Question

The practical nurse (PN) observes an unlicensed assistive personnel (UAP) performing oral hygiene on an unconscious client who is lying in a ﬂat side-lying position with an emesis basin on the bedside table near the chin. Which action should the PN take?

Answer 1

Correct Answers:

Tell the UAP to continue because the unconscious client is positioned safely.

Rationale :

🔹 Side-lying position is appropriate for an unconscious client during oral hygiene because it helps prevent aspiration.

🔹 The head to the side with an emesis basin nearby allows secretions or fluids to drain from the mouth safely.

🔹 Flat positioning with the head turned reduces the risk of aspiration, which could occur if the client were placed upright.

🔹 The UAP is demonstrating correct technique, indicating proper training and adherence to safe practice guidelines.

🔹 The PN’s role includes reinforcing safe care behaviors and recognizing when no intervention is needed.

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Answer 2

Correct Answers:

Measure the next voiding, then palpate the client's bladder.

Rationale :

🔸 Frequent urination postpartum is expected, as the body eliminates excess fluid accumulated during pregnancy.

🔸 Postpartum diuresis typically peaks 24 to 48 hours after delivery due to hormonal shifts, especially oxytocin.

🔸 Measuring the next voiding helps assess bladder emptying—essential for detecting retention with overflow.

🔸 Palpating the bladder after voiding determines whether it has fully emptied or remains distended.

🔸 Early detection of urinary retention with frequent voiding helps prevent complications like bladder overdistention or postpartum hemorrhage.

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Answer 3

Correct Answers:

Administer the medication and document the heart rate.

Rationale :

🟢 A heart rate of 120 bpm is normal for a 2-month-old infant, falling within the safe range for digoxin administration.

🟢 Digoxin should be withheld only if the apical heart rate is below the threshold—typically <90-100 bpm for infants.

🟢 Since the rate is appropriate, the PN should administer the medication as prescribed without delay.

🟢 Documenting the pre-administration heart rate is a key nursing responsibility to monitor therapeutic response and safety.

🟢 Accurate charting helps track trends and supports clinical decision-making if bradycardia develops later.

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Answer 4

Correct Answers:

Serum creatinine.

Rationale :

🔶 Serum creatinine is a key indicator of renal function, which is vital to assess before administering nephrotoxic antibiotics.

🔶 Nephrotoxic drugs such as aminoglycosides or vancomycin can worsen kidney function, especially if baseline creatinine is already elevated.

🔶 A high creatinine level suggests reduced glomerular filtration rate (GFR), meaning the kidneys may not clear the drug effectively.

🔶 Reviewing creatinine helps determine whether dose adjustments or alternative therapies are necessary.

🔶 Monitoring renal function prevents complications such as acute kidney injury, electrolyte imbalance, or drug accumulation.

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Answer 5

Correct Answers:

Initiation of changes in infection control measures.

Rationale :

🔷 Anti-Glycan Neu5Gc Antibodies (AGNA) target a non-human sugar (Neu5Gc) found in animal-derived tissues and foods, which can trigger immune activation and inflammation when incorporated into human cells.

🔷 Carcinoma in situ is a non-invasive cancer with high curability, but increased AGNA levels in this context raise concern for inflammatory complications and delayed healing post-treatment.

🔷 The presence of AGNA may heighten the client's risk for postoperative or radiation-induced infections, due to immune responses at tissue sites where Neu5Gc is deposited.

🔷 The plan of care should include enhanced infection prevention protocols, such as prophylactic antibiotics, sterile dressing changes, and frequent monitoring for early signs of infection.

🔷 This approach aims to reduce wound complications, safeguard surgical recovery, and enhance immune protection due to the client’s immunological sensitivity.

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Answer 6

Correct Answers:

"It's OK if you don't want to look or talk about the mastectomy. I will be available when you're ready."

Rationale :

💠 Demonstrates emotional support by acknowledging the client’s current emotional state without imposing pressure.

💠 Respects the client’s autonomy and right to process body image changes at her own pace after a mastectomy.

💠 Encourages trust and therapeutic communication by showing empathy and availability for future discussions.

💠 Recognizes that readiness to view the incision varies and may take time, especially with body image concerns.

💠 This approach aligns with client-centered care principles, fostering psychological healing and adjustment post-surgery.

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Answer 7

Correct Answers:

Determine the client's usual bowel pattern.

Rationale :

🟣 Knowing a client’s baseline bowel habits helps differentiate normal variation from constipation.

🟣 A pattern of every 2–3 days may be normal for some individuals, requiring no intervention.

🟣 Interventions without assessment may be inappropriate or unnecessary.

🟣 A focused GI assessment includes diet, activity, and bowel pattern as essential data.

🟣 This assessment supports individualized care and prevents premature medication use.

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Answer 8

Correct Answers:

Elevated energy level

Rationale :

🔴 Cocaine is a central nervous system stimulant that causes a rapid increase in alertness and energy.

🔴 Users often display hyperactivity, restlessness, and exaggerated confidence.

🔴 Elevated dopamine levels create intense, short-lived euphoria followed by mental overactivation.

🔴 Physical signs may include increased heart rate, dilated pupils, and hypervigilance.

🔴 Energy elevation is one of the most observable effects after acute cocaine use.

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Answer 9

Correct Answers:

Demonstrate the correct pulse site to the UAP.

Rationale :

💠 The UAP was using the thumb to palpate, which has its own pulse and compromises accuracy.

💠 The radial pulse should be taken with index and middle fingers only, below the wrist crease.

