A) Administer PRN opioid analgesic.
- B) Restrict family visitation.
- C) Apply a non-rebreather mask.
- D) Place client in high fowler’s position.
Explanation:
For a client with end-stage COPD experiencing labored respirations and dyspnea, positioning is critical to ease breathing. The high Fowler’s position (sitting upright at 60-90 degrees) helps expand the lungs and reduce the work of breathing by allowing gravity to assist with diaphragmatic movement.
3.A client reports experiencing persistent pain, redness, and warmth in the right elbow. Which information should the practical nurse obtain to effectively document the medical history?
- A) Mechanism of injury.
- B) Duration of pain.
- C) Pattern of inflammation.
- D) Use of pain medication.
Explanation:
Persistent pain, redness, and warmth in the elbow suggest a possible injury or inflammatory process (e.g., bursitis, arthritis, or infection). The mechanism of injury is critical to document in the medical history because it helps identify the cause of the symptoms (e.g., trauma, overuse, or infection). This information guides further assessment and treatment.
4.The neonate was born vaginally at 0918. Mother is a 29-year-old gravidity-1 parity-1 abortion-0 (G1P1A0). The neonate was born at 41 weeks gestation. APGAR score 8 at 1 minute and 9 at 5 minutes. The neonate is alert and crying. She is being held by her mother in warm blankets. When placed in the crib and unwrapped, her extremities are flexed and moving. Focused assessment indicates she has nasal flaring. Her extremities are cyanotic. She has coarse crackles in the right and left lung fields upon auscultation. Sucking and grab reflexes noted. Vital signs: Axillary temperature 97.9°F (36.6°C), Heart rate 147 beats/minute, Respiratory rate 83 breaths/minute. Click to highlight the assessment findings that require the PN’s immediate attention.
Highlighted Findings: Nasal flaring, extremities are cyanotic, coarse crackles in the right and left lung fields, respiratory rate 83 breaths/minute.
Explanation:
These findings indicate respiratory distress in the neonate, which requires immediate attention. Nasal flaring and a respiratory rate of 83 breaths/minute (normal for a neonate is 30-60 breaths/minute) suggest increased work of breathing. Cyanotic extremities indicate poor oxygenation, and coarse crackles in the lungs may suggest fluid or meconium aspiration, common in late-term neonates. These are critical signs that need urgent intervention to prevent further deterioration.
5.The neonate is alert and crying. She is being held by her mother in warm blankets. When placed in the crib and unwrapped, her extremities are flexed and moving. Focused assessment indicates she has nasal flaring. Her extremities are pink and well perfused with strong pulses. She has coarse crackles in the right and left lung fields upon auscultation. Based on the current information, which further focused respiratory assessment data would the PN want to collect? Select all that apply.
- A) Hemoglobin level
- B) Oxygen saturation
- C) Electrocardiogram
- D) Rectal temperature
- E) Urine output
- F) Bilirubin level
- G) Chest movement
Explanation:
The neonate has signs of respiratory distress (nasal flaring, coarse crackles). The PN should focus on respiratory assessment data. Oxygen saturation is critical to determine if the neonate is adequately oxygenating, especially with crackles indicating possible fluid in the lungs. Chest movement helps assess for symmetry and effort, which can indicate respiratory distress or obstruction.
7.The neonate was born vaginally at 0918. Mother is a 29-year-old gravidity-1 parity-1 abortion-0 (G1P1A0). The neonate was born at 41 weeks gestation. APGAR score 8 at 1 minute and 9 at 5 minutes. To use the bulb suction, the PN should first compress the bulb suction [Options for 1: After inserting into the side of the mouth, After inserting into the nose, Before inserting into the side of the mouth, Before inserting into the nose] and then [Options for 2: Assess the neonate’s respiratory status, Provide chest percussion, Suction both nares, Place the bulb in soapy water] once the mouth is clear of secretions.
Answer: Before inserting into the side of the mouth, Suction both nares.
Explanation:
When using a bulb syringe to clear a neonate’s airway, the correct technique is to compress the bulb before inserting it into the mouth to create suction. The mouth should be suctioned first, followed by the nares, to prevent aspiration of secretions. So, the PN should first compress the bulb “before inserting into the side of the mouth” and then “suction both nares” once the mouth is clear. This sequence ensures the airway is cleared safely and effectively.
8.The neonate was born vaginally at 0918. Mother is a 29-year-old gravidity-1 parity-1 abortion-0 (G1P1A0). The neonate was born at 41 weeks gestation. APGAR score 8 at 1 minute and 9 at 5 minutes. Data is reviewed by the practical nurse (PN). Which is the best next action for the PN to take?
- A) Place a peripheral intravenous line
- B) Place the neonate in a radiant warmer
- C) Provide supplemental oxygen via a nasal cannula
- D) Call for a chest x-ray
- E) Have the mother hold the neonate
Explanation:
From previous questions (e.g., Question 4), the neonate shows signs of respiratory distress: nasal flaring, cyanotic extremities, coarse crackles, and a respiratory rate of 83 breaths/minute. The priority is to address the respiratory distress and improve oxygenation. Providing supplemental oxygen via a nasal cannula (C) is the best immediate action.
17.A 22-year-old female client is brought to the emergency department by her mother after the client became dizzy and fell. The mother says that the client has been away at college and is home for winter break. The client’s mother is greatly concerned because while her daughter has always been thin and athletic, she has never seen her so skinny and emaciated. The client responds by telling her mother, “That is not true. You keep trying to force food down my throat even though it is obvious that I have so much weight to lose!” Have only one response option selected.
| Characteristic finding | Anorexia nervosa | Bulimia nervosa | Binge eating |
|-------------------------------|------------------|-----------------|--------------|
| Binging without compensatory behavior | | | |
| Vomiting after eating | | | |
| Intense fear of weight gain | | | |
| Caloric restriction | | | |
| Significantly low body mass index (BMI) | | | |
Answer:
Anorexia nervosa: Intense fear of weight gain, Caloric restriction, Significantly low body mass index (BMI).
Explanation:
The client’s emaciated appearance, intense fear of weight gain (“I have so much weight to lose”), and history of being thin suggest anorexia nervosa. Anorexia nervosa is characterized by caloric restriction, a significantly low BMI, and an intense fear of weight gain. Bulimia nervosa involves vomiting after eating, which isn’t mentioned. Binge eating involves binging without compensatory behavior, which doesn’t fit the client’s presentation.
20.The practical nurse (PN) is planning care for a client who has a fourth degree midline laceration that occurred during vaginal delivery of an 8 lb 10 oz (3.91 kg) infant. Which intervention has the highest priority for this client?
