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Following an admission for severe heart failure exacerbation, a client is prescribed scheduled doses of furosemide. Which of the following nursing actions must the practical nurse implement to minimize the client's risk of physiological complications? (Select all that apply.)

Select all that apply

Verify the client's identity by asking them to state their name and date of birth prior to giving the medication

Obtain the client's daily weight using the same scale at the same time each morning

Withhold the diuretic and notify the registered nurse if the client exhibits new-onset resting tachycardia

Administer the furosemide via direct intravenous push to ensure rapid therapeutic diuresis

Delay reporting a morning serum potassium level of 2.8 mEq/L (2.8 mmol/L) until the provider's afternoon rounds

Proceed with the scheduled dose if the client's blood pressure decreases to 88/54 mmHg without further evaluation

Show answer & explanation

Answer: Verify the client's identity by asking them to state their name and date of birth prior to giving the medication; Obtain the client's daily weight using the same scale at the same time each morning; Withhold the diuretic and notify the registered nurse if the client exhibits new-onset resting tachycardia

Answer

The correct actions include verifying the client's identity prior to medication administration, obtaining daily weights using consistent methods, and withholding the medication while notifying the registered nurse if the client exhibits new-onset resting tachycardia.

The correct actions demonstrate safe clinical judgment within the practical nurse's scope of practice by minimizing risks associated with diuretic therapy. Verifying two patient identifiers prevents medication administration errors. Monitoring daily weights provides essential data to evaluate fluid volume status and prevent complications. Recognizing new-onset resting tachycardia as a potential early compensatory sign of hypovolemia correctly prompts the nurse to withhold the medication and escalate the finding to the registered nurse.

Step-by-Step Solution

Analyze the client's clinical scenario and prescribed treatment.

The client has heart failure and is receiving furosemide, a loop diuretic that reduces fluid volume but can cause electrolyte loss and hypovolemia.

Understanding the medication's mechanism of action highlights the risk for hypovolemia, electrolyte imbalances (like hypokalemia), and physiological instability.

Evaluate each nursing action against the practical nurse scope of practice and safety standards.

The nurse must verify patient identifiers, measure daily weights accurately, and escalate early signs of hypovolemia such as tachycardia. The nurse must avoid giving IV push medications, ignoring critical laboratory values, or disregarding hypotensive vital signs.

The primary objective is the reduction of risk potential, which requires strict adherence to scope of practice and prompt recognition of clinical deterioration.

Key Concept

Reduction of Risk Potential (Scope of Practice and Complication Prevention)

Estimated Time:1m 30s

Question 2162Question →

An 18-month-old toddler is brought to the pediatric outpatient clinic for a well-child checkup. The practical nurse is observing the child's behaviors while gathering initial data. Which of the following findings should the nurse recognize as expected developmental milestones? Select all that apply.

Select all that apply

Building a tower using three to four small blocks

Speaking in complete three-word sentences

Walking independently across the examination room

Engaging in cooperative play by sharing a toy building set with another child

Pointing to named body parts such as the nose and eyes

Show answer & explanation

Answer: Building a tower using three to four small blocks; Walking independently across the examination room; Pointing to named body parts such as the nose and eyes

Answer

The correct findings that demonstrate expected development for an 18-month-old are building a tower of three to four blocks, walking independently, and pointing to named body parts.

At 18 months of age, expected developmental achievements include gross motor skills like walking independently, fine motor skills such as building a tower of three to four blocks, and cognitive/receptive language skills like pointing to one or more body parts when requested. These specific findings indicate a normal progression through the toddler stage.

Step-by-Step Solution

Identify the client's developmental age group and relevant milestones.

The client is an 18-month-old toddler. Expected milestones focus on early walking, basic fine motor stacking, and early receptive language.

Establishing the baseline age expectations is necessary to differentiate between normal development and delayed or advanced behaviors.

Evaluate the motor skill observations against expected 18-month milestones.

Walking independently and stacking three to four blocks are age-appropriate gross and fine motor skills for this age.

These specific actions confirm normal physical maturation for an 18-month-old.

Evaluate the psychosocial and language observations.

