Question

Twenty four hours after receiving a telephone prescription for a client's medication, the practical nurse (PN) observes that the prescription has not been signed by the prescriber, which conflicts with agency policy. Which action should the PN take?

Answer 1

Correct Answers:

Contact the prescriber for a renewal of the prescription.

Rationale :

💎The PN must ensure that all prescriptions are signed within the required timeframe to meet legal and agency policy requirements.

💎Administering medication without a valid signed order could place the nurse at risk for legal liability and unsafe practice.

💎By contacting the prescriber, the PN is ensuring that the prescription is validated and continued safely.

💎This action also ensures continuity of care without unnecessary interruption of treatment.

💎Maintaining clear communication with the prescriber helps avoid medication errors and protects both the client and the nurse.

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Answer 2

Correct Answers:

Take the ampule from the newly' hired PN and demonstrate how to safely open the ampule.

Rationale :

💎The image shows the newly hired PN attempting to open an ampule incorrectly, which poses a risk of cuts from glass shards and medication contamination.

💎The safest intervention is for the experienced PN to take the ampule and demonstrate proper technique using a protective barrier (gauze or alcohol pad) at the ampule neck.

💎This action provides hands-on teaching, which ensures the new PN learns the correct method while avoiding injury.

💎Proper demonstration allows the new PN to later perform a return demonstration, reinforcing skill development.

💎The PN’s role includes promoting safety, preventing errors, and supporting professional growth in newly hired staff.

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Answer 3

Correct Answers:

Instruct the UAP to wash the hands for one minute.

Rationale :

🔷When hands are visibly soiled, alcohol-based hand rubs are not effective because they cannot remove dirt, organic material, or spores.

🔷The correct procedure is to use soap and water, scrubbing thoroughly for at least 20 seconds (up to 1 minute when heavy soil is present).

🔷This practice ensures mechanical removal of pathogens such as Clostridium difficile spores and prevents cross-contamination.

🔷The PN’s responsibility is to provide real-time correction to ensure infection control protocols are properly followed.

🔷Reinforcing correct hygiene habits protects both the client and healthcare team by reducing healthcare-associated infections (HAIs).

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Answer 4

Correct Answers:

Observe and monitor skin integrity under the traction straps.

Rationale :

✔Observation of skin integrity is within the PN’s scope and crucial in clients with Buck’s traction.

✔Traction straps can cause skin breakdown, pressure injuries, or impaired circulation if not monitored.

✔The PN can identify early signs of redness, irritation, or ulcers and report them promptly to the RN.

✔Preventing complications from immobility is part of the PN’s role in supporting safe client outcomes.

✔This task allows the RN to focus on responsibilities requiring higher-level clinical judgment, such as teaching and therapy coordination.

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Answer 5

Correct Answers:

Covering a skin tear with a transparent dressing.

Rationale :

🔴Applying dressings is considered a sterile or semi-sterile procedure and requires nursing judgment.

🔴PNs are responsible for assessing wound condition before selecting an appropriate dressing.

🔴Delegating this task to a UAP would compromise infection control and wound care standards.

🔴Dressing selection and application involve clinical assessment, which is not within a UAP’s scope.

🔴Keeping wound care under PN/RN responsibility ensures proper healing and reduces complications.

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Answer 6

Correct Answers:

Evaluate the medication effectiveness and plan with the client pain management.

Rationale :

⚫Addressing the client’s concern about delayed pain relief requires active listening and planning.

⚫Evaluating the effectiveness of PRN medication ensures it is meeting the client’s needs.

⚫Involving the client in pain management planning promotes collaboration and trust.

⚫This approach empowers the client to communicate timely pain needs and prevents future dissatisfaction.

⚫Effective pain control improves healing, comfort, and overall satisfaction with care.

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Answer 7

Correct Answers:

Obtain further data about the client's activity intolerance to position changes.

Rationale :

🔹The PN should first assess and collect data about the client’s response to position changes.

🔹Gathering information about vital signs, tolerance, and symptoms ensures appropriate interventions.

🔹Identifying whether the shortness of breath is related to orthopnea, deconditioning, or cardiopulmonary issues is essential.

🔹Comprehensive assessment prevents unnecessary escalation before knowing the client’s baseline tolerance.

🔹This action guides the PN in determining whether further provider notification or intervention is needed.

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Answer 8

Correct Answers:

Replace the canister when full.

Rationale :

♦ Replacing the suction canister is a non-invasive, routine task suitable for UAPs.

♦ This does not require clinical judgment and helps maintain suction system functionality.

♦ Keeping the canister from overflowing prevents contamination and infection risks.

♦ Assigning this task to the UAP allows the PN to focus on clinical responsibilities such as tube placement checks.

♦ This delegation aligns with the scope of practice for assistive personnel.

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Answer 9

Correct Answers:

Keep the head of the bed raised while the tube feeding is infusing.

Rationale :

🌟Elevating the head of the bed reduces the risk of aspiration pneumonia during feedings.

🌟Aspiration is one of the most serious complications of enteral nutrition therapy.

🌟This position promotes gastric emptying and minimizes reflux of feeding contents.

🌟Teaching the UAP this priority helps ensure safe and effective feeding administration.

🌟Safety of the airway is the highest priority when providing care for a client with a GT.

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Answer 10

Correct Answers:

Remove the sequential compression devices.

Rationale :

⏺️Removing SCDs is a non-invasive task that does not require nursing judgment.

⏺️This task can be safely delegated to UAP since it involves basic equipment removal.

⏺️Discontinuing SCDs does not interfere with sterile technique or invasive care.

⏺️Assigning this allows the PN to focus on medication administration, wound assessment, and teaching.