- A) Encourage breastfeeding to promote uterine involution.
- B) Recommend using a prescribed analgesic perineal spray.
- C) Give a prescribed PRN sleep medication.
- D) Administer a prescribed stool softener.
Explanation:
A fourth-degree midline laceration extends through the perineum, anal sphincter, and rectal mucosa, making it a severe injury. The highest priority is to prevent complications like wound dehiscence or infection, which can occur if the client strains during a bowel movement. Administering a prescribed stool softener (D) helps ensure soft stools, reducing strain and promoting healing.
21.A client with lung cancer is receiving hospice care at an inpatient facility. Currently, the client’s heart rate is 46 beats/minute, respirations are 10 breaths/minute, and the blood pressure is 73/49 mm Hg. The client tells the practical nurse (PN) that, “I am ready to make peace with God.” Which intervention should the PN implement?
- A) Encourage client to remain hopeful for recovery.
- B) Invite family and staff to pray at the client’s bedside.
- C) Contact the facility’s chaplain for spiritual support.
- D) Ask family to request that the client’s clergy visit.
Explanation:
The client is in hospice care with vital signs indicating they are nearing the end of life (bradycardia, low blood pressure, and slow respirations). Their statement about making peace with God reflects a spiritual need. The PN should facilitate this by contacting the facility’s chaplain (C), who is trained to provide spiritual support.
24.To obtain a clean catch urine sample for a urine culture, which instruction should the practical nurse (PN) provide the client?
- A) Void into the bedpan but place toilet tissue in the trash container.
- B) Collect the urine specimen immediately upon awakening in the morning.
- C) Place the urine collection cup in the stream of urine while voiding.
- D) Discard the first urine specimen and collect the second voiding.
Explanation:
A clean catch urine sample requires a midstream collection to minimize contamination from the external genitalia. The client should start voiding, then place the collection cup in the stream (C) to collect the sample, and finish voiding.
25.A client is prescribed beclomethasone to treat allergic rhinitis. The practical nurse (PN) should reinforce to the client which common effects may develop with this medication? Select all that apply.
- A) Hoarseness.
- B) Oral thrush.
- C) Angioedema.
- D) Throat irritation.
- E) Dry mouth.
Explanation:
Beclomethasone is an inhaled corticosteroid commonly used for allergic rhinitis. Common side effects include hoarseness (A), throat irritation (D), and dry mouth (E) due to local irritation of the throat and mouth. Oral thrush (B) is also a common side effect because corticosteroids can suppress local immunity, allowing fungal overgrowth (Candida albicans) in the mouth.
26.The healthcare provider prescribes a continuous delivery of half strength tube feeding 250 mL to be infused every 8 hours for a client with a gastrostomy tube (GT). The practical nurse (PN) should program the enteral pump to deliver how many mL/hour? (Enter numeric value only. If rounding is required, round to the nearest whole number).
Answer: 31 mL/hour.
Explanation:
To calculate the infusion rate, divide the total volume by the total time. The client is receiving 250 mL every 8 hours. So, 250 mL ÷ 8 hours = 31.25 mL/hour. Since rounding to the nearest whole number is required, 31.25 rounds to 31. Therefore, the enteral pump should be programmed to deliver 31 mL/hour.
27.A male client who is agitated is gesturing at the television in the day room and talking to an empty chair. Which interventions should the practical nurse (PN) implement? Select all that apply.
- Use simple commands in a calm, soothing voice.
- Acknowledge that the client’s perception is not real to others.
- Restrict the client to his room and apply soft wrist restraints.
- Instruct team members to ignore the client’s hallucinations.
- Instruct the client to stop scaring the other clients.
- Offer support and reassure the client that he is in a safe place.
Explanation:
The client is agitated and likely experiencing hallucinations (gesturing at the TV and talking to an empty chair), which may be due to a psychiatric condition. The best interventions are to de-escalate the situation using a calm, soothing voice with simple commands (A) and to provide reassurance by offering support and ensuring the client feels safe (F). These actions help reduce agitation without confrontation. ---
- Select the 5 foods that the practical nurse (PN) should encourage the client to integrate into her diet to best address the diagnosis of folic acid deficiency anemia.
- Green leafy vegetables
- Avocado
- Peanuts
- Orange juice
- Beef
- Enriched grains
- Potatoes
- Vegetable oil
Explanation:
Folic acid deficiency anemia is treated by increasing dietary intake of folate-rich foods. Green leafy vegetables (A), avocados (B), peanuts (C), orange juice (D), and enriched grains (F) are all good sources of folate.
35.Which finding(s) indicate(s) that the client is adhering to the treatment plan? Select all that apply.
- Record of medication administration
- Physical assessment
- Body mass index
- Complete blood count
- Subjective report from client
- Vital signs
- Meal diary
Explanation:
Adherence to a treatment plan can be assessed through direct evidence of following prescribed interventions. A record of medication administration (A) confirms the client is taking prescribed medications. A subjective report from the client (E) provides insight into their compliance with the plan (e.g., reporting they are following dietary or activity recommendations). A meal diary (G) shows adherence to dietary recommendations.
41.The practical nurse (PN) is working in a surgical preoperative area and reviewing a signed consent form. The form reads "amputation of the right lower leg" but the client’s preoperative area for amputation is the left lower leg. The client has already received preoperative medication from the anesthesiologist. Which should be the PN’s next action?
- A. Contact the healthcare provider to reschedule the surgery.
- B. Transport the client to the surgery suite since medications were administered.
- C. Obtain verbal consent from the client’s nearest relative or significant other.
- D. Cross out the error and initial the form to ensure the correct surgery.
Explanation:
The discrepancy between the consent form ("right lower leg") and the preoperative marking ("left lower leg") indicates a potential error that could lead to a wrong-site surgery, a serious sentinel event. The PN must halt the process and contact the healthcare provider to clarify and correct the consent form before proceeding.
### Question 10 of 130
A client with lung cancer was given an oral narcotic for pain one-hour ago. Which finding should the practical nurse (PN) report to the charge nurse?
A Pain decreased to a 2 on a 0 to 10 point pain scale.
B Heart rate reduced to 100 beats/minute.
C Bilateral pupils equal and reactive to light.
**D Respiratory rate of 6 breaths/minute.**
**Explanation:** A respiratory rate of 6 breaths/minute is significantly below the normal range for an adult (12-20 breaths/minute) and indicates respiratory depression, a potential side effect of narcotic use. This is a critical finding that should be reported immediately to the charge nurse for further intervention, as it could lead to respiratory arrest if not addressed.
