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The practical nurse (PN) is checking residual volume prior to the administration of a bolus feeding to a client with a percutaneous endoscopic gastrostomy (PEG) tube when the unlicensed assistive personnel (UAP) reports that another client has requested pain medication for postoperative pain. Which action should the PN take?

Have the UAP notify the client in pain that the PN will be in to check on the client after completing the procedure in progress.

Finish measuring the residual and assign the UAP to provide the bolus feeding so the PN can administer an analgesic.

Tell the UAP that the client's pain will subside when the client is not disturbed and is allowed uninterrupted rest.

Ask the UAP to finish measuring the residual volume while the PN assesses the pain level of the surgical client.

Answer and Explanation

The Correct Answer is A

A. Have the UAP notify the client in pain that the PN will be in to check on the client after completing the procedure in progress:
Pain assessment and medication administration require licensed personnel. The PN should finish the current task and promptly address the client in pain.
B. Finish measuring the residual and assign the UAP to provide the bolus feeding so the PN can administer an analgesic:
UAPs cannot administer tube feedings unless trained and delegated appropriately, and in most settings, PEG bolus feeding is the PN’s responsibility.
C. Tell the UAP that the client's pain will subside when the client is not disturbed:
Ignoring or delaying pain relief is inappropriate and unethical.
D. Ask the UAP to finish measuring the residual volume while the PN assesses the pain level of the surgical client:
Measuring gastric residual requires clinical judgment and is a PN responsibility, not a UAP task.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Obtain a specimen of urethral drainage for culture:
Symptoms suggest possible gonorrhea or chlamydia; culture needed for diagnosis and treatment guidance.

B. Identify all sexual partners in the last four days:
Partner notification is important but follows confirmed diagnosis.

C. Observe the perineal area for a chancroid-like lesion:
Chancroid presents differently; symptoms point to urethritis.

D. Assess for perineal itching, erythema, and excoriation:
These are signs of fungal infection or dermatitis, not primary concern here.

A. Loosen the fistula dressing. B. Document that the fistula is intact. C. Apply gentle pressure over the site. D. Report the presence of a bounding pulse.

Correct Answer is B

Explanation

A. Loosen the fistula dressing: Not indicated unless the dressing is too tight, which is not mentioned.
B. Document that the fistula is intact: A palpable thrill indicates patency; no intervention needed.
C. Apply gentle pressure over the site: Could obstruct blood flow and damage the fistula.
D. Report the presence of a bounding pulse: A thrill is expected and normal; not a sign of complication.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A male client who had sexual intercourse with a causal partner three days ago tells the practical nurse (PN) that he is experiencing painful urination, urinary frequency, and discharge from the penis. Which action should the PN implement?

Correct Answer is A

Explanation

While caring for a client with an arteriovenous (AV) fistula in the left forearm, the practical nurse (PN) observed a palpable buzzing sensation over the fistula. Which action should the PN take?

Correct Answer is B

Explanation

The practical nurse (PN) is assisting the nurse (RN) during the admission of a client with a possible cerebrovascular accident (CVA). Which action(s) should the PN complete in the assessment phase of the admitting process? Select all that apply.

At 2100, an older adult client turns on the call light and reports to the practical nurse (PN) concerns of difficulty falling asleep. Which priority action should the PN implement?

When changing a diaper on a 2-day-old infant, the practical nurse (PN) observes that the baby's legs are flexed with limited abduction. Based on this finding, which action should the PN take next?

The practical nurse (PN) is caring for an older client who was informed about a diagnosis of terminal cancer two days ago. Which intervention would be most helpful for the client's spouse at this time?

During an interview, an older adult client answers some questions inappropriately. The practical nurse (PN) observes there is a hearing aid in one ear. Which intervention is most helpful in assisting the client to hear the PN's question?

Which problem should the practical nurse (PN) expect a severely depressed client to exhibit?

The practical nurse (PN) finds a client who is assigned to another nurse bleeding from an IV site and the IV tubing and fluid are on the floor. The PN immediately applies a dressing to stop the bleeding. Which action should the PN take next?

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?