Pointing to named body parts is expected. Speaking in three-word sentences and cooperative play represent milestones of older children (3- to 4-year-olds).

Toddlers typically engage in parallel play and utilize single words or short two-word phrases, making the advanced social and language options incorrect.

Key Concept

Toddler Developmental Milestones (18 Months)

Question 2163Question →

During the afternoon shift, an 82-year-old client recovering from a total hip arthroplasty three days ago becomes acutely restless and repeatedly attempts to climb over the bed rails. The client was previously oriented but is now calling out for a deceased spouse. Current vital signs reveal a heart rate of 108 beats/minute, blood pressure of 106/64 mm Hg, and respiratory rate of 24 breaths/minute. Which action should the practical nurse prioritize?

Consult the family members to determine if there is a baseline history of dementia

Document the vital signs as stable and continue with routine postoperative monitoring

Obtain a peripheral pulse oximetry reading to evaluate for potential systemic hypoxia

Reorient the client to the hospital environment and immediately implement strict fall precautions

Show answer & explanation

Answer: Obtain a peripheral pulse oximetry reading to evaluate for potential systemic hypoxia

Answer

The nurse should prioritize obtaining a peripheral pulse oximetry reading to evaluate for potential systemic hypoxia.

Sudden onset of confusion, restlessness, and tachypnea in a postoperative client strongly suggests a physiological complication such as hypoxia, pulmonary embolism, or early shock. The nurse must first prioritize airway and breathing (ABCs) by assessing oxygen saturation before addressing behavioral symptoms.

Step-by-Step Solution

Analyze the clinical presentation and recognize acute changes.

The client exhibits sudden onset confusion, restlessness, slight tachycardia (108 beats/minute), and tachypnea (24 breaths/minute).

Identifying acute deviations from a client's baseline is essential for early recognition of life-threatening complications.

Apply the ABC (Airway, Breathing, Circulation) prioritization framework.

The elevated respiratory rate combined with acute behavioral changes strongly indicates a potential breathing or oxygenation issue.

Physiological needs, especially oxygenation, take precedence over psychosocial or environmental safety needs during acute deterioration.

Determine the most appropriate immediate action within the practical nursing scope.

Measuring oxygen saturation directly and rapidly assesses the client's respiratory status.

Objective data regarding oxygenation is required to confirm hypoxia and guide immediate therapeutic interventions, such as oxygen administration.

Key Concept

Prioritizing ABCs and recognizing hypoxia as a primary cause of acute confusion in older adults.

Question 2164Question →

An adult client is prescribed cefazolin $0.75\text{ g}$ intramuscularly for surgical prophylaxis. The medication is supplied as a $1\text{ g}$ vial of dry powder. The manufacturer's instructions state to reconstitute the powder by adding $2.0\text{ mL}$ of sterile water for injection, yielding a total volume of $2.5\text{ mL}$ with a final concentration of $400\text{ mg/mL}$ . How many $\text{mL}$ should be administered to the client? (Record the answer to the nearest tenth. Do not include units in your answer.)

Show answer & explanation

Answer: 1.9

Answer

1.9

To determine the correct volume, the prescribed dose must first be converted to match the available unit:

0.75\text{ g} = 750\text{ mg}

. When a final concentration is provided (

400\text{ mg/mL}

), the diluent amount and total volume become extraneous information. Using the standard formula, divide the desired dose (

750\text{ mg}

) by the available concentration (

400\text{ mg}

) and multiply by the base volume (

1\text{ mL}

), which equals

1.875\text{ mL}

. Rounding to the nearest tenth yields

1.9\text{ mL}

Step-by-Step Solution

Convert the prescribed dose from grams to milligrams.

0.75\text{ g} \times 1000\text{ mg/g} = 750\text{ mg}

The available concentration is provided in milligrams, so the prescribed dose must be in the same unit of measurement.

Identify the final medication concentration from the provided instructions.

The final concentration is

400\text{ mg/mL}

Extraneous information such as the diluent volume (

2.0\text{ mL}

) and total reconstituted volume (

2.5\text{ mL}

) should be ignored when the final concentration is explicitly provided.