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### Question 12 of 130
An older adult client, who has type 2 diabetes mellitus (DM), is at an adult daycare center. The client becomes confused, and unable to interact with the other daycare participants. The client tells the practical nurse (PN), "I just dont feel right." Which initial action should the PN take?
A Administer glucagon 0.5 mg IM.
**B Give 4 oz (120 mL) of apple juice.**
C Evaluate deep tendon reflexes.
D Assess temperature.
**Explanation:** The clients symptoms of confusion and feeling unwell in the context of type 2 diabetes suggest possible hypoglycemia, a common issue in diabetic patients. The initial action should be to provide a quick source of glucose, such as 4 oz of apple juice, to raise the blood sugar level. This follows the "15-15 rule" for treating hypoglycemia (15 grams of carbs, wait 15 minutes).
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### Question 14 of 130
The practical nurse (PN) overhears a conversation between an unlicensed assistive personnel (UAP) and another staff member in the hospital cafeteria line concerning a clients reaction to being given a diagnosis of terminal cancer. Which is the best nursing action?
A Tell the client of the UAPs concern for him.
**B Approach the individuals involved and ask them to stop.**
C Write an incident report and submit it to the unit manager.
D Try not to listen to the conversation since it is confidential.
**Explanation:** The UAP discussing a clients diagnosis in a public area like the cafeteria violates patient confidentiality, which is protected under HIPAA and ethical nursing standards. The best immediate action is to intervene by approaching the individuals and asking them to stop the conversation to prevent further breach of privacy.
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### Question 16 of 130
The practical nurse (PN) observes a client with the diagnosis of schizophrenia sitting all alone and talking quietly. Which action should the PN take?
A Ask the client if he is currently hearing voices.
B Have the unlicensed assistive personnel (UAP) escort the client down to his room.
**C Record the event but do not disturb the client.**
D Administer a PRN dose of haloperidol.
**Explanation:** The client with schizophrenia is sitting alone and talking quietly, which may indicate they are experiencing hallucinations, a common symptom of the condition. However, the client is not displaying agitation, aggression, or distress, so there is no immediate need for intervention. The best action is to document the observation for the healthcare team to monitor the clients behavior over time, without disturbing the client unnecessarily.
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### Question 22 of 130
An older client with a continuous peripheral infusion in the antecubital fossa site is reporting that the infusion pump keeps beeping. The practical nurse (PN) determines the pump is displaying a digital alarm reading, "occlusion." Which client assessment should the PN perform first?
A Measure fluid intake and output.
B Assess range of motion of the joint.
C Compare the radial pulse volume bilaterally.
**D Check for swelling underneath the elbow.**
**Explanation:** An "occlusion" alarm on an infusion pump indicates that the flow of the IV fluid is blocked, which could be due to a kinked line, a clot, or infiltration (fluid leaking into surrounding tissue). The first assessment should be to check the IV site for signs of infiltration, such as swelling underneath the elbow, as this could indicate that the fluid is not entering the vein properly.
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### Question 28 of 130
An older client is admitted to the hospital with frequent episodes of vomiting for the past two days. Which finding is most important for the practical nurse (PN) to report to the healthcare provider?
Reference Range: pH [7.35 to 7.45]
A Tenting skin turgor.
B Disoriented to place.
C Weight loss of 2 pounds (0.91 kg).
**D Venous pH of 7.48.**
**Explanation:** Frequent vomiting can lead to metabolic alkalosis due to the loss of stomach acid (HCl), which increases the blood pH. The reference range for pH is 7.35 to 7.45, and a venous pH of 7.48 is above this range, indicating alkalosis. This is a critical finding that needs to be reported to the healthcare provider for further management.
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### Question 29 of 130
The practical nurse (PN) is assisting with the plan of care for a client with costochondritis who is now experiencing increased difficulty in breathing. The client receives a prescription for tramadol. Which intervention should the PN ensure is included in the clients plan of care?
A Perform a daily whisper test of the clients hearing to detect symptoms of ototoxicity.
**B Implement ongoing assessments for signs of shallow or slow breathing.**
C Ensure peak and trough serum levels are collected with the third medication dose.
D Examine the client for stomatitis and erosion of tooth enamel.
**Explanation:** Tramadol is an opioid analgesic, and a common side effect of opioids is respiratory depression, which can manifest as shallow or slow breathing. This is especially concerning for a client with costochondritis who is already experiencing breathing difficulties. Monitoring for respiratory depression is a critical intervention.
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### Question 32 of 130
The practical nurse (PN) reviews the laboratory results and is assisting the registered nurse (RN) in preparing a plan of care for the client. The PN recognizes that the client is most at risk for [Select Response] anemia as evidenced by increased mean corpuscular volume and decreased folate.
**Answer: Megaloblastic anemia.**
**Explanation:** Increased mean corpuscular volume (MCV) and decreased folate levels are indicative of megaloblastic anemia, which is caused by folate or vitamin B12 deficiency. Folate is essential for DNA synthesis, and its deficiency leads to impaired red blood cell production, resulting in larger-than-normal red blood cells (increased MCV).
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### Question 33 of 130
The practical nurse is reinforcing education on the clients medications. Drag and drop phrases from the provided list to best complete the sentences.
Folic acid allows for the synthesis of [red blood cells].
Ferrous sulfate is a supplement that should be taken [with food] to increase the amount of iron available for uptake.
Vitamin C should be taken with iron supplements to [enhance] the uptake of iron.
**Answer:**
Folic acid allows for the synthesis of **red blood cells**.
Ferrous sulfate is a supplement that should be taken **with food** to increase the amount of iron available for uptake.
Vitamin C should be taken with iron supplements to **enhance** the uptake of iron.
**Explanation:** Folic acid is necessary for the synthesis of red blood cells, as it plays a key role in DNA synthesis and cell division. Ferrous sulfate is often recommended to be taken with food to reduce gastrointestinal irritation. Vitamin C enhances the absorption of iron in the gut by reducing ferric iron (Fe3+) to ferrous iron (Fe2+), which is more easily absorbed.
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### Question 38 of 130
The unlicensed assistive personnel (UAP) is assisting the practical nurse (PN) with client care. Which client should the PN instruct the UAP to help first?
A A frail older adult who needs help to ambulate to the dining room for a meal.
B An older adult with a colostomy who needs the bag emptied.
C An older adult who needs mouth care for a dry mouth.
