Exam 1: PRN1409 / PRN 1409
Client-Centered Care III Review
Latest Update 2026/2027 | 100% Correct | Grade A |
Verified Answers
Section 1: Complex Medical-Surgical Conditions
Q1: A practical nurse (PN) is caring for a client with heart failure who reports sudden shortness
of breath. The PN notes bilateral crackles in the lungs and an oxygen saturation of 88% on room
air. Which action should the PN take first?
A. Elevate the head of the bed to 45 degrees.
B. Administer the prescribed daily furosemide.
C. Apply supplemental oxygen at 2L via nasal cannula. [CORRECT]
D. Check the client's current weight and compare it to yesterday.
Correct Answer: C
Rationale: Applying supplemental oxygen addresses the immediate physiological need for
oxygenation and aligns with the NCSBN Clinical Judgment Model (CJM) step of taking action
to address an acute cue (88% SpO2) using the ABC (airway, breathing, circulation) framework.
This intervention stabilizes the client before further assessments are completed.
Elevating the head of the bed is a correct intervention to decrease preload, but it does not resolve
the critical hypoxia as rapidly as applying oxygen, making it not the priority. Administering
furosemide is a correct but secondary intervention that will take time to resolve fluid overload.
Checking the weight is an important assessment for chronic management but is an acute vs.
chronic error, as it does not help in an acute respiratory distress situation.
,Q2: A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2L per
minute via nasal cannula. The PN observes the client using accessory muscles to breathe and
notes a respiratory rate of 32 breaths/min. Which statement by the PN demonstrates accurate
understanding of COPD management?
A. "I will increase the oxygen to 4L to treat the hypoxia and decrease the work of breathing."
B. "I will encourage the client to perform pursed-lip breathing and monitor for resolution
of accessory muscle use." [CORRECT]
C. "I will immediately administer a prescribed short-acting bronchodilator via nebulizer."
D. "I will instruct the client to take deep, rapid breaths to maximize oxygen intake."
Correct Answer: B
Rationale: Pursed-lip breathing prolongs exhalation, prevents airway collapse, and helps release
trapped air, which is the most appropriate independent nursing intervention within the PN scope
for a COPD exacerbation. Monitoring the effectiveness of this intervention falls within the PN's
responsibility to evaluate outcomes of chronic disease management.
Increasing oxygen to 4L is incorrect because clients with severe COPD rely on a hypoxic drive
to breathe; high-flow oxygen can suppress this drive and cause respiratory arrest. Administering
a bronchodilator requires a provider's assessment and order, and while it may be needed, pursed-
lip breathing is an immediate, independent PN action. Instructing deep, rapid breathing is a
common clinical reasoning error, as it will increase air trapping and worsen the client's
respiratory distress.
Q3: A client with type 2 diabetes mellitus presents with a blood glucose level of 48 mg/dL. The
client is awake but slightly confused. Which intervention is most appropriate for the PN to
implement?
A. Administer 1 mg of intramuscular glucagon as prescribed.
B. Provide 4 oz of apple juice and recheck the blood glucose in 15 minutes. [CORRECT]
C. Initiate a 50% dextrose intravenous bolus as prescribed.
D. Obtain a hemoglobin A1c level to assess long-term glycemic control.
Correct Answer: B
Rationale: Because the client is awake and able to swallow, the administration of 15 to 20 grams
of fast-acting carbohydrates is the first-line, safest intervention for hypoglycemia within the PN
scope. Rechecking in 15 minutes ensures the intervention was effective and prevents
overtreatment.
,Administering glucagon is incorrect because it is indicated for unconscious patients or those
unable to swallow, representing an action that is correct but not the priority for this client's
current level of consciousness. Initiating an IV dextrose bolus is outside the PN scope of practice
in many jurisdictions without specific advanced IV certification and is unnecessarily invasive.
Obtaining a hemoglobin A1c is incorrect because it is a chronic assessment metric and fails to
address the acute, life-threatening hypoglycemia using Maslow's hierarchy.
Q4: The PN is assessing a client's central venous catheter (CVC) site and notices redness,
warmth, and purulent drainage at the insertion site. What is the priority action by the PN?
A. Apply a warm compress to the site to decrease inflammation.
B. Flush the catheter with normal saline to maintain patency.
C. Discontinue the infusion and notify the registered nurse (RN) immediately. [CORRECT]
D. Cleanse the site vigorously with chlorhexidine and apply a new dressing.
Correct Answer: C
Rationale: Redness, warmth, and purulent drainage are classic cues of a central line-associated
bloodstream infection (CLABSI), posing an acute safety threat. The PN must stop the infusion to
prevent further bacterial introduction and immediately report to the RN, as removing a CVC is
typically outside the PN scope of practice.
