Question

While turning and positioning a bedfast client, the practical (PN) observes that the client is dyspneic. Which action should the PN take first?

Answer 1

Correct Answers:

Apply a pulse oximeter.

Rationale :

🌟 Dyspnea indicates potential hypoxia, which is a priority over routine assessments.

🌟 Using a pulse oximeter allows for continuous monitoring of oxygen saturation.

🌟 Early detection of low SpO₂ can prevent respiratory complications.

🌟 Observing pressure areas or measuring BP is important but secondary to airway and oxygenation.

🌟 Notifying the charge nurse is necessary, but assessment comes first to guide interventions.

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Answer 2

Correct Answers

The client is a 59-year-old male with hypertension and heart failure. [ Situation ]
He is currently taking furosemide and digoxin. His systolic blood pressure is usually in the 140's mm Hg [ Background ]
The client's heart rate was 54 beats/minute, and his blood pressure was 109/76 mm Hg. [ Assessment ]
I am holding the digoxin because the client's heart rate is too low. [ Situation ]
Do you want to recheck the digoxin level to see if there is toxicity? [ Recommendation ]
I will monitor the client's heart rate, blood pressure, and perfusion with a continuous monitor until his heart rate returns to normal. [ Recommendation ]

Rationale :

🌟 SBAR organizes critical information for clear provider communication.

🌟 Holding digoxin prevents bradycardia or toxicity.

🌟 Includes baseline vitals and history for context.

🌟 Provides a recommendation for safe follow-up.

🌟 Ensures continuous monitoring until HR stabilizes.

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Answer 3

Correct Answers:

Care focuses on quality of life at the end of life.
Care can be provided in the home.
Curative measures are optional.

Rationale :

🌟 Hospice emphasizes comfort, symptom management, and emotional support.

🌟 Care can be home-based, promoting family involvement.

🌟 Curative treatments are secondary or optional.

🌟 Family participates in decision-making, but responsibility may vary.

🌟 Medication management focuses on symptom control, not limiting to pain only.

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Answer 4

Correct Answers:

When the client was last weighed.

Rationale :

🌟 Consistency in timing of daily weights ensures accurate trends.

🌟 Prevents misinterpretation due to fluid shifts or food intake.

🌟 Essential for monitoring heart failure or fluid retention.

🌟 Helps guide medication adjustments like diuretics.

🌟 Standard practice: weigh same time, same scale, similar clothing.

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Answer 5

Correct Answers:

When the client was last weighed.

Rationale :

🌟 Consistency ensures accurate fluid balance monitoring.

🌟 Variations in timing can misrepresent weight gain or loss.

🌟 Important for medication titration.

🌟 Daily weight trends help assess hydration status.

🌟 Aligns with unit protocols and nursing standards.

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Answer 6

Correct Answers:

Figure-eight turns.

Rationale :

🌟 Figure-eight bandaging secures dressing while allowing joint mobility.

🌟 Prevents slippage of medicated gauze.

🌟 Provides moderate compression to reduce swelling.

🌟 Ensures comfort and maintains circulation.

🌟 Alternative methods (circular/spiral) restrict movement or fail to stabilize.

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Answer 7

Correct Answers:

As soon as the client begins to feel pain.

Rationale :

🌟 Early analgesia prevents pain escalation and promotes comfort.

🌟 Reduces physiological stress and complications (tachycardia, hypertension).

🌟 Helps maintain mobility and participation in activities.

🌟 Avoids breakthrough pain that requires higher doses.

🌟 Encourages patient-controlled pain management for better outcomes.

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Answer 8

Correct Answers:

Tetany.

Rationale :

🌟 Hypocalcemia increases neuromuscular excitability, causing tetany.

🌟 Manifested as muscle spasms, twitching, or carpopedal spasm.

🌟 Important to monitor vital signs and airway, as severe cases affect breathing.

🌟 Can result from malabsorption syndromes or vitamin D deficiency.

🌟 Early detection allows calcium replacement therapy and prevents complications.

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Answer 9

Correct Answers:

Sacrum.

Rationale :

🌟 Supine patients develop pressure ulcers at sacrum due to bony prominence.

🌟 Pressure + immobility → reduced perfusion and skin breakdown.

🌟 Early erythema is a reversible stage 1 ulcer.

🌟 Regular turning and repositioning prevent progression.

🌟 Skin assessment should include other pressure points (heels, elbows).

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Answer 10

Correct Answers:

Work with the UAP to use a mechanical lift and sling for the transfer.

Rationale :

🌟 Client cannot bear weight and is confused, increasing injury risk.

🌟 Mechanical lift ensures safe transfer for both client and staff.