**D An older adult who received a diuretic 30 minutes ago and is asking for a bedpan.**
**Explanation:** Diuretics increase urine production, and the client who received a diuretic 30 minutes ago is likely experiencing an urgent need to urinate. This need should be prioritized to prevent discomfort or potential accidents (e.g., incontinence).
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### Question 40 of 130
An older adult client tells the home health practical nurse (PN) of not having any money, and a belief of not deserving to eat, so the client has not asked anyone to help provide food. Which information is most important for PN to obtain?
A Community resources to provide financial aid.
B Medication history for antipsychotic agents.
C Availability of family members to provide meals.
**D Client thoughts about wanting to hurt himself.**
**Explanation:** The clients statement about not deserving to eat raises a red flag for potential depression or suicidal ideation, which are serious concerns. The PN must first assess for any thoughts of self-harm or suicide to ensure the clients safety, as this is the most immediate and critical issue.
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### Question 42 of 130
Which instruction should the practical nurse (PN) reinforce with a client who is scheduled to begin external radiation therapy?
A After radiation, place ice bags over the treatment area.
B Place a heating pad on low setting to the area.
**C Cleanse the skin to be treated with a mild soap.**
D Apply nonperfumed moisturizing lotion to the site.
**Explanation:** For clients undergoing external radiation therapy, the skin in the treatment area should be kept clean and dry. Cleansing with a mild soap is a standard recommendation to maintain hygiene without irritating the skin.
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### Question 44 of 130
The practical nurse (PN) is closely monitoring the clients condition. The PN determines that the client is experiencing [Select Response] and the blood pressure changes are the result of [Select Response].
**Answer:** The PN determines that the client is experiencing **bradycardia** and the blood pressure changes are the result of **decreased cardiac output**.
**Explanation:** The client has a history of symptomatic bradycardia (low heart rate), which is why she is getting a pacemaker. Bradycardia can lead to decreased cardiac output because the heart is not pumping enough blood to meet the bodys needs, which can result in blood pressure changes (e.g., hypotension).
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### Question 48 of 130
The practical nurse (PN) is reviewing the clients progress and nursing implementations. Click to highlight the findings that would indicate the client has recovered from the adverse drug reaction.
Nurses Notes:
1230: Shaking is lessened. Client is no longer flushed. No longer itching. Anxiety has decreased. Skin warm and dry. Heart rate 62 beats/minute, blood pressure 130/72 mm Hg. No chest pain noted. Respirations are even and unlabored. Drowsy.
**Answer:**
**Shaking is lessened. Client is no longer flushed. No longer itching. Anxiety has decreased. Skin warm and dry. Heart rate 62 beats/minute, blood pressure 130/72 mm Hg. No chest pain noted. Respirations are even and unlabored.**
**Explanation:** These findings indicate the client has recovered from an adverse drug reaction, likely an allergic or anaphylactic reaction. The resolution of shaking, flushing, itching, and anxiety, along with stable vital signs (heart rate, blood pressure, respirations) and the absence of chest pain, suggest the reaction has subsided.
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### Question 50 of 130
The practical nurse (PN) is assigning tasks to an unlicensed assistive personnel (UAP) who is giving basic care to a group of clients in a long-term care facility. Which clients task should be completed by a PN, rather than the UAP?
A A client with urinary urgency and incontinence who is asking for a bedpan.
B A client with a full urinary bedside drainage unit after receiving a diuretic.
**C A client with continuous urinary bladder irrigation via a 3-way catheter.**
D A client with paraplegia who needs an urinary condom-catheter change.
**Explanation:** Continuous urinary bladder irrigation (CBI) via a 3-way catheter is a complex procedure that requires monitoring for complications (e.g., catheter blockage, infection) and adjusting the irrigation rate, which is beyond the scope of practice for a UAP. This task should be performed by a PN.
**Question 30 of 130 (2001799)**
The symptoms began with increased fatigue and have increased in severity gradually over the last 2 months. Palpitations occur sporadically but more often after a period of activity; no other chest pain reported. Fatigue is relieved with periods of rest but is beginning to interfere with her ability to perform at work. Client denies any head injuries or adverse events occurring in the last 6 months. Medical history includes heavy menstrual bleeding treated with daily oral contraceptives and mild rheumatoid arthritis for which she takes methotrexate once weekly. Client reports drinking 2 to 3 glasses of wine daily and denies smoking.
- Cardiovascular: Normal heart tones. Denies chest pain. Radial pulses 3+, pedal pulses 2+, dorsalis pedis 2+. Capillary refill 2 seconds.
- Gastrointestinal: Denies nausea, vomiting, and diarrhea. Mild anorexia with 8 lb (3.6 kg) unintentional weight loss over 2 months. Denies blood in stool.
- Genitourinary: Reported chronic dysmenorrhea with heavy menstrual bleeding. Denies pain with urination. Denies blood in urine. Uterus is palpated one finger breadth above pubic symphysis.
Which problem should the practical nurse (PN) expect a severely depressed client to exhibit?
A) Mild mood swings.
B) Episodes of guilt.
C) Alcohol consumption.
**D) Disorders of sleep.**
**Explanation**: Severe depression often manifests with physical symptoms such as fatigue, changes in appetite, and sleep disturbances. The client reports increased fatigue and unintentional weight loss, which are consistent with depression. Among the options, **disorders of sleep** (D) is a hallmark symptom of severe depression, as it aligns with the client’s reported fatigue and potential disruptions in sleep patterns due to her mental health condition. Options A, B, and C are less directly tied to the primary symptoms of severe depression in this context.
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**Question 37 of 130 (47337)**
Which problem should the practical nurse (PN) expect a severely depressed client to exhibit?
A) Mild mood swings.
B) Episodes of guilt.
C) Alcohol consumption.
**D) Disorders of sleep.**
**Explanation**: This question is identical to Question 30. Severe depression commonly includes symptoms like sleep disturbances, which can manifest as insomnia or excessive sleeping. The client’s fatigue and other symptoms align with this. **Disorders of sleep** (D) is the most appropriate choice, as it directly correlates with the typical presentation of severe depression, more so than mood swings, guilt, or alcohol consumption in this context.
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**Question 43 of 130 (2003287)**
The client is a 75-year-old female admitted to the preoperative area to prepare for a pacemaker insertion. Client reports she is having this done because her heart rate has been staying very low, she is always tired, and she has passed out once from a low heart rate. Client has history of worsening symptomatic bradycardia. History of atrial fibrillation controlled by medication. Has been off anticoagulants for 4 days to prepare for the procedure.
The practical nurse (PN) is reviewing the client’s plan of care. Select 4 findings that would indicate to the PN that the administration of the vancomycin antibiotic would be safe.