Applying a warm compress is incorrect because it could facilitate the spread of the localized
infection into the systemic circulation. Flushing the catheter is incorrect because it will push
infected purulent material directly into the client's bloodstream, representing a severe safety
violation. Cleansing the site is incorrect because it is an insufficient intervention for an
established CVC infection and delays the necessary discontinuation of the line.
Q5: A client has a new colostomy and is anxious about participating in the care. Which action by
the PN aligns with client-centered care standards for ostomy management?
A. Perform the ostomy care quickly while the client looks away to reduce anxiety.
B. Provide the client with written materials and tell them to read it before the next care session.
C. Involve the client in the ostomy care by having them hold supplies or clean the skin
under guidance. [CORRECT]
D. Delegate the ostomy care entirely to unlicensed assistive personnel (UAP) to prevent client
distress.
, Correct Answer: C
Rationale: Involving the client gradually in their own care empowers them, reduces fear of the
unknown, and aligns with patient education strategies that promote self-efficacy. This approach
respects the client's pace while ensuring they learn necessary skills for discharge.
Performing care quickly while the client looks away is incorrect because it isolates the client
from their care and fails to promote long-term coping. Providing only written materials is
incorrect because it ignores the client's current anxiety and does not provide the psychomotor
demonstration required for complex skills. Delegating entirely to UAP is incorrect because it
violates client-centered care principles and UAP scope of practice, as UAP cannot perform initial
ostomy teaching or assessment of a new stoma.
Q6: Select all that apply: The PN is caring for a client with a stage 3 pressure injury on the
sacrum. Which interventions are within the PN scope of practice and align with standard wound
care protocols?
A. Performing a comprehensive head-to-toe assessment to determine the underlying etiology of
the wound.
B. Applying a hydrocolloid dressing after cleaning the wound with normal saline.
[CORRECT]
C. Documenting the wound's location, size, exudate, and tissue type. [CORRECT]
D. Ordering a nutritional consult to optimize wound healing.
E. Repositioning the client off the sacrum every 2 hours and as needed. [CORRECT]
Correct Answer: B, C, E
Rationale: Applying prescribed hydrocolloid dressings, accurately documenting wound
characteristics to track healing, and repositioning the client to relieve pressure are all standard,
independent, and dependent interventions firmly within the PN scope of practice for wound
management.
A comprehensive assessment to determine etiology is incorrect because this level of diagnostic
reasoning is typically reserved for the RN or wound care specialist. Ordering a nutritional
consult is incorrect because it requires a provider's order and is outside the prescriptive authority
of the practical nurse.
Client-Centered Care III Review
Latest Update 2026/2027 | 100% Correct | Grade A |
Verified Answers
Section 1: Complex Medical-Surgical Conditions
Q1: A practical nurse (PN) is caring for a client with heart failure who reports sudden shortness
of breath. The PN notes bilateral crackles in the lungs and an oxygen saturation of 88% on room
air. Which action should the PN take first?
A. Elevate the head of the bed to 45 degrees.
B. Administer the prescribed daily furosemide.
C. Apply supplemental oxygen at 2L via nasal cannula. [CORRECT]
D. Check the client's current weight and compare it to yesterday.
Correct Answer: C
Rationale: Applying supplemental oxygen addresses the immediate physiological need for
oxygenation and aligns with the NCSBN Clinical Judgment Model (CJM) step of taking action
to address an acute cue (88% SpO2) using the ABC (airway, breathing, circulation) framework.
This intervention stabilizes the client before further assessments are completed.
Elevating the head of the bed is a correct intervention to decrease preload, but it does not resolve
the critical hypoxia as rapidly as applying oxygen, making it not the priority. Administering
furosemide is a correct but secondary intervention that will take time to resolve fluid overload.
Checking the weight is an important assessment for chronic management but is an acute vs.
chronic error, as it does not help in an acute respiratory distress situation.
,Q2: A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2L per
minute via nasal cannula. The PN observes the client using accessory muscles to breathe and
notes a respiratory rate of 32 breaths/min. Which statement by the PN demonstrates accurate
understanding of COPD management?
A. "I will increase the oxygen to 4L to treat the hypoxia and decrease the work of breathing."
B. "I will encourage the client to perform pursed-lip breathing and monitor for resolution
of accessory muscle use." [CORRECT]
C. "I will immediately administer a prescribed short-acting bronchodilator via nebulizer."
D. "I will instruct the client to take deep, rapid breaths to maximize oxygen intake."
Correct Answer: B
Rationale: Pursed-lip breathing prolongs exhalation, prevents airway collapse, and helps release
trapped air, which is the most appropriate independent nursing intervention within the PN scope
for a COPD exacerbation. Monitoring the effectiveness of this intervention falls within the PN's
responsibility to evaluate outcomes of chronic disease management.
Increasing oxygen to 4L is incorrect because clients with severe COPD rely on a hypoxic drive
to breathe; high-flow oxygen can suppress this drive and cause respiratory arrest. Administering
a bronchodilator requires a provider's assessment and order, and while it may be needed, pursed-
lip breathing is an immediate, independent PN action. Instructing deep, rapid breathing is a
common clinical reasoning error, as it will increase air trapping and worsen the client's
respiratory distress.
Q3: A client with type 2 diabetes mellitus presents with a blood glucose level of 48 mg/dL. The
client is awake but slightly confused. Which intervention is most appropriate for the PN to
implement?
A. Administer 1 mg of intramuscular glucagon as prescribed.
B. Provide 4 oz of apple juice and recheck the blood glucose in 15 minutes. [CORRECT]
C. Initiate a 50% dextrose intravenous bolus as prescribed.
D. Obtain a hemoglobin A1c level to assess long-term glycemic control.
Correct Answer: B
Rationale: Because the client is awake and able to swallow, the administration of 15 to 20 grams
of fast-acting carbohydrates is the first-line, safest intervention for hypoglycemia within the PN
scope. Rechecking in 15 minutes ensures the intervention was effective and prevents
overtreatment.
,Administering glucagon is incorrect because it is indicated for unconscious patients or those
unable to swallow, representing an action that is correct but not the priority for this client's
current level of consciousness. Initiating an IV dextrose bolus is outside the PN scope of practice
in many jurisdictions without specific advanced IV certification and is unnecessarily invasive.
Obtaining a hemoglobin A1c is incorrect because it is a chronic assessment metric and fails to
address the acute, life-threatening hypoglycemia using Maslow's hierarchy.
Q4: The PN is assessing a client's central venous catheter (CVC) site and notices redness,
warmth, and purulent drainage at the insertion site. What is the priority action by the PN?
A. Apply a warm compress to the site to decrease inflammation.
B. Flush the catheter with normal saline to maintain patency.
C. Discontinue the infusion and notify the registered nurse (RN) immediately. [CORRECT]
D. Cleanse the site vigorously with chlorhexidine and apply a new dressing.
Correct Answer: C
Rationale: Redness, warmth, and purulent drainage are classic cues of a central line-associated
bloodstream infection (CLABSI), posing an acute safety threat. The PN must stop the infusion to
prevent further bacterial introduction and immediately report to the RN, as removing a CVC is
typically outside the PN scope of practice.
Applying a warm compress is incorrect because it could facilitate the spread of the localized
infection into the systemic circulation. Flushing the catheter is incorrect because it will push
infected purulent material directly into the client's bloodstream, representing a severe safety
violation. Cleansing the site is incorrect because it is an insufficient intervention for an
established CVC infection and delays the necessary discontinuation of the line.
Q5: A client has a new colostomy and is anxious about participating in the care. Which action by
the PN aligns with client-centered care standards for ostomy management?
A. Perform the ostomy care quickly while the client looks away to reduce anxiety.
B. Provide the client with written materials and tell them to read it before the next care session.
C. Involve the client in the ostomy care by having them hold supplies or clean the skin
under guidance. [CORRECT]
D. Delegate the ostomy care entirely to unlicensed assistive personnel (UAP) to prevent client
distress.
, Correct Answer: C
Rationale: Involving the client gradually in their own care empowers them, reduces fear of the
unknown, and aligns with patient education strategies that promote self-efficacy. This approach
respects the client's pace while ensuring they learn necessary skills for discharge.
Performing care quickly while the client looks away is incorrect because it isolates the client
from their care and fails to promote long-term coping. Providing only written materials is
incorrect because it ignores the client's current anxiety and does not provide the psychomotor
demonstration required for complex skills. Delegating entirely to UAP is incorrect because it
violates client-centered care principles and UAP scope of practice, as UAP cannot perform initial
ostomy teaching or assessment of a new stoma.
Q6: Select all that apply: The PN is caring for a client with a stage 3 pressure injury on the
sacrum. Which interventions are within the PN scope of practice and align with standard wound
care protocols?
A. Performing a comprehensive head-to-toe assessment to determine the underlying etiology of
the wound.
B. Applying a hydrocolloid dressing after cleaning the wound with normal saline.
[CORRECT]
C. Documenting the wound's location, size, exudate, and tissue type. [CORRECT]
D. Ordering a nutritional consult to optimize wound healing.
E. Repositioning the client off the sacrum every 2 hours and as needed. [CORRECT]
Correct Answer: B, C, E
Rationale: Applying prescribed hydrocolloid dressings, accurately documenting wound
characteristics to track healing, and repositioning the client to relieve pressure are all standard,
independent, and dependent interventions firmly within the PN scope of practice for wound
management.
A comprehensive assessment to determine etiology is incorrect because this level of diagnostic
reasoning is typically reserved for the RN or wound care specialist. Ordering a nutritional
consult is incorrect because it requires a provider's order and is outside the prescriptive authority
of the practical nurse.