Calculate the volume to administer.

\frac{750\text{ mg}}{400\text{ mg}} \times 1\text{ mL} = 1.875\text{ mL}

This formula determines the exact liquid volume containing the required dose.

Round the final answer to the nearest tenth.

1.875\text{ mL}

rounds to

1.9\text{ mL}

Standard rounding rules state that if the hundredths digit is 5 or greater, the tenths digit is rounded up.

Key Concept

Medication Reconstitution and Dosage Calculation

Question 2165Question →

A client recovering from a fractured femur is placed in a high-acuity trauma unit. The client is exposed to continuous fluorescent lighting, frequent monitor alarms, and loud conversations from adjacent bays. The client becomes visibly agitated, pulls the blanket over their head, and states, "I cannot take all this noise and bright light anymore." Which of the following is the most appropriate initial nursing action?

Consolidate nursing tasks to minimize room entries and dim the lighting in the client's immediate area.

Administer a prescribed as-needed sedative medication to help calm the client's agitation.

Explain to the client that the constant monitoring and alarms are necessary for their safety.

Request that the healthcare provider evaluate the client for the acute onset of delirium.

Show answer & explanation

Answer: Consolidate nursing tasks to minimize room entries and dim the lighting in the client's immediate area.

Answer

Consolidate nursing tasks to minimize room entries and dim the lighting in the client's immediate area.

The client is experiencing sensory overload due to excessive environmental stimuli. The most effective and immediate intervention is to modify the environment by reducing noise, dimming lights, and grouping care activities to provide periods of uninterrupted rest.

Step-by-Step Solution

Analyze the client's presentation and environmental factors.

The client is exhibiting classic signs of sensory overload caused by continuous environmental stimuli.

Alarms, bright lights, and noise are exceeding the client's sensory tolerance.

Determine the priority nursing intervention within the PN scope of practice.

The priority is to modify the environment to reduce sensory input.

Decreasing the offending stimuli directly addresses the root cause of the client's acute agitation.

Key Concept

Sensory Overload Management

Question 2166Question →

An adult client with pneumonia is prescribed a diagnostic chest imaging study using intravenous contrast dye. The morning metabolic panel reveals a serum creatinine level of $2.4$ mg/dL. Which action is the priority for the practical nurse to take to reduce the client's risk for potential complications?

Document the result in the medical record and continue routine preparations for the imaging study.

Instruct the client to drink additional oral fluids to flush the kidneys prior to the test.

Immediately communicate the abnormal laboratory finding to the supervising registered nurse.

Contact the laboratory department directly to order a repeat blood draw for confirmation.

Show answer & explanation

Answer: Immediately communicate the abnormal laboratory finding to the supervising registered nurse.

Answer

Immediately communicate the abnormal laboratory finding to the supervising registered nurse.

The serum creatinine level of

2.4

mg/dL is significantly elevated, indicating impaired kidney function. Because intravenous contrast dye is highly nephrotoxic, the practical nurse must immediately alert the registered nurse or healthcare provider to prevent contrast-induced nephropathy.

Step-by-Step Solution

Identify the client's scheduled procedure and current laboratory values.

The client is scheduled for imaging with intravenous contrast and has a serum creatinine of

2.4

mg/dL.

Intravenous contrast dye is nephrotoxic and poses a high risk to clients with pre-existing kidney impairment.

Determine the normal reference range for serum creatinine.

The normal serum creatinine range is typically

0.6

1.2

mg/dL.

Recognizing that

2.4

mg/dL is significantly elevated is necessary for safe clinical reasoning.

Select the priority nursing intervention based on the practical nurse's scope of practice.

The nurse must immediately escalate the finding to the registered nurse or healthcare provider.

The provider may need to cancel the contrast study, order protective hydration protocols, or switch to a non-contrast imaging modality to prevent acute kidney injury.

Key Concept

Identifying critical laboratory values and escalating findings to prevent procedural complications.

Question 2167Question →

Following a right femoral cardiac catheterization, a client is admitted to the medical-surgical unit. As part of providing basic comfort and safety, which actions by the practical nurse are appropriate? Select all that apply.