A) Potassium 4.4 mEq/L (4.4 mmol/L).
B) Dosage in safe range.
C) Peripheral IV in large vein.
D) Blood urea nitrogen (BUN) 17 mg/dL (6.07 mmol/L).
E) No known allergies.
F) Used for prophylaxis.
**A) Potassium 4.4 mEq/L (4.4 mmol/L).**
**B) Dosage in safe range.**
**C) Peripheral IV in large vein.**
**E) No known allergies.**
**Explanation**: Vancomycin is an antibiotic that requires careful administration. **Potassium 4.4 mEq/L** (A) is within the normal range (3.5-5.0 mEq/L), indicating safe electrolyte levels for administration. **Dosage in safe range** (B) ensures the client receives a therapeutic dose without toxicity. **Peripheral IV in large vein** (C) is important because vancomycin can be irritating to veins, and a large vein reduces the risk of phlebitis. **No known allergies** (E) confirms the client is not at risk for an allergic reaction to vancomycin. Option D (BUN) is within normal limits but does not directly indicate safety for vancomycin administration, as it is more related to kidney function, which is not the primary concern here. Option F (used for prophylaxis) is not a finding but a purpose, so it does not apply.
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**Question 45 of 130 (2003285)**
The client is a 75-year-old female admitted to the preoperative area to prepare for a pacemaker insertion. Client reports she is having this done because her heart rate has been staying very low, she is always tired, and she has passed out once from a low heart rate. Client has history of worsening symptomatic bradycardia. History of atrial fibrillation controlled by medication. Has been off anticoagulants for 4 days to prepare for the procedure.
Drag from Word Choices to complete the sentence. The client is at immediate risk for developing __________, __________, and __________.
Word Choices:
- anaphylaxis
- peripheral edema
- cardiac arrest
- arrhythmias
- necrosis
- renal failure
The client is at immediate risk for developing **cardiac arrest**, **arrhythmias**, and **peripheral edema**.
**Explanation**: The client’s history of worsening symptomatic bradycardia and low heart rate puts her at risk for **cardiac arrest** (a sudden cessation of heart function) and **arrhythmias** (irregular heart rhythms, especially given her history of atrial fibrillation). **Peripheral edema** may occur due to poor cardiac output from bradycardia, leading to fluid retention. Anaphylaxis, necrosis, and renal failure are less immediate risks in this context, as they are not directly tied to her current cardiac condition.
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**Question 47 of 130 (2003283)**
The client is a 75-year-old female admitted to the preoperative area to prepare for a pacemaker insertion. Client reports she is having this done because her heart rate has been staying very low, she is always tired, and she has passed out once from a low heart rate. Client has history of worsening symptomatic bradycardia. History of atrial fibrillation controlled by medication. Has been off anticoagulants for 4 days to prepare for the procedure.
For each body system, click to specify the potential nursing intervention that would be appropriate for the care of the client. Each body system may support more than one potential nursing intervention. Each category must have at least one response option selected.
Body System: Cardiovascular
- Provide warmth
- Monitor vital signs continuously
- Defibrillator at bedside
- Echocardiogram (ECHO)
Body System: Immunological
- Observe for rash
- Administer steroid
- Administer antihistamine
- IV fluids
**Cardiovascular:**
- **Monitor vital signs continuously**
- **Defibrillator at bedside**
- **Echocardiogram (ECHO)**
**Immunological:**
- **Observe for rash**
**Explanation**: For the **Cardiovascular** system, the client’s bradycardia and history of atrial fibrillation necessitate **monitoring vital signs continuously** to track heart rate and rhythm, a **defibrillator at bedside** in case of a life-threatening arrhythmia, and an **echocardiogram (ECHO)** to assess heart function before pacemaker insertion. For the **Immunological** system, **observing for rash** is appropriate as a precaution for potential allergic reactions (e.g., to medications), but there’s no indication for steroids, antihistamines, or IV fluids at this time, as no allergic reaction is reported.
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**Question 49 of 130 (44005)**
A healthcare provider prescribes metronidazole 750 mg PO for a client with a vaginal infection. The medication is available, “metronidazole 250 mg tablets.” How many tablets should the practical nurse (PN) administer? (Enter the numeric value only. If rounding required, round to the whole number.)
**Answer: 3**
**Explanation**: To determine the number of tablets, divide the prescribed dose by the available dose per tablet: 750 mg ÷ 250 mg/tablet = 3 tablets. Since the result is a whole number, no rounding is required. The PN should administer **3** tablets.
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**Question 51 of 130 (55424)**
The practical nurse (PN) assists a client to a supine position. Which should the PN use to prevent external rotation of the client’s hips?
A) Draw sheet.
B) Foam mattress pad.
**C) Trochanter rolls.**
D) Trapeze bar.
**Explanation**: When a client is in the supine position, external rotation of the hips can occur, leading to discomfort or misalignment. **Trochanter rolls** (C) are specifically designed to prevent this by being placed along the sides of the thighs to keep the hips in a neutral position. A draw sheet (A) is used for repositioning, a foam mattress pad (B) is for pressure relief, and a trapeze bar (D) assists with client movement, none of which address hip rotation.
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**Question 53 of 130 (49429)**
A practical nurse (PN) who works on a 16-bed wing of an extended care facility with an additional PN and an unlicensed assistive personnel (UAP) is told that the other PN will not be in because of illness. The facility manager agrees to obtain another UAP for the day. Which action should the PN take?
A) Prioritize assessment of safety issues in addition to administration of daily medication.
B) Refuse to take charge and go home rather than risk working in an unsafe situation.
C) Inform the manager that the facility will have to assume responsibility for incidents related to staffing.
**D) Assign some tasks usually performed by the additional PN to the UAP who is normally on the wing.**
**Explanation**: The PN must ensure safe care despite the staffing shortage. **Assigning some tasks usually performed by the additional PN to the UAP** (D) who is normally on the wing is appropriate, as long as the tasks are within the UAP’s scope of practice (e.g., basic care like bathing or feeding). This helps manage the workload effectively. Option A is a good practice but not a direct action to address the staffing issue. Options B and C are unprofessional and do not solve the problem, as they avoid responsibility rather than addressing the situation.
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**Question 54 of 130 (153094)**
The practical nurse (PN) is monitoring care activities of an unlicensed assistive personnel (UAP). What behavior(s) observed by the PN indicate that the UAP needs additional guidance? Select all that apply.
A) Uses client’s same finger when obtaining a blood drop for glucometer.
B) Removes the water pitcher from room of client on fluid restriction.
C) Applies disposable gown and mask as part of standard precautions.
