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1. Describe the appropriate initial action a practical nurse should take upon
noticing excessive sanguineous drainage from a client's incision.
The practical nurse should document the drainage and continue
monitoring.
The practical nurse should apply a new dressing without further
assessment.
The practical nurse should ignore it if the patient is stable.
The practical nurse should assess the incision site and notify the
healthcare provider.
2. Why is it important for a practical nurse to redirect a patient's inappropriate
comment during a clinical interaction?
Redirecting the conversation maintains professionalism and focuses
on patient care.
Complimenting the patient can build rapport.
Laughing it off makes the situation less awkward.
Ignoring the comment shows that the nurse is not affected by it.
3. If a practical nurse encounters a patient with darkened membranes and
smoky breath, what immediate action should they take?
Document the findings and wait for the physician's orders.
Assess the patient's oxygen saturation and call for emergency
assistance.
Administer an antihistamine for potential allergies.
, Provide the patient with fluids and monitor their intake.
4. A patient with a history of chronic kidney disease is prescribed a nephrotoxic
antibiotic. What should the practical nurse do before administering the
medication?
Administer the antibiotic without any further checks.
Increase the dosage of the antibiotic to ensure effectiveness.
Monitor the patient for signs of infection only.
Review the patient's creatinine level and consult with the healthcare
provider.
5. A client is admitted with a WBC count of 85,000. The absolute neutrophil
count (ANC) is 750. What does the nurse determine as the client's priority
problem?
Sepsis related to unknown cause related to severely elevated WBC
Risk for altered tissue perfusion related to low number of clotting
factors
Altered tissue pefusion related to potential clot formation
Risk for infection related to moderately low ANC
6. Why is it important to administer an oil retention enema solution at the
correct temperature?
The temperature has no effect on the enema's effectiveness.
A colder solution is preferred to stimulate bowel movement.
Administering at the correct temperature helps ensure comfort and
effectiveness of the enema.
A hotter solution is necessary to dissolve the oil.
,7. If a patient is experiencing cocaine withdrawal, what intervention should a
practical nurse prioritize to ensure the patient's safety?
Provide the patient with caffeine to alleviate fatigue.
Encourage the patient to engage in physical exercise immediately.
Monitor the patient for severe anxiety and potential suicidal
thoughts.
Ignore the patient's complaints as they are part of the withdrawal
process.
8. What is one task that a practical nurse (PN) can delegate to unlicensed
assistive personnel (UAP)?
Administering medications
Performing a physical assessment
Assisting with activities of daily living
Developing a care plan
9. Why is it important for a practical nurse to monitor for signs of ototoxicity in
patients receiving aminoglycosides?
Aminoglycosides can lead to gastrointestinal disturbances that must
be managed.
Aminoglycosides primarily affect the liver and require regular liver
function tests.
Aminoglycosides are known to increase blood pressure, necessitating
frequent monitoring.
Aminoglycosides can cause damage to the auditory and vestibular
systems, leading to hearing loss and balance issues.
, 10. Why is it important for a practical nurse to address leg cramps in a client
during active labor?
Leg cramps indicate the need for a cesarean section.
Leg cramps are a sign of dehydration that must be treated
immediately.
Leg cramps are irrelevant during active labor.
Addressing leg cramps helps ensure the client's comfort and can
prevent further complications.
11. While conducting an assessment, a practical nurse (PN) notices an
unexpected finding in the client's blood pressure readings. What is the
appropriate action for the PN to take according to the nursing process?
Administer medication to address the unexpected finding
immediately.
Disregard the finding as it may be within the normal range for that
client.
Report the unexpected finding to the registered nurse (RN) or the
client's healthcare provider.
Document the finding and continue with the assessment.
12. If a patient begins to show signs of respiratory depression after receiving
hydrocodone/acetaminophen, what should the practical nurse do first?
Notify the physician without assessing the patient.
Assess the patient's respiratory rate and oxygen saturation.
Increase the patient's fluid intake.
Administer an additional dose of pain medication.