Select all that apply

Keep the head of the bed at an angle of 30 degrees or lower.

Instruct the client to keep the right leg straight and avoid bending it.

Provide a fracture bedpan when the client reports the urge to urinate.

Position a pillow under the client's knees to reduce strain on the lower back.

Raise the head of the bed to a high-Fowler's position while the client eats meals.

Assist the client to stand at the bedside to promote regular voiding.

Show answer & explanation

Answer: Keep the head of the bed at an angle of 30 degrees or lower.; Instruct the client to keep the right leg straight and avoid bending it.; Provide a fracture bedpan when the client reports the urge to urinate.

Answer

The appropriate actions are keeping the head of the bed at or below 30 degrees, keeping the right leg straight, and using a fracture bedpan for elimination.

Following a femoral cardiac catheterization, strict hemostasis is vital. The client must remain on bed rest with the affected leg fully extended. Keeping the head of the bed elevated no more than 30 degrees prevents hip flexion, which could dislodge the clot. When elimination is needed, a fracture bedpan is the appropriate choice because its low profile requires minimal hip elevation, adhering to the strict movement restrictions.

Step-by-Step Solution

Identify the primary physiological risk associated with a femoral cardiac catheterization.

The main risk is hemorrhage or hematoma formation at the femoral artery puncture site in the groin.

Arterial access points are under high pressure and require strict hemostasis protocols post-procedure.

Determine the positioning constraints required to protect the insertion site.

The affected hip must remain straight (unflexed). Therefore, the head of the bed must remain low (≤30 degrees), and the right leg must be kept fully extended.

Flexion of the hip joint places physical stress on the femoral artery, increasing the likelihood of disrupting the newly formed clot.

Select basic care interventions that align with these strict mobility constraints.

Using a fracture pan is necessary because it minimizes the need to lift the hips. Interventions like ambulation, sitting completely upright, and placing pillows under the knees all cause dangerous hip flexion and must be avoided.

Basic nursing care (such as assisting with elimination or eating) must be adapted to the physical limitations of the prescribed bed rest and limb immobilization.

Key Concept

Post-procedure basic care for femoral arterial access requires strict bed rest, maintaining the affected extremity in a straight position, and avoiding hip flexion to prevent severe hemorrhage.

Question 2168Question →

After undergoing a right-sided mastectomy with axillary lymph node dissection, a client is admitted to the surgical recovery unit. The healthcare provider prescribes basic interventions to prevent lymphedema in the affected extremity. Which positioning strategy is correct for the client's right arm?

Elevated on a pillow above the level of the heart

Placed flat on the mattress directly beside the torso

Immobilized tightly across the chest in a standard medical sling

Positioned in a dependent manner below the level of the mattress

Show answer & explanation

Answer: Elevated on a pillow above the level of the heart

Answer

The right arm should be elevated on a pillow above the level of the heart.

Following a mastectomy with lymph node dissection, elevating the affected arm on a pillow above the level of the heart is a fundamental comfort and basic care measure. This position uses gravity to promote continuous lymphatic and venous drainage, thereby preventing or reducing the onset of lymphedema.

Step-by-Step Solution

Identify the surgical procedure and its associated risks.

The client had a mastectomy with axillary lymph node dissection, which disrupts normal lymphatic drainage and places the client at high risk for lymphedema.

Understanding the physiological impact of the surgery dictates the required basic care interventions.

Determine the basic care principles for preventing edema in an extremity.

Raising the extremity above the level of the heart is required.

Elevation uses gravity to facilitate the return of venous blood and lymphatic fluid back toward the central circulation.

Key Concept

Postoperative Positioning for Lymphedema Prevention

Question 2169Question →

A practical nurse is collecting data on an adult client who is receiving intravenous fluid resuscitation for severe hypovolemia caused by acute gastrointestinal bleeding. Which of the following clinical findings indicate that the client is experiencing a positive therapeutic response to the fluid therapy? Select all that apply.

Select all that apply

Heart rate decreases from 128 to 92 beats per minute.

Urine output is documented as 50 mL per hour.

The client is alert, awake, and oriented to person, place, and time.