D) Positions bed in highest position before leaving all client rooms.
E) Maintains Fowler’s position for a client with breathing difficulty.
**A) Uses client’s same finger when obtaining a blood drop for glucometer.**
**D) Positions bed in highest position before leaving all client rooms.**
**Explanation**: **Using the same finger for glucometer testing** (A) can cause tissue damage and increase infection risk; the UAP should rotate fingers. **Positioning the bed in the highest position** (D) before leaving poses a fall risk for clients, as beds should be lowered for safety. Option B is correct, as removing the water pitcher aligns with fluid restriction. Option C is appropriate for standard precautions in certain contexts. Option E is correct, as Fowler’s position helps with breathing difficulty.
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**Question 55 of 130 (2003781)**
The practical nurse (PN) is acting as a peer coach for a new PN graduate. Which observed behavior(s) demonstrate to the PN that the new graduate can safely perform client care? Select all that apply.
A) Uses sanitizing gel when hands are visibly soiled.
B) Plans fluid allowances per shift for fluid restricted clients.
C) Recaps needles prior to placing in sharps container.
**D) Applies fresh gloves after completing hand hygiene.**
**E) Repositions clients who are immobile every 1 to 2 hours.**
**Explanation**: **Applying fresh gloves after hand hygiene** (D) demonstrates proper infection control practices. **Repositioning immobile clients every 1 to 2 hours** (E) prevents pressure ulcers, showing good care. Option A is incorrect, as sanitizing gel is not effective for visibly soiled hands; soap and water should be used. Option B is appropriate but not a direct behavior demonstrating safety. Option C is unsafe, as recapping needles increases the risk of needlestick injury.
**Question 30 of 130**
**Patient Data**
- Temperature 98.7° F (37.1° C)
- Heart rate 106 beats/minute
- Respirations 18 breaths/minute
- Blood pressure 139/82 mm Hg
- Oxygen saturation 92% on room air
- Height is 5 ft 7 in (170.2 cm)
- Weight is 110 lb (49.9 kg)
- Body mass index (BMI) is 17 kg/m² (normal 18.0 to 24.9 kg/m²)
**For each body system, click to highlight the findings that require follow up.**
- Neurological: Alert and oriented. Reported generalized fatigue. Mild headache. Ringing in ears described as “roaring.”
- Cardiovascular: Normal heart tones. Denies chest pain. Radial pulses 3+, pedal pulses 2+, dorsalis pedis 2+. Capillary refill 2 seconds.
- Gastrointestinal: Denies nausea, vomiting, and diarrhea. Mild anorexia with 8 lb (3.6 kg) unintentional weight loss over 2 months. Denies blood in stool.
- Genitourinary: Reported chronic dysmenorrhea with heavy menstrual bleeding. Denies pain with urination. Denies blood in urine.
**Options for follow-up (not a multiple-choice question, but requires identifying key findings):**
The findings that require follow-up are:
- Neurological: Reported generalized fatigue, mild headache, ringing in ears described as “roaring.”
- Cardiovascular: No immediate concerns.
- Gastrointestinal: Mild anorexia with 8 lb (3.6 kg) unintentional weight loss over 2 months.
- Genitourinary: Chronic dysmenorrhea with heavy menstrual bleeding.
**Explanation**: Fatigue, headache, and tinnitus (“roaring” in ears) could indicate an underlying issue like anemia or neurological concern. Unintentional weight loss of 8 lb in 2 months is significant and may suggest malnutrition or a systemic illness. Chronic dysmenorrhea with heavy menstrual bleeding could be related to the low BMI (17 kg/m², underweight) and may indicate anemia or a gynecological issue. These findings warrant further investigation.
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**Question 39 of 130**
The practical nurse (PN) hears an older adult resident of a long-term care facility shout profanities at an unlicensed assistive personnel (UAP) who shouts back at the resident. Which is the first action the PN should take?
- A Tell the resident and the UAP that shouting is not permitted.
- **B Report the incident and the UAP for further action by the nurse-manager.**
- C Tell both of them to lower their voices in consideration of other residents.
- D Enter the room and tell the UAP to leave the room immediately.
**Explanation**: The PN must address unprofessional behavior immediately. Shouting profanities, especially by the UAP, is inappropriate in a healthcare setting and can escalate the situation. Reporting the incident to the nurse-manager ensures proper disciplinary action and maintains a safe environment for residents. Option A addresses the behavior but doesn’t ensure accountability. Option C is too passive, and Option D may not address the root issue of unprofessional conduct.
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**Question 46 of 130**
The client is a 75-year-old female admitted to the preoperative area to prepare for a pacemaker insertion. Client reports she is having this done because her heart rate has been staying very low, she is always tired, and she has passed out once from a low heart rate. Client has history of worsening symptomatic bradycardia. History of atrial fibrillation controlled by medication. Has been off anticoagulants for 4 days to prepare for the procedure.
The practical nurse (PN) is implementing solutions to provide care. Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided.
The PN determines that the client is still having an adverse reaction resulting in symptoms of **bradycardia**, **fatigue**, and **syncope**.
**Explanation**: The client’s history of symptomatic bradycardia, low heart rate, tiredness, and passing out aligns with the symptoms of bradycardia (low heart rate), fatigue (due to reduced cardiac output), and syncope (fainting from inadequate cerebral perfusion). These are the most likely symptoms the PN would identify based on the client’s presentation.
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**Question 47 of 130**
The client is a 75-year-old female admitted to the preoperative area to prepare for a pacemaker insertion. Client reports she is having this done because her heart rate has been staying very low, she is always tired, and she has passed out once from a low heart rate. Client has history of worsening symptomatic bradycardia. History of atrial fibrillation controlled by medication. Has been off anticoagulants for 4 days to prepare for the procedure.
**For each body system, click to specify the potential nursing intervention that would be appropriate for the care of the client. Each body system may have at least one potential nursing intervention. Each category must have at least one response option selected.**
- Cardiovascular
- Provide warmth
- **Monitor vital signs continuously**
- Defibrillator at bedside
- Echocardiogram (ECHO)
- Immunological
- Observe for rash
- Administer steroid
- Administer antihistamine
- **IV fluids**
**Explanation**: For the cardiovascular system, the client has symptomatic bradycardia, which requires continuous monitoring of vital signs to detect any further deterioration in heart rate or rhythm, especially preoperatively. For the immunological system, IV fluids are appropriate as a general supportive measure to maintain hydration and circulation, especially since the client is off anticoagulants and may be at risk for complications. The other options (e.g., defibrillator, ECHO, steroids, antihistamine) are not directly indicated based on the current information.
