Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?

An adult who is one day postoperative for a laparoscopic cholecystectomy.

An older client who is one day postoperative with a colostomy for colon cancer.

An older adult who is scheduled for foot amputation due to diabetes complications.

An adult with alcoholism, cirrhosis, and hepatic encephalopathy.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Assigning a client who is one day postoperative for a laparoscopic cholecystectomy to the practical nurse (PN) is appropriate. This procedure is minimally invasive, and the client is likely stable, requiring routine postoperative care such as wound assessment, pain management, and monitoring for any signs of complications.

Choice B rationale:

An older client who is one day postoperative with a colostomy for colon cancer may have complex postoperative needs, including colostomy care, monitoring for complications, and pain management. This level of care is usually within the scope of the registered nurse (RN) rather than a practical nurse (PN).

Choice C rationale:

An older adult who is scheduled for foot amputation due to diabetes complications is likely to have complex care needs, including wound care, diabetes management, and potential complications. This client would require the expertise of an RN rather than a PN.

Choice D rationale:

An adult with alcoholism, cirrhosis, and hepatic encephalopathy may have complex medical and psychosocial issues that require specialized nursing care. This client's condition is not appropriate for a practical nurse (PN) to manage, and the care should be provided by an RN or other specialized healthcare provider.

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Correct Answer is B

Explanation

Choice B rationale:

Observing for extrapyramidal symptoms, such as dystonia, is the most important intervention immediately after seclusion because haloperidol is an antipsychotic medication known to have the potential for causing extrapyramidal side effects. Identifying and managing these side effects promptly is crucial to ensure the client's safety.

Choice A rationale:

Releasing the client as soon as composure is regained may not be safe if the client is still at risk of harming themselves or others. Monitoring for the resolution of symptoms and stabilization is important before releasing the client.

Choice C rationale:

Securing the room with padded walls and minimal furnishings is not the immediate priority. While seclusion rooms should be safe and comfortable, observing for potential side effects takes precedence.

Choice D rationale:

Providing one-on-one observation at all times is a resource-intensive intervention and may not be necessary for all clients. Observing for extrapyramidal symptoms is more targeted and appropriate in this scenario.

A. Monitor ETT markings between 22 and 26 cm at teeth line. B. Check for capillary refill of 3 seconds or less. C. Obtain a portable chest x-ray to verify ETT location. D. Assess for symmetrical chest movement. E. Auscultate for presence of bilateral breath sounds.

Correct Answer is ["A","C","D","E"]

Explanation

Choice A rationale:

Monitoring ETT markings between 22 and 26 cm at the teeth line is essential to ensure proper placement of the endotracheal tube (ETT). This helps confirm that the ETT is positioned correctly in the trachea.

Choice B rationale:

Checking for capillary refill is not a reliable method for verifying the placement of an ETT. It is more indicative of peripheral circulation and not related to airway management.

Choice C rationale:

Obtaining a portable chest x-ray is a crucial step to verify the exact placement of the ETT within the trachea and to rule out potential complications such as pneumothorax.

Choice D rationale:

Assessing for symmetrical chest movement is important because unequal chest rise and fall could indicate an issue with ETT placement or lung function.

Choice E rationale:

Auscultating for bilateral breath sounds is another method to confirm that the ETT is correctly positioned in the trachea and that both lungs are being ventilated adequately.

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Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? (Select all that apply.).

Correct Answer is ["A","C","D","E"]

Explanation

The medication aide at a long-term care facility is sick and requests to go home before all medications are administered. Which action should the practical nurse (PN) in charge take?

The healthcare provider prescribes the antibiotic cefdinir 300 mg by mouth every 12 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat?

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