A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the practical nurse (PN) implement first?

Explain the daily schedule of unit activities.

Review client rights of hospitalization.

Offer the client an as-needed (PRN) medication.

Describe the functions of the practical nurse (PN).

Answer and Explanation

The Correct Answer is D

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Correct Answer is A

Explanation

A client with continuous urinary bladder irrigation via a 3-way catheter: This task requires specialized knowledge and skill to ensure proper management of the irrigation process, monitoring for complications, and adjusting the irrigation rate as needed. It falls within the scope of practice of the PN, who has the necessary training and expertise.
B. A client with urinary urgency and incontinence who is asking for a bedpan: This task can be safely and appropriately assigned to the UAP. Assisting the client with using a bedpan for voiding is a basic care task that does not require specialized nursing knowledge or skills.
C. A client with a full urinary bedside drainage unit after receiving a diuretic: Emptying a full urinary bedside drainage unit is a task that can be assigned to the UAP. It involves routine emptying and documentation of the drainage bag and does not require specialized nursing knowledge or skills.
D. A client with paraplegia who needs a urinary condom-catheter change: This task requires specialized knowledge and skill to perform a sterile procedure, ensure proper placement and securement of the condom catheter, and assess for any complications. It falls within the scope of practice of the PN, who has the necessary training and expertise.

A. Report any drainage observed around the GT insertion site. B. Use plenty of pillows to position the client on the side after bathing. C. Keep the head of the bed raised while the tube feeding is infusing. D. Raise the entire bed while bathing the client to reduce back strain.

Correct Answer is C

Explanation

A. Reporting any drainage observed around the gastrostomy tube insertion site is important for monitoring potential infection or complications; however, it is not the most immediate concern during a total bed bath.
B. While using plenty of pillows to position the client on the side after bathing is important for comfort and skin integrity, it does not address the safety of the feeding during the bath.
C. Keeping the head of the bed raised while the tube feeding is infusing is the most critical instruction. This position helps prevent aspiration and ensures that the feeding is administered safely while maintaining the client’s airway during the bathing process.
D. Raising the entire bed while bathing the client is helpful for the caregiver's ergonomics but does not take precedence over ensuring the client’s safety regarding the gastrostomy tube feeding.

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A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the practical nurse (PN) implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is assigning tasks to an unlicensed assistive personnel (UAP) who is giving basic care to a group of residents in a long-term care facility. Which client's task should be completed by a PN, rather than the UAP?

Correct Answer is A

Explanation

The practical nurse (PN) is providing instructions to the unlicensed assistive personnel (UAP) preparing to give a total bed bath to an immobile client who has continuous feeding via a gastrostomy tube (GT). Which instruction is most important for the PN to emphasize?

Correct Answer is C

Explanation

The practical nurse (PN) applies and then releases pressure to a client's fingernail as seen in the photo. Normal nail color returns in 2 seconds. Which action should the PN take?

The practical nurse (PN) receives shift reports for four newborns in the full-term newborn nursery. Which infant should the PN assess first?

The parents of a one-year-old child with the diagnosis of hypospadias informed the practical nurse (PN) that they plan to delay corrective surgery to see if the child will outgrow the problem. Which information should the PN provide to these parents?

A client whose first child was delivered by cesarean section is 20 weeks pregnant with her second child and wishes to have a vaginal birth after cesarean (VBAC). What information is most important for the practical nurse (PN) to obtain?

A female client with immune thrombocytopenic purpura (ITP) is transferred to a long-term care facility for physical rehabilitation. To prevent injury, which action is most important for the practical nurse to implement?

Which action should the practical nurse (PNA) prioritize for postoperative patient with a PCA (Patient- Controlled Analgesia) machine?

A client who had a knee replacement surgery and received a prescription for enoxaparin 30 mg subcutaneously every 12 hours for 10 days. The medication is available in 30 mg per 0.3 mL pre-filled syringes. How many mL should the practical nurse (PN) administer each day? (Enter numerical value only.)