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**Question 52 of 130**
An older male client is transferred to the rehabilitation unit with the diagnosis of cerebrovascular accident (CVA) with left-sided hemiplegia. The practical nurse (PN) addresses the client from the right side, and the client points to the left leg and states, “There is a leg in my bed!” How should the PN respond?
- A Direct him to look at his legs and see that they both belong to him.
- B Reply that he may think there is an extra leg in his bed, the PN does not see it.
- **C Ask him to explain what he thinks happened to his leg if that is not his.**
- D Tell him the stroke has impaired his ability to recognize his paralyzed leg.
**Explanation**: The client is likely experiencing a perceptual disturbance (e.g., neglect or anosognosia) common after a CVA, where he doesn’t recognize his own left leg due to left-sided hemiplegia. Asking him to explain his perception (Option C) allows the PN to assess his cognitive and sensory deficits while engaging him therapeutically. Option A may confuse him further, Option B dismisses his concern, and Option D, while factual, doesn’t promote understanding or engagement.
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**Question 60 of 130**
34-year-old female presents to the emergency department (ED) with chest pain, difficulty breathing, and lightheadedness. She reports a feeling of doom and fears she might be dying. When the symptoms began at 0630, the client was at work completing an important report. She works as a project manager for a large finance company. She works six days a week, for 10 to 12 hours.
The practical nurse (PN) reviews the chart and notes the healthcare provider has diagnosed the client with generalized anxiety disorder. Select the 3 interventions the PN should perform related to the new diagnosis.
- A Listen for covert messages as the client speaks.
- **B Encourage the client to talk about her strengths.**
- **C Identify how the client coped with past anxiety.**
- **D Encourage the client to form supportive relationships.**
- E Provide opportunities for exercise.
- F Discourage overgeneralizations and self-blame.
**Explanation**: For generalized anxiety disorder, therapeutic interventions focus on empowering the client and reducing anxiety. Encouraging the client to talk about her strengths (Option B) builds self-esteem. Identifying past coping mechanisms (Option C) helps the PN tailor interventions. Encouraging supportive relationships (Option D) provides a support system to reduce anxiety. Options A, E, and F, while potentially helpful, are less directly tied to the immediate needs of a new anxiety diagnosis.
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**Question 66 of 130**
At 2100, an older adult client turns on the call light and reports to the practical nurse (PN) concerns of difficulty falling asleep. Which priority action should the PN implement?
- A Reassure the client that it is still early.
- B Shut the client’s room door securely.
- **C Recommend using guided imagery to relax.**
- D Inspect the room’s environmental aspects.
**Explanation**: Difficulty falling asleep in an older adult may be due to anxiety, discomfort, or environmental factors. Recommending guided imagery (Option C) is a non-pharmacological, client-centered intervention that promotes relaxation and sleep. Option A dismisses the client’s concern, Option B is unrelated to sleep, and Option D, while useful, is not the priority over a direct relaxation technique.
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**Question 72 of 130**
A client with endocarditis is receiving antibiotic therapy. Which priority should the practical nurse (PN) consider in planning this client’s care and activities of daily living (ADL)?
- **A Sequencing activities with rest periods.**
- B Constipation and dietary modification.
- C Oral antibiotic administration.
- D Personal hygiene and oral care.
**Explanation**: Endocarditis, an infection of the heart’s inner lining, often causes fatigue and weakness due to systemic infection and reduced cardiac efficiency. Sequencing activities with rest periods (Option A) helps conserve the client’s energy and prevent overexertion, which is a priority in managing their condition. Options B, C, and D, while important, are not the primary focus for ADLs in this context.
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**Question 77 of 130**
The home health practical nurse (PN) suspects elder abuse after observing fresh lacerations on the arms and leg of an older male client who lives with his daughter. Which action is most important for the PN to take?
- **A Report findings to supervisor for referral to adult protective services.**
- B Ask the daughter who has been taking care of client on a daily basis.
- C Document the lacerations in the client’s record.
- D Apply dry dressings after cleansing the wounds.
**Explanation**: Suspected elder abuse is a serious concern, and the PN has a legal and ethical obligation to report it. Reporting to the supervisor for referral to adult protective services (Option A) ensures the client’s safety and initiates an investigation. Options B, C, and D are secondary actions; reporting takes precedence to protect the client from potential harm.
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**Question 79 of 130**
The mother of an infant who was diagnosed with respiratory syncytial virus (RSV) yesterday calls the clinic to inquire if it will be alright to take her infant to the first birthday party of a friend’s child the following day. Which response should the practical nurse (PN) provide this mother?
- **A Do not expose other children as the virus is very contagious even without direct oral contact.**
- B Make sure there are no children under the age of 6 months around the infected child.
- C The child will no longer be contagious, no need to take any further precautions.
- D The child can be around other children but should wear a mask at all times.
**Explanation**: RSV is highly contagious, especially in young children, and can spread through respiratory droplets even without direct contact. The infant, diagnosed just yesterday, is still in the contagious period (typically 3-8 days). Option A is the most appropriate response to prevent transmission at a social gathering. Options B, C, and D either underestimate the contagiousness or provide impractical solutions (e.g., masking an infant).
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**Question 57 of 130**
The practical nurse (PN) reviews the trend in vital signs and client symptoms. Choose the most likely options for the information missing from the statement by selecting from the lists of options provided.
The nurse determines the client’s [Select Response] is one of multiple symptoms displayed that indicate [Select Response].
A 34-year-old female presents to the emergency department (ED) with chest pain, difficulty breathing, and lightheadedness. She reports a feeling of doom and fears she might be dying. When the symptoms began at 0630, the client was at work completing an important report. She works as a project manager for a large finance company. She works six days a week, for 10 to 12 hours.
- The nurse determines the client’s [Select Response]:
- Anxiety
- **Stress**
- Depression
- Fatigue
- is one of multiple symptoms displayed that indicate [Select Response]:
- **Panic attack**
- Heart failure
- Pulmonary embolism
- Asthma
**Explanation**: The client’s symptoms—chest pain, difficulty breathing, lightheadedness, and a feeling of doom—along with her high-stress job (working long hours as a project manager), suggest a **panic attack** triggered by **stress**. These symptoms are classic for a panic attack, often linked to acute stress rather than a physical condition like heart failure or asthma in this context.
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**Question 64 of 130**
A 70-year-old client with Parkinson’s disease is receiving carbidopa/levodopa to help relieve the symptoms associated with the disease. Which finding will demonstrate the effectiveness of the medication?
