A client who is experiencing paralysis of the left arm curses at the practical nurse (PN) and throws a hairbrush against the wall using the right arm. How should the PN respond?

Acknowledge the client's anger and offer to listen.

Play some soft music to help relax the client.

Initiate deep breathing exercises to soothe the client.

Offer to return later when the client is calmer.

Answer and Explanation

The Correct Answer is A

A. Acknowledging the client's anger and offering to listen validates their feelings and provides an opportunity for the client to express their emotions. This approach can help de-escalate the situation and address the underlying frustrations related to their condition.
B. Playing soft music might be soothing but does not directly address the client's expressed anger or the immediate situation. It is not as effective as acknowledging and listening to the client's concerns.
C. Initiating deep breathing exercises might be helpful but is less effective than directly acknowledging the client's anger and providing a space for them to talk about their feelings.
D. Offering to return later may avoid the immediate conflict but does not address the client’s current emotional state or provide support. It is better to engage with the client in the moment to manage their anger and offer support.

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Correct Answer is B

Explanation

A. Move away from the overbed table: This action can be done after the gloves are completely removed and disposed of. Moving away too early increases the risk of bumping into something and contaminating the gloves.
B. Sterile gloves are contaminated on the outside after performing a procedure like a dressing change. Pulling the glove down and everting it (turning it inside out) confines the contamination to the inside of the glove, reducing the risk of transferring germs to the hands or surrounding surfaces. This maintains a sterile field and minimizes the risk of healthcare-associated infections (HAIs).
C. Loosen the glove from the fingers: This might be the initial step while grasping the glove for removal, but the key is to maintain aseptic technique by keeping the outside of the glove contained throughout removal.
D. Raise the hands above waist level: Raising hands above the waist level increases the risk of contaminating the sterile field or nearby surfaces if the glove integrity is compromised.

A. Heart rate 99 beats/minute B. Dark, yellow urine C. Urinated 30 mL D. Temperature 101° F (38.3° C)

Correct Answer is ["A","B","C"]

Explanation

A. Heart rate 99 beats/minute
A heart rate of 99 beats/minute is slightly elevated. Tachycardia can be a sign of fluid volume deficit, as the body compensates for decreased blood volume and pressure by increasing heart rate to maintain adequate perfusion.
B. Dark, yellow urine
Dark yellow urine indicates concentrated urine, which is a sign of dehydration or fluid volume deficit. Proper hydration would typically result in light yellow urine.
C. Urinated 30 mL
A urine output of 30 mL is low, especially for an adult in a 1-hour period. Low urine output can be a sign of fluid volume deficit, as the kidneys may not be excreting enough urine due to inadequate fluid intake or retention.
D. Temperature 101° F (38.3° C)
An elevated temperature indicates a fever, which is related to the infection (pneumonia) rather than fluid volume status. It does not directly indicate a fluid volume deficit.
E. Client is awake and alert
Being awake and alert indicates that the client’s neurological status is stable and is not indicative of fluid volume deficit. It does not reflect the client’s fluid volume status.
F. Blood pressure 115/71 mm Hg
A blood pressure of 115/71 mm Hg is within normal limits. While fluid volume deficits can affect blood pressure, this finding alone does not indicate a deficit since the blood pressure is stable.

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A client who is experiencing paralysis of the left arm curses at the practical nurse (PN) and throws a hairbrush against the wall using the right arm. How should the PN respond?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

As seen in the picture, the practical nurse (PN) begins to remove a pair of sterile gloves after changing a client's dressing. Which action should the PN take next?

Correct Answer is B

Explanation

Exhibits Following the infusion of sodium chloride, the practical nurse (PN) does a focused assessment and documents the findings. Which three of the following client findings indicate that the client may still have a fluid volume deficit?

Correct Answer is ["A","B","C"]

Explanation

Exhibits Choose the most likely options for the information missing from the statement by selecting from the lists of options provided. When the laboratory results are available, the practical nurse (PN) would expect the child to have dropdown related to dropdown during the submersion.

An older adult client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The practical nurse (PN) notes that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the PN to implement?

The practical nurse (PN) observes an unlicensed assistive personnel (UAP) using an alcohol-based cleanser after delivering a client's breakfast tray to the room. The UAP rubs both hands thoroughly for 2 minutes while standing at the door to the client's room. Which action should the PN take?

A client with schizophrenia reports auditory hallucinations when admitted to the hospital. Which question is most important for the practical nurse (PN) to include in the assessment of this client?

During a nonstress test of a 38-week client, the practical nurse (PN) observes the fetal heart rate increases 15 beats above baseline lasting 10 seconds twice during a 20-minute tracing. Which finding should the PN document in the electronic medical record?

The practical nurse (PN) is assisting with the plan of care for a client who is receiving the nonsteroidal anti-inflammatory drug ketorolac for painful muscle spasms of the back. Which intervention should the PN include in the client's plan of care?