The practical nurse (PN) assisting a walker-dependent client to ambulate in the hall notices another client lying on the floor. Which is the best action for the PN to take?

Send a UAP into the room to help the client on the floor get back into the bed

Call the nursing supervisor and ask for additional personnel to help complete the ambulation

Have a UAP stay with the ambulating client and assist the client who is on the floor

Take the ambulating client back to the room and return to assist the client

Answer and Explanation

The Correct Answer is C

A. Send a UAP into the room to help the client on the floor get back into the bed: The PN must first assess the client on the floor before any movement to rule out injury. Delegating this to a UAP without assessment can lead to harm if the fallen client has fractures or head trauma.

B. Call the nursing supervisor and ask for additional personnel to help complete the ambulation: While calling for help may be appropriate later, the PN must ensure the current client’s safety first by returning them to their room before addressing the emergency.

C. Have a UAP stay with the ambulating client and assist the client who is on the floor: In a clinical setting, a client found on the floor represents an acute change in status and a potential emergency. According to the Scope of Practice, a Unlicensed Assistive Personnel (UAP) cannot perform the initial assessment of a fallen client. Therefore, the nurse (PN) must be the one to physically go to the fallen client to assess for airway patency, head injury, or fractures. By having the UAP stand with and support the stable, ambulating client, the nurse is effectively re-delegating a low-risk task (standing/supporting) to attend to a high-priority, unstable situation.

D. Take the ambulating client back to the room and return to assist the client on the floor: Safely returning the current client prevents potential falls, then allows the PN to assess the fallen client promptly. This action prioritizes both safety and proper nursing assessment.

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Correct Answer is B

Explanation

A. Assess the client for nerve pain or paralysis: Assessing for nerve pain or paralysis may be relevant in clients with neurological or musculoskeletal conditions, but immune thrombocytopenic purpura (ITP) primarily affects platelet levels, increasing bleeding risk rather than nerve dysfunction.

B. Ensure the client has minimal clutter in the room: Keeping the client’s room free from clutter is the most important preventive action, as it minimizes the risk of falls, bruises, or trauma that can lead to serious bleeding in ITP.

C. Monitor the client's blood cell laboratory values: Monitoring laboratory values such as platelet counts helps assess disease progression but does not actively prevent physical injury. Injury prevention in ITP focuses on minimizing trauma and fall risk rather than tracking lab results.

D. Evaluate client's neurological status after exercising: Evaluating neurological status after exercise is beneficial for detecting complications like intracranial bleeding, but it is a secondary measure that occurs after an event. The primary goal is to prevent injury.

Correct Answer is ["15"]

Explanation

Prescribed dose = 3 mg

Available concentration = 1 mg per 5 mL

Calculate the volume in milliliters (mL) to administer.

Volume (mL) = (Prescribed dose (mg) / Available concentration (mg)) x Available volume (mL)

= (3 mg / 1 mg) x 5 mL

= 3 x 5 mL

= 15 mL.

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The practical nurse (PN) assisting a walker-dependent client to ambulate in the hall notices another client lying on the floor. Which is the best action for the PN to take?

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Naxlex Comprehensive Predictor Exams

A female client with immune thrombocytopenic purpura 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?

Correct Answer is B

Explanation

The practical nurse (PN) plans to administer a PRN dose of loperamide via a client's gastrostomy tube. The prescribed dose is 3 mg. The label on the medication bottle reads, "1 mg/5 mL." How many mL should the PN administer? (Enter numeric value only.)

Correct Answer is ["15"]

Explanation

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