The practical nurse (PN) hears an auscultatory gap in the Korotkoff sounds of an older
client with hypertension. What action should the practical nurse (PN) implement when
obtaining the client's blood pressure?
Stop deflating the cuff midway and re-inflate it again.
Continue to listen for the next Korotkoff sound until the cuff is deflated.
Pump up the cuff until no sound is heard, then let the air escape slowly.
Place the bell of the stethoscope firmly over the artery.
Give this one a try later!
Continue to listen for the next Korotkoff sound until the cuff is deflated.
Rationale
When an auscultatory gap in the Korotkoff sounds is heard while taking the
blood pressure, it is important to listen carefully for the diastolic sounds as
the cuff is deflated completely and then continue to listen for the next
Korotkoff sound until the cuff is deflated which would indicate the systolic
sound.
,The practical nurse (PN) notifies the healthcare provider that a male client has
become combative and needs a protective device to prevent injury to self and others.
Which principle should the PN use when selecting a protective device?
A protective device must be applied by qualified personnel.
A restraining device is provided for behavioral use only.
A protective device provides the least amount of immobilization.
A restraining device ensures modification of unsafe client behavior.
Give this one a try later!
A protective device provides the least amount of immobilization.
Rationale
The use of restraints is set by federal law and The Joint Commission (TJC)
standards that ensure all clients have the right to be free from seclusion
and physical or chemical restraints, except to ensure the client's and other's
safety. The use of protective or restraining devices must include
documentation of the restrictive interventions causing the least limited
mobility and scheduled follow-up assessments. The need for a restraint
must be assessed, reviewed and if deemed necessary, a prescription must
be obtained every 24 hours for continuance of the restraint.
The practical nurse (PN) is reviewing the schedule of yearly inservice programs for
competency-based nursing care. Which criteria should the PN use in selecting
programs that provide the best content to maintain nursing competency?
Complex procedures that are done only a few times a month.
Techniques that involve management of biohazard waste products.
Competency demonstrated in orientation with electronic medication administration.
Urgent needs identified by quality assurance to ensure national patient safety goals.
Give this one a try later!
, Complex procedures that are done only a few times a month.
Rationale
Competency-based nursing care should be established with yearly
inservice education to ensure staff competency. Refresher inservice for
procedures that are used infrequently, are potentially invasive, and pose
safety risks for the client should be selected for annual validation of
competency. To ensure client safety, urgent change in policy or procedure
identified by quality assurance studies should have been already
addressed immediately, and not as a yearly competency.
The practical nurse (PN) is working with a newly employed PN who is having difficulty
preparing the infusion pump for administration of an IV medication per secondary
infusion. What action should the PN implement?
Demonstrate the use of the IV infusion pump.
Assume responsibility of giving the secondary infusion.
Refer the newly employed PN to a company-provided instructional video.
Provide information about administering the IV medication without the pump.
Give this one a try later!
Demonstrate the use of the IV infusion pump.
Rationale
In the interest of time management and delivery of client care, the PN
should demonstrate the use the IV infusion pump, so the newly employed
PN can become familiar with the use of the equipment.
The practical nurse (PN) is documenting the administration of a client's medication.
Which entry by the PN complies with The Joint Commission (TJC) g uidelines for use of
abbreviations?
MS 4.0 mg IM given for pain rated "8" on a scale of "0-10."
, Novolog insulin 4 u given SC in the right arm.
Doses of clonidine 0.15 mg given AC BID.
Oral liquid vitamin supplement changed from 2.0 cc to 3.00 cc qd.
Give this one a try later!
Doses of clonidine 0.15 mg given AC BID.
Rationale
Recommendations from The Joint Commission (TJC) about the use of
abbreviations with medication administration include using a zero to
precede the decimal point in dosage such as 0.15 mg and do not exclude
using AC (before meals) or BID (twice a day). The "Do Not Use" list from the
TJC includes initials for drug names, trailing zeros, and the abbreviations u,
SC, cc, and qd.
A client has an automatic blood pressure cuff on the right arm where an intravenous
(IV) is infusing. In the left arm, a saline lock is present. The practical nurse (PN) notes
the presence of blood in the IV infusion line. What action should the PN implement?
Discontinue the intravenous infusion.
Pause the infusion to take the blood pressure.
Move the blood pressure cuff to the left arm.
Ask the charge nurse to move the infusion site.
Give this one a try later!
Move the blood pressure cuff to the left arm.