⏺️Proper delegation ensures efficiency in preparing the client for discharge.

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QLexNursing

1 :
Twenty four hours after receiving a telephone prescription for a client's medication, the practical nurse (PN) observes that the prescription has not been signed by the prescriber, which conflicts with agency policy. Which action should the PN take?

2 :
The practical nurse (PN) observes a newly hired PN who is preparing to open an ampule as seen in the picture. Which action should the PN take?

3 :
The practical nurse (PN) observes unlicensed assistive personnel (UAP) prepare to exit a client's room. The UAPs hands appear visibly soiled as the UAP uses a hand rub for 10 seconds to cleanse the hands. Which action should the PN take?

4 :
An older client is admitted for a right hip fracture and is placed in Buck's traction. The practical nurse (PN) is working with a registered nurse (RN). Which nursing action is most appropriate for the RN to delegate to the PN?

5 :
The practical nurse is working with unlicensed assistive personnel (UAP) to provide care for an immobile client. Which task should not be delegated to the UAP?

6 :
At the beginning of shift, a client angrily reports that a pain medication was requested over 2 hours ago. After administering the as needed (PRN) pain medication, which is the best way for the practical nurse (PN) to address this client's concern?

7 :
The unlicensed assistive personnel (UAP) reports to the practical nurse (PN) that an assigned client experiences shortness of breath when the bed is lowered for bathing. Which action should the PN implement?

8 :
In providing care for a client with a nasogastric tube (NGT) connected to intermittent suction. Which task can be assigned to the unlicensed assistive personnel (UAP)?

9 :
The practical nurse (PN) is providing instructions to the unlicensed assistive personnel (UAP) preparing to give a total bed bath to an immobile client who has a continuous feeding via gastrostomy tube (GT). Which instruction is most important for the PN to emphasize?

10 :
In preparing a postoperative client for discharge, which task can be assigned to the unlicensed assistive personnel (UAP) who is assisting the practical nurse (PN)?

QLexNursing

1 : Twenty four hours after receiving a telephone prescription for a client's medication, the practical nurse (PN) observes that the prescription has not been signed by the prescriber, which conflicts with agency policy. Which action should the PN take?

2 : The practical nurse (PN) observes a newly hired PN who is preparing to open an ampule as seen in the picture. Which action should the PN take?

3 : The practical nurse (PN) observes unlicensed assistive personnel (UAP) prepare to exit a client's room. The UAPs hands appear visibly soiled as the UAP uses a hand rub for 10 seconds to cleanse the hands. Which action should the PN take?

4 : An older client is admitted for a right hip fracture and is placed in Buck's traction. The practical nurse (PN) is working with a registered nurse (RN). Which nursing action is most appropriate for the RN to delegate to the PN?

5 : The practical nurse is working with unlicensed assistive personnel (UAP) to provide care for an immobile client. Which task should not be delegated to the UAP?

6 : At the beginning of shift, a client angrily reports that a pain medication was requested over 2 hours ago. After administering the as needed (PRN) pain medication, which is the best way for the practical nurse (PN) to address this client's concern?

7 : The unlicensed assistive personnel (UAP) reports to the practical nurse (PN) that an assigned client experiences shortness of breath when the bed is lowered for bathing. Which action should the PN implement?

8 : In providing care for a client with a nasogastric tube (NGT) connected to intermittent suction. Which task can be assigned to the unlicensed assistive personnel (UAP)?

9 : The practical nurse (PN) is providing instructions to the unlicensed assistive personnel (UAP) preparing to give a total bed bath to an immobile client who has a continuous feeding via gastrostomy tube (GT). Which instruction is most important for the PN to emphasize?

10 : In preparing a postoperative client for discharge, which task can be assigned to the unlicensed assistive personnel (UAP) who is assisting the practical nurse (PN)?

1 :
Twenty four hours after receiving a telephone prescription for a client's medication, the practical nurse (PN) observes that the prescription has not been signed by the prescriber, which conflicts with agency policy. Which action should the PN take?

2 :
The practical nurse (PN) observes a newly hired PN who is preparing to open an ampule as seen in the picture. Which action should the PN take?

3 :
The practical nurse (PN) observes unlicensed assistive personnel (UAP) prepare to exit a client's room. The UAPs hands appear visibly soiled as the UAP uses a hand rub for 10 seconds to cleanse the hands. Which action should the PN take?

4 :
An older client is admitted for a right hip fracture and is placed in Buck's traction. The practical nurse (PN) is working with a registered nurse (RN). Which nursing action is most appropriate for the RN to delegate to the PN?

5 :
The practical nurse is working with unlicensed assistive personnel (UAP) to provide care for an immobile client. Which task should not be delegated to the UAP?

6 :
At the beginning of shift, a client angrily reports that a pain medication was requested over 2 hours ago. After administering the as needed (PRN) pain medication, which is the best way for the practical nurse (PN) to address this client's concern?

7 :
The unlicensed assistive personnel (UAP) reports to the practical nurse (PN) that an assigned client experiences shortness of breath when the bed is lowered for bathing. Which action should the PN implement?

8 :
In providing care for a client with a nasogastric tube (NGT) connected to intermittent suction. Which task can be assigned to the unlicensed assistive personnel (UAP)?

9 :
The practical nurse (PN) is providing instructions to the unlicensed assistive personnel (UAP) preparing to give a total bed bath to an immobile client who has a continuous feeding via gastrostomy tube (GT). Which instruction is most important for the PN to emphasize?

10 :
In preparing a postoperative client for discharge, which task can be assigned to the unlicensed assistive personnel (UAP) who is assisting the practical nurse (PN)?