Capillary refill time remains at 5 seconds.

Respiratory rate increases to 28 breaths per minute with new bilateral crackles.

Blood pressure reading is 86/52 mm Hg.

Show answer & explanation

Answer: Heart rate decreases from 128 to 92 beats per minute.; Urine output is documented as 50 mL per hour.; The client is alert, awake, and oriented to person, place, and time.

Answer

The findings that indicate a positive response to fluid resuscitation are a decrease in heart rate to 92 beats per minute, a urine output of 50 mL per hour, and an alert and oriented mental status.

A positive therapeutic response to fluid resuscitation in a hypovolemic client is evidenced by signs of restored intravascular volume and adequate organ perfusion. A heart rate returning toward a normal baseline (from 128 to 92 beats per minute) indicates the heart is no longer compensating for low fluid volume. A urine output of 50 mL per hour demonstrates that the kidneys are receiving adequate blood flow (normal is greater than 30 mL/hr). An alert and oriented mental status indicates that the brain is being properly perfused.

Step-by-Step Solution

Analyze the client's current clinical condition and the goal of the prescribed treatment.

The client is experiencing severe hypovolemia; the goal of intravenous fluid resuscitation is to restore intravascular volume and improve systemic tissue perfusion.

Understanding the pathophysiology of hypovolemic shock establishes the baseline needed to evaluate if interventions are working.

Evaluate each clinical finding to determine if it reflects improved perfusion or an ongoing/worsening complication.

A decreasing heart rate, adequate urine output (> 30 mL/hr), and normal mental status show improved perfusion. Prolonged capillary refill, hypotension, and tachypnea with crackles show ongoing shock or fluid overload.

Systematic evaluation of assessment data ensures accurate differentiation between expected therapeutic benefits and adverse responses.

Key Concept

Evaluation of Fluid Resuscitation and Tissue Perfusion

Question 2170Question →

A practical nurse (PN) is preparing to collect an anaerobic wound culture from a client with a deep, foul-smelling stage 4 pressure injury. To ensure a viable specimen and reduce the risk of a false laboratory result, in what chronological order should the PN perform the following actions? (Arrange the steps from first to last.)

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to cleanse the wound, swab the deep tissue, insert the swab into the tube, crush the ampule, and label the specimen.

To reduce the risk of inaccurate laboratory results and improper treatment, the practical nurse must first clear away surface contaminants using normal saline. Next, because anaerobic bacteria die in the presence of oxygen, the swab must be taken from deep, tunneling tissue and immediately placed into the designated transport tube. Activating the ampule at the base is critical because it releases an oxygen-scavenging medium that preserves the anaerobes. Finally, the tube must be labeled at the bedside to ensure safe and accurate processing.

Step-by-Step Solution

Cleanse the wound bed thoroughly with sterile normal saline.

Surface exudate and colonizing skin flora are removed.

Reduces the risk of a false laboratory result caused by culturing non-pathogenic surface bacteria.

Rotate the sterile swab deep inside the tunneling tissue of the wound.

Pathogens responsible for the deep infection are collected.

Anaerobic bacteria cannot survive in oxygen-rich environments and must be collected from deep, unexposed tissues.

Insert the swab immediately into the designated anaerobic culture tube.

The specimen is secured in the transport container.

Minimizes the time the anaerobic bacteria are exposed to ambient room oxygen, which is lethal to them.

Crush the ampule at the base of the culture tube to activate the medium.

The transport medium coats the swab.

The chemical medium eliminates remaining oxygen inside the sealed tube, maintaining viability during transport to the laboratory.

Affix the client's identification label to the tube and document the procedure.

The specimen is accurately identified and ready for transport.

Ensures client safety and prevents laboratory processing errors.

Key Concept

Anaerobic Specimen Collection Protocol

Question 2171Question →

A practical nurse (PN) is reinforcing teaching for a client with severe osteoarthritis of the hips who is learning to use a sock aid to dress independently. In which order should the PN instruct the client to perform the following steps? (Arrange the actions in the correct chronological sequence.)

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to load the sock onto the trough on the lap, lower the device to the floor using the cords, insert the foot into the opening, pull the cords evenly to draw the sock up the leg, and finally remove the device.

The correct sequence follows the logical progression of preparing the assistive device (loading the sock), positioning it without breaking physical precautions (lowering with cords), engaging with the device (inserting the foot), executing the task (pulling the sock on), and finally removing the equipment. This step-by-step process maximizes client independence and safety by eliminating the need to bend at the waist or hips.

Step-by-Step Solution

Slide the sock over the plastic trough while the device is resting on the lap.

The sock is fully loaded onto the assistive device.

Preparing the device on the lap prevents painful and potentially dangerous bending at the hips.

Lower the device to the floor using the pull cords.

The device is positioned directly in front of the foot.

Using the cords to lower the device eliminates the need for the client to lean forward, maintaining independence and safety.

Insert the foot into the sock opening.

The foot is positioned inside the trough.

Proper foot placement ensures the sock will slide smoothly over the heel in the next step.

Pull evenly on both pull cords.

The sock glides up over the foot and calf.

Applying even tension prevents the device from twisting and ensures the sock goes on straight.

Pull the device completely out of the sock.

The sock is correctly worn and the device is freed.

Removing the device completes the dressing process while allowing the client to remain upright.

Key Concept

Promoting independence in ADLs using assistive equipment

Question 2172Question →

During the morning shift on a trauma step-down unit, the practical nurse assumes care for a client who sustained a closed pelvic fracture two days prior. The unlicensed assistive personnel reports that the client has suddenly become combative and is trying to get out of bed. Upon evaluation, the nurse notes the client is tachypneic at 28 breaths per minute, has a heart rate of 115 beats per minute, and displays pinpoint reddish-purple spots across the axillary region. Which action must the practical nurse prioritize?

Initiate oxygen therapy, position the client upright, and urgently alert the registered nurse.

Implement fall precautions, dim the room lights, and attempt to reorient the client to the current time and place.

Auscultate bilateral lung fields and assess the client's pupillary responses to light.

Record the findings in the electronic health record and schedule a vital sign reassessment in 15 minutes.

Show answer & explanation

Answer: Initiate oxygen therapy, position the client upright, and urgently alert the registered nurse.

Answer

The correct action is to initiate oxygen therapy, position the client upright, and urgently alert the registered nurse.

The correct answer immediately addresses the physiological threat of hypoxia caused by a suspected fat embolism. Upright positioning and oxygen therapy stabilize the client's respiratory status while the registered nurse is promptly alerted to coordinate advanced, intensive care.

Step-by-Step Solution

Analyze the clinical cues presented in the scenario.

The client has a recent pelvic fracture, sudden combativeness, tachypnea, tachycardia, and axillary petechiae.

Identifying abnormal data points is the first step in recognizing acute physiological deterioration.

Correlate the symptoms with potential complications.

The triad of respiratory distress, neurological compromise, and a petechial rash 48 hours after a pelvic fracture strongly indicates fat embolism syndrome (FES).

FES is a life-threatening systemic complication that requires immediate recognition.

Determine the physiological priority using the ABC (Airway, Breathing, Circulation) framework.

The tachypnea and hypoxia-induced combativeness indicate an immediate threat to breathing and systemic oxygenation.

Prioritization frameworks dictate that acute respiratory compromise must be addressed before secondary assessments or environmental modifications.

Select the intervention that best aligns with the practical nurse's scope of practice.

Applying oxygen, positioning for optimal lung expansion, and immediately escalating to the registered nurse is required.

The PN must stabilize the client using basic supportive measures while securing advanced RN or provider intervention.

Key Concept

Fat Embolism Syndrome Recognition and Acute ABC Prioritization

Question 2173Question →

A practical nurse is providing care for a 75-year-old client who is recovering from a total knee arthroplasty. During morning rounds, the client, who was previously alert and oriented, suddenly becomes highly agitated, does not know their location, and insists they must leave immediately to pick up their young children from school. Which action should the practical nurse take first?

Document the sudden confusion as an expected, normal cognitive transition for older adults during hospitalization.

Immediately apply a soft vest restraint to keep