The PN Identifies that the client is having a tonic-clonic seizure. The oxygen saturation is 40% and the respiratory rate is 4 breaths/min. The PN calls for help and 2 other PNs enter the room. Which three actions will the PN anticipate taking next?

Begin chest compressions.

Watch the seizure activity and document the time and client movement.

Place pillows around the bed rails to provide padding.

Stop the IV fluids.

Increase the supplemental oxygen to 10 L/min via nasal cannula.

Manually ventilate the client with a bag-valve mask.

Answer and Explanation

Correct Answer : C,E,F

C. Place pillows around the bed rails to provide padding: During a tonic-clonic seizure, the client may experience uncontrolled movements and convulsions. Placing pillows around the bed rails helps prevent injury by providing padding and cushioning.

E. Increase the supplemental oxygen to 10 L/min via nasal cannula: The client's oxygen saturation is dangerously low at 40%. Increasing the supplemental oxygen to 10 L/min via nasal cannula will help improve oxygenation and prevent hypoxia.

F. Manually ventilate the client with a bag-valve-mask: Since the respiratory rate is only 4 breaths/min, the client is not adequately ventilating on their own. Manual ventilation with a bag-valve mask will provide necessary oxygenation and ventilation support during the seizure.

The other options are not appropriate actions at this time:

Begin chest compressions: Chest compressions are indicated if the client's heart has stopped or if they are in cardiac arrest. Since the scenario describes a seizure, the client's heart is presumed to be functioning.
Watch the seizure activity and document the time and client movement: Although documentation is important, during an active seizure, the priority is to ensure the client's safety and provide immediate interventions. Documentation can be done after the seizure has ended.
Stop the IV fluids: There is no indication to stop the IV fluids based on the given information. IV fluids are generally continued unless there is a specific reason to discontinue them.

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Correct Answer is B

Explanation

the practical nurse (PN) should engage in regular contact with the client who demonstrates an inability to communicate effectively. Regular contact helps establish a therapeutic relationship and provides opportunities for observation and assessment of the client's needs and behavior. It also helps the PN to build trust with the client over time.
The other options listed are not appropriate methods for interacting with a client with psychosis who has difficulty communicating effectively:
A. Discouraging group activities: Group activities can be beneficial for individuals with psychosis as they provide opportunities for social interaction, skill-building, and support. It is important to encourage participation in appropriate group activities that are tailored to the client's needs and abilities.
C. Touching the client when speaking: Touching the client without their consent may be perceived as invasive or threatening, especially for individuals with psychosis who may already have difficulties with sensory processing or boundaries. It is important to respect the client's personal space and communicate through verbal means, maintaining a respectful and
non-intrusive approach.
D. Establishing a no-harm contract: No-harm contracts are typically used in the context of suicidal or self-harming behaviors to promote safety and identify support systems. While safety is important, it is not directly related to the communication difficulties associated with psychosis. Instead, the focus should be on developing a therapeutic relationship and finding effective means of communication with the client.

A. A client with continuous urinary bladder irrigation via a 3-way catheter. B. A client with urinary urgency and incontinence who is asking for a bedpan. C. A client with a full urinary bedside drainage unit after receiving a diuretic. D. A client with paraplegia who needs an urinary condom-catheter change.

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.

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The PN Identifies that the client is having a tonic-clonic seizure. The oxygen saturation is 40% and the respiratory rate is 4 breaths/min. The PN calls for help and 2 other PNs enter the room. Which three actions will the PN anticipate taking next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is caring for a client with psychosis who demonstrates an inability to communicate effectively. Which method should the PN use to interact with the client?

Correct Answer is B

Explanation

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

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.)

A client's daughter phones the charge nurse to report that the night nurse did not provide good care for her mother. Which response should the practical nurse (PN) make?

In preparing to discontinue a client's saline lock, the practical nurse (PN) notes that the client is receiving an antiplatelet medication. Which action should the PN implement?

The practical nurse (PN) is auscultating a client's heart sounds. Which abnormal heart sound should the PN report to the charge nurse? (Please listen to the audio file to select the option that applies.)

Prior to administering pain medication to an adult postoperative client, what information should the practical nurse (PN) obtain? (Select all that apply.)

Which statement by an older female client who lost her spouse two years ago should indicate to the practical nurse (PN) that the client may need bereavement counseling?