🌟 Prevents falls and musculoskeletal injuries to staff.

🌟 UAP can assist without compromising client safety.

🌟 Transfer belts or pivot techniques are inappropriate for non-weight-bearing, confused clients.

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Parameter	Day 1	Day 2	Day 3
Urine Output	1,200 mL	1,500 mL	1,400 mL
Blood Pressure	140/81 mm Hg	142/79 mm Hg	109/76 mm Hg
Heart Rate	71 beats/minute	79 beats/minute	54 beats/minute

options	Situation	Background	Assessment	Recommendation
The client is a 59-year-old male with hypertension and heart failure.
He is currently taking furosemide and digoxin. His systolic blood pressure is usually in the 140's mm Hg
The client's heart rate was 54 beats/minute, and his blood pressure was 109/76 mm Hg.
I am holding the digoxin because the client's heart rate is too low.
Do you want to recheck the digoxin level to see if there is toxicity?
I will monitor the client's heart rate, blood pressure, and perfusion with a continuous monitor until his heart rate returns to normal.

QLexNursing

1 :
While turning and positioning a bedfast client, the practical (PN) observes that the client is dyspneic. Which action should the PN take first?

2 :
The client is a 59-year-old male with hypertension and heart failure.

Correct Answers

4 :
The practical nurse (PN) is implementing a nursing plan of care (POC) that requires daily weights. Which factor is most important for the PN to consider regarding daily weights?

5 :
The practical nurse (PN) is implementing a nursing plan of care (POC) that requires daily weights. Which factor is most important for the PN to consider regarding daily weights?

7 :
The practical nurse (PN) is reviewing instructions about use of postoperative analgesia with a client before surgery. The PN should remind the client to ask for pain medication at which time? A When the client can no longer move comfortably.

8 :
A client with a malabsorption syndrome has a low serum calcium level. The practical nurse should monitor the client for which problem?

9 :
The practical nurse (PN) turns a client with right sided paralysis from a supine to a left lateral position. Which bony prominence is most likely to manifest signs of erythema when first turned?

10 :
The practical nurse (PN) assigns an unlicensed assistive personnel (UAP) the task of transferring an alert client from the bed to the chair. The UAP reports to the PN that the client is confused and cannot bear weight. Which action should the PN implement?

QLexNursing

1 : While turning and positioning a bedfast client, the practical (PN) observes that the client is dyspneic. Which action should the PN take first?

2 : The client is a 59-year-old male with hypertension and heart failure.

Correct Answers

4 : The practical nurse (PN) is implementing a nursing plan of care (POC) that requires daily weights. Which factor is most important for the PN to consider regarding daily weights?

5 : The practical nurse (PN) is implementing a nursing plan of care (POC) that requires daily weights. Which factor is most important for the PN to consider regarding daily weights?

7 : The practical nurse (PN) is reviewing instructions about use of postoperative analgesia with a client before surgery. The PN should remind the client to ask for pain medication at which time? A When the client can no longer move comfortably.

8 : A client with a malabsorption syndrome has a low serum calcium level. The practical nurse should monitor the client for which problem?

9 : The practical nurse (PN) turns a client with right sided paralysis from a supine to a left lateral position. Which bony prominence is most likely to manifest signs of erythema when first turned?

10 : The practical nurse (PN) assigns an unlicensed assistive personnel (UAP) the task of transferring an alert client from the bed to the chair. The UAP reports to the PN that the client is confused and cannot bear weight. Which action should the PN implement?

1 :
While turning and positioning a bedfast client, the practical (PN) observes that the client is dyspneic. Which action should the PN take first?

2 :
The client is a 59-year-old male with hypertension and heart failure.

4 :
The practical nurse (PN) is implementing a nursing plan of care (POC) that requires daily weights. Which factor is most important for the PN to consider regarding daily weights?

5 :
The practical nurse (PN) is implementing a nursing plan of care (POC) that requires daily weights. Which factor is most important for the PN to consider regarding daily weights?

7 :
The practical nurse (PN) is reviewing instructions about use of postoperative analgesia with a client before surgery. The PN should remind the client to ask for pain medication at which time? A When the client can no longer move comfortably.

8 :
A client with a malabsorption syndrome has a low serum calcium level. The practical nurse should monitor the client for which problem?

9 :
The practical nurse (PN) turns a client with right sided paralysis from a supine to a left lateral position. Which bony prominence is most likely to manifest signs of erythema when first turned?

10 :
The practical nurse (PN) assigns an unlicensed assistive personnel (UAP) the task of transferring an alert client from the bed to the chair. The UAP reports to the PN that the client is confused and cannot bear weight. Which action should the PN implement?