- **A Muscle control.**
- B Bladder control.
- C Mental state.
- D Nutritional status.
**Explanation**: Carbidopa/levodopa is used in Parkinson’s disease to improve motor symptoms by increasing dopamine levels in the brain. The primary effect is on **muscle control**, helping reduce tremors, rigidity, and bradykinesia, which are hallmark symptoms of Parkinson’s.
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**Question 65 of 130**
A client with foot pain is receiving a newly prescribed peripheral vasodilator. It is most important for the practical nurse (PN) to monitor which client parameter?
- **A Vital signs.**
- B Oxygen saturation.
- C Urinary output.
- D Range of motion.
**Explanation**: Peripheral vasodilators increase blood flow by dilating blood vessels, which can affect blood pressure and heart rate. Monitoring **vital signs** is critical to detect potential side effects like hypotension or tachycardia, ensuring the client’s safety during treatment.
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**Question 70 of 130**
The practical nurse (PN) enters the room of an older adult client. In preparation for transporting the client to the day room, the unlicensed assistive personnel (UAP) has positioned the client in a wheelchair as seen in the picture. Which action by the PN takes priority?
- A Offer to cover the client’s arms and chest with the blanket.
- **B Confirm with the client of being ready to go to the day room.**
- C Instruct the UAP in repositioning the urinary drainage bag.
- D Document the amount and appearance of the client’s urine.
**Explanation**: Before transporting the client, the PN should prioritize **confirming with the client** if they are ready to go to the day room. This ensures the client’s comfort, consent, and readiness, which is a fundamental aspect of patient-centered care and safety during transfers.
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**Question 71 of 130**
The practical nurse (PN) is caring for a client who is receiving enteral nutrition via a nasogastric tube with a daily caloric goal of 1800 calories. The prescribed formula contains 200 calories/240 mL. How many mL of the formula should the client receive to meet daily caloric goal? (Enter numerical value only.)
**Answer**: 2160
**Explanation**: To calculate the mL needed:
- The formula provides 200 calories per 240 mL.
- First, find the calories per mL: 200 calories ÷ 240 mL = 0.833 calories/mL.
- To meet 1800 calories, divide the goal by calories per mL: 1800 ÷ 0.833 = 2160 mL.
Thus, the client needs **2160 mL** of the formula.
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**Question 73 of 130**
The practical nurse (PN) prepares to provide wound care. In which order should the PN implement these steps? (Place the first action on top and the last action on the bottom.)
- Remove old dressing.
- Apply prescribed medications to the wound.
- Don a pair of procedure gloves.
- Remove soiled gloves, perform handwashing, and don new procedure gloves.
**Correct Order**:
- **Don a pair of procedure gloves.**
- **Remove old dressing.**
- **Remove soiled gloves, perform handwashing, and don new procedure gloves.**
- **Apply prescribed medications to the wound.**
**Explanation**: The correct sequence for wound care prioritizes infection control and proper procedure:
1. **Don a pair of procedure gloves** to maintain a sterile environment.
2. **Remove old dressing** while wearing gloves to avoid contamination.
3. **Remove soiled gloves, perform handwashing, and don new procedure gloves** to ensure cleanliness before proceeding.
4. **Apply prescribed medications to the wound** as the final step to treat the wound with clean hands and gloves.
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**Question 74 of 130**
The practical nurse (PN) is assisting with screening examinations at a community clinic where a toddler is brought by a parent for scheduled vaccines. The toddler clings to the caregiver and cowers when approached. Which assessment warrants immediate intervention by the PN?
- A One-inch laceration across center of forehead.
- B Small bruises on the lower extremities.
- **C Several dime-sized circular burns on the back.**
- D Refusal to answer simple questions.
**Explanation**: **Several dime-sized circular burns on the back** are highly concerning as they may indicate abuse (e.g., cigarette burns), which requires immediate intervention to ensure the child’s safety. The other options, while concerning, are less indicative of urgent harm.
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**Question 80 of 130**
A client develops diarrhea after two weeks of treatment with an oral penicillin. Which dietary recommendations should the practical nurse (PN) offer the client to help restore the normal flora to the bowel?
- A Buttermilk, cottage cheese, yogurt, or kefir.
- B Meats, poultry, seafood, and soy products.
- **C Fresh fruit and vegetables.**
- D Whole grain products.
**Explanation**: Diarrhea after antibiotic use often results from disruption of gut flora. While yogurt (option A) can help with probiotics, **fresh fruit and vegetables** are a better choice to restore normal flora as they provide prebiotic fiber that supports the growth of beneficial gut bacteria.
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**Question 82 of 130**
Upon entering the home to establish home health care and perform an initial assessment, the practical nurse (PN) was greeted by the client’s adult daughter who introduced herself as the client’s primary caregiver. The PN was escorted to a room where the 84-year-old client was lying in bed. A foul odor was noted and the room appeared dark except for the television that was turned on. The client lay in bed. Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the practical nurse (PN) should take to address that condition, and two parameters the PN should monitor to assess the client’s progress.
- Condition the client is most likely experiencing:
- **Neglect**
- Dehydration
- Infection
- Actions to Take:
- **Assess the client’s skin for breakdown.**
- **Coordinate with social services for support.**
- Provide hydration therapy.
- Parameters to Monitor:
- **Skin integrity.**
- **Nutritional status.**
- Blood pressure.
**Explanation**: The foul odor, dark room, and the client lying in bed suggest **neglect** by the caregiver. The PN should **assess the client’s skin for breakdown** (e.g., pressure ulcers) and **coordinate with social services** to address the neglect. Monitoring **skin integrity** and **nutritional status** will help track the client’s progress and recovery from neglect.
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**Question 83 of 130**
The practical nurse (PN) is reviewing postoperative goals for a client who recently underwent a right above the knee amputation. Which of the following instructions should the PN reinforce to help the client function without the amputated extremity? Select all that apply.
- **A Reinforce the proper use of assistive devices.**
- B The client must learn to function without the amputated extremity.
- **C Gradually guide the client to adapt to the lost limb and encourage more independence.**
- **D Learn the medications and other treatments that can be used to treat phantom pain.**
- **E Encourage and assist the client to do exercises to strengthen remaining limbs.**
**Explanation**: After an above-the-knee amputation, the PN should focus on helping the client adapt and regain independence:
- **A** teaches the client to use assistive devices for mobility.
- **C** supports gradual adaptation and independence.
- **D** addresses phantom pain, a common issue post-amputation.
- **E** strengthens remaining limbs to improve overall function.
Option B is not an instruction but a statement, so it’s not applicable.
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