💠 Demonstration promotes proper skill development and client safety.

💠 Immediate correction prevents repeated inaccurate vital signs recording.

💠 Effective supervision includes teaching, not just instructing, to correct technical errors.

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Answer 10

Correct Answers:

Children need time to actively explore their environment.

Rationale :

🌱 Exploration supports development of motor, cognitive, and social skills in toddlers.

🌱 Prolonged confinement limits learning, creativity, and emotional regulation.

🌱 Active play is essential for brain development and environmental learning.

🌱 Encouraging exploration respects the child’s natural curiosity and independence.

🌱 The statement aligns with growth milestones for toddlers (ages 1–3).

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QLexNursing

1 :
The practical nurse (PN) observes an unlicensed assistive personnel (UAP) performing oral hygiene on an unconscious client who is lying in a ﬂat side-lying position with an emesis basin on the bedside table near the chin. Which action should the PN take?

2 :
A woman who delivered a normal newborn 24 hours ago reports, "I seem to be urinating every hour or so. Is that OK?" Which action should the practical nurse (PN) implement?

3 :
Prior to giving digoxin, the practical nurse (PN) assesses that a 2-month-old infant's heart rate is 120 beats/minute. Based on this finding, what action should the PN take?

4 :
Before administering an antibiotic that can cause nephrotoxicity, which laboratory value is most important for the practical nurse (PN) to review?

5 :
While receiving report for a client with carcinoma in situ of the left breast, the practical nurse (PN) reviews a pending lab report and notices increased levels of Anti-Glycan Neu5Gc Antibodies (AGNA). Which changes should the PN anticipate to be included in the client's plan of care?

6 :
At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best?

7 :
When performing a focused gastrointestinal system assessment, the practical nurse (PN) asks a male client when his last bowel movement occurred. The client answers, "Three days ago." Which action should the PN implement first?

8 :
The practical nurse (PN) is caring for a client whose urine drug screen is positive for cocaine. Which behavior is most likely seen in this client?

9 :
The practical nurse (PN) observes newly hired unlicensed assistive personnel (UAP) who is counting a client's radial pulse as seen in the picture. Which action should the PN take?

10 :
The practical nurse (PN) is told that she keeps her 2-year-old child in a playpen so he will not get dirty. Which statement should the PN use in responding to this concern about using a playpen?

QLexNursing

1 : The practical nurse (PN) observes an unlicensed assistive personnel (UAP) performing oral hygiene on an unconscious client who is lying in a ﬂat side-lying position with an emesis basin on the bedside table near the chin. Which action should the PN take?

2 : A woman who delivered a normal newborn 24 hours ago reports, "I seem to be urinating every hour or so. Is that OK?" Which action should the practical nurse (PN) implement?

3 : Prior to giving digoxin, the practical nurse (PN) assesses that a 2-month-old infant's heart rate is 120 beats/minute. Based on this finding, what action should the PN take?

4 : Before administering an antibiotic that can cause nephrotoxicity, which laboratory value is most important for the practical nurse (PN) to review?

5 : While receiving report for a client with carcinoma in situ of the left breast, the practical nurse (PN) reviews a pending lab report and notices increased levels of Anti-Glycan Neu5Gc Antibodies (AGNA). Which changes should the PN anticipate to be included in the client's plan of care?

6 : At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best?

7 : When performing a focused gastrointestinal system assessment, the practical nurse (PN) asks a male client when his last bowel movement occurred. The client answers, "Three days ago." Which action should the PN implement first?

8 : The practical nurse (PN) is caring for a client whose urine drug screen is positive for cocaine. Which behavior is most likely seen in this client?

9 : The practical nurse (PN) observes newly hired unlicensed assistive personnel (UAP) who is counting a client's radial pulse as seen in the picture. Which action should the PN take?

10 : The practical nurse (PN) is told that she keeps her 2-year-old child in a playpen so he will not get dirty. Which statement should the PN use in responding to this concern about using a playpen?

1 :
The practical nurse (PN) observes an unlicensed assistive personnel (UAP) performing oral hygiene on an unconscious client who is lying in a ﬂat side-lying position with an emesis basin on the bedside table near the chin. Which action should the PN take?

2 :
A woman who delivered a normal newborn 24 hours ago reports, "I seem to be urinating every hour or so. Is that OK?" Which action should the practical nurse (PN) implement?

3 :
Prior to giving digoxin, the practical nurse (PN) assesses that a 2-month-old infant's heart rate is 120 beats/minute. Based on this finding, what action should the PN take?

4 :
Before administering an antibiotic that can cause nephrotoxicity, which laboratory value is most important for the practical nurse (PN) to review?

5 :
While receiving report for a client with carcinoma in situ of the left breast, the practical nurse (PN) reviews a pending lab report and notices increased levels of Anti-Glycan Neu5Gc Antibodies (AGNA). Which changes should the PN anticipate to be included in the client's plan of care?

6 :
At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best?

7 :
When performing a focused gastrointestinal system assessment, the practical nurse (PN) asks a male client when his last bowel movement occurred. The client answers, "Three days ago." Which action should the PN implement first?

8 :
The practical nurse (PN) is caring for a client whose urine drug screen is positive for cocaine. Which behavior is most likely seen in this client?

9 :
The practical nurse (PN) observes newly hired unlicensed assistive personnel (UAP) who is counting a client's radial pulse as seen in the picture. Which action should the PN take?

10 :
The practical nurse (PN) is told that she keeps her 2-year-old child in a playpen so he will not get dirty. Which statement should the PN use in responding to this concern about using a playpen?