Rationale
When the blood pressure cuff inflates, blood flow backs up into the
intravenous infusion line, so the PN should move the cuff to the left arm
with the saline lock.
client with hypertension. What action should the practical nurse (PN) implement when
obtaining the client's blood pressure?
Stop deflating the cuff midway and re-inflate it again.
Continue to listen for the next Korotkoff sound until the cuff is deflated.
Pump up the cuff until no sound is heard, then let the air escape slowly.
Place the bell of the stethoscope firmly over the artery.
Give this one a try later!
Continue to listen for the next Korotkoff sound until the cuff is deflated.
Rationale
When an auscultatory gap in the Korotkoff sounds is heard while taking the
blood pressure, it is important to listen carefully for the diastolic sounds as
the cuff is deflated completely and then continue to listen for the next
Korotkoff sound until the cuff is deflated which would indicate the systolic
sound.
,The practical nurse (PN) notifies the healthcare provider that a male client has
become combative and needs a protective device to prevent injury to self and others.
Which principle should the PN use when selecting a protective device?
A protective device must be applied by qualified personnel.
A restraining device is provided for behavioral use only.
A protective device provides the least amount of immobilization.
A restraining device ensures modification of unsafe client behavior.
Give this one a try later!
A protective device provides the least amount of immobilization.
Rationale
The use of restraints is set by federal law and The Joint Commission (TJC)
standards that ensure all clients have the right to be free from seclusion
and physical or chemical restraints, except to ensure the client's and other's
safety. The use of protective or restraining devices must include
documentation of the restrictive interventions causing the least limited
mobility and scheduled follow-up assessments. The need for a restraint
must be assessed, reviewed and if deemed necessary, a prescription must
be obtained every 24 hours for continuance of the restraint.
The practical nurse (PN) is reviewing the schedule of yearly inservice programs for
competency-based nursing care. Which criteria should the PN use in selecting
programs that provide the best content to maintain nursing competency?
Complex procedures that are done only a few times a month.
Techniques that involve management of biohazard waste products.
Competency demonstrated in orientation with electronic medication administration.
Urgent needs identified by quality assurance to ensure national patient safety goals.
Give this one a try later!
, Complex procedures that are done only a few times a month.
Rationale
Competency-based nursing care should be established with yearly
inservice education to ensure staff competency. Refresher inservice for
procedures that are used infrequently, are potentially invasive, and pose
safety risks for the client should be selected for annual validation of
competency. To ensure client safety, urgent change in policy or procedure
identified by quality assurance studies should have been already
addressed immediately, and not as a yearly competency.
The practical nurse (PN) is working with a newly employed PN who is having difficulty
preparing the infusion pump for administration of an IV medication per secondary
infusion. What action should the PN implement?
Demonstrate the use of the IV infusion pump.
Assume responsibility of giving the secondary infusion.
Refer the newly employed PN to a company-provided instructional video.
Provide information about administering the IV medication without the pump.
Give this one a try later!
Demonstrate the use of the IV infusion pump.
Rationale
In the interest of time management and delivery of client care, the PN
should demonstrate the use the IV infusion pump, so the newly employed
PN can become familiar with the use of the equipment.
The practical nurse (PN) is documenting the administration of a client's medication.
Which entry by the PN complies with The Joint Commission (TJC) g uidelines for use of
abbreviations?
MS 4.0 mg IM given for pain rated "8" on a scale of "0-10."
, Novolog insulin 4 u given SC in the right arm.
Doses of clonidine 0.15 mg given AC BID.
Oral liquid vitamin supplement changed from 2.0 cc to 3.00 cc qd.
Give this one a try later!
Doses of clonidine 0.15 mg given AC BID.
Rationale
Recommendations from The Joint Commission (TJC) about the use of
abbreviations with medication administration include using a zero to
precede the decimal point in dosage such as 0.15 mg and do not exclude
using AC (before meals) or BID (twice a day). The "Do Not Use" list from the
TJC includes initials for drug names, trailing zeros, and the abbreviations u,
SC, cc, and qd.
A client has an automatic blood pressure cuff on the right arm where an intravenous
(IV) is infusing. In the left arm, a saline lock is present. The practical nurse (PN) notes
the presence of blood in the IV infusion line. What action should the PN implement?
Discontinue the intravenous infusion.
Pause the infusion to take the blood pressure.
Move the blood pressure cuff to the left arm.
Ask the charge nurse to move the infusion site.
Give this one a try later!
Move the blood pressure cuff to the left arm.
Rationale
When the blood pressure cuff inflates, blood flow backs up into the
intravenous infusion line, so the PN should move the cuff to the left arm
with the saline lock.
