The practical nurse (PN) assists a client to a supine position. What should the PN use to prevent external rotation of the client's hips?

Foam mattress pad.

Trapeze bar.

Trochanter rolls.

Draw sheet.

Answer and Explanation

The Correct Answer is C

A.   Foam mattress pad - Foam mattress pads primarily provide cushioning and pressure relief, not specifically designed to prevent hip rotation.
B.   Trapeze bar - Trapeze bars assist with mobility but do not directly prevent hip rotation.
C.   Trochanter rolls - These are specifically designed to prevent external rotation of the hips by supporting the thighs, aiding in maintaining proper hip alignment.
D.   Draw sheet - While useful for repositioning and transferring patients, a draw sheet doesn't prevent hip rotation when the patient is in a supine position

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Correct Answer is D

Explanation

A. Ask about pain. This is not the most important action because pain is not the primary problem in this situation. Pain may or may not be present, but it does not address the underlying cause of cyanosis.

B. Provide mouth care. This is not the most important action because mouth care does not improve oxygenation. Mouth care may be helpful to prevent infection and promote comfort, but it is not a priority in this case.

C. Offer fluids. This is not the most important action because fluids do not increase oxygen levels in the blood. Fluids may be beneficial to prevent dehydration and maintain circulation, but they are not urgent in this scenario.

D. Administer oxygen. This is the most important action because oxygen is essential for cellular function and survival. Oxygen therapy can reverse hypoxia and improve the client's condition.

A. Check for kinks in the drainage tubing. B. Observe the drainage again in one hour. C. Report the finding to the charge nurse. D. Stop the irrigation solution immediately.

Correct Answer is C

Explanation

A. Checking for kinks in the drainage tubing is important, but the observed clots and thick red fluid suggest potential complications that require immediate attention and should be reported. B. Waiting for an hour to observe again could delay necessary interventions if there's an issue with bleeding or clot formation, so reporting immediately is more prudent.
C. Reporting the finding to the charge nurse is crucial as it indicates potential complications such as bleeding or clot formation that need immediate intervention.
D. Stopping the irrigation solution without proper assessment and guidance could lead to complications and isn't the initial action warranted in this situation. Reporting to a superior nurse allows for prompt evaluation and intervention.

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The practical nurse (PN) assists a client to a supine position. What should the PN use to prevent external rotation of the client's hips?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) observes a client's mouth and lips as seen in the picture. Which follow-up action is most important for the PN to take?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

The practical nurse (PN) observes a client's initial postoperative dressing and drain as seen in the picture. Which follow-up actions should the PN implement? (Select all that apply.)

When assessing a client at 38-weeks gestation, the practical nurse (PN) determines that she has one set of female twins, who are now 6 years old, a son who is 4 years old, and last year she had a fetal loss at 24-weeks gestation. Which is the correct gravidity and parity for this client?

An older female client who resides in a long-term care facility has a male friend who often visits her in the evenings. The practical nurse (PN) enters the room to administer medications and finds the couple in bed together. What action should the PN take?

A female client who is scheduled to be discharged within several hours shows the practical nurse (PN) a knife on her tray and states that she could use it to cut herself. What intervention is most important for the PN to implement?

The practical nurse (PN) palpates a client's radial pulse and notes that the pulse disappears when light pressure is applied. How should the PN document this finding?

When a small fire breaks out in the kitchen of a long-term care facility, which task should be performed by the practical nurse (PN) rather than the unlicensed assistive personnel (UAP)?

A chronically depressed older male resident of a long-term care facility has become more reclusive and today refuses to leave his room. His family has away and are unable to visit as much as in the past. Which comment by the practical nurse (PN) is likely to be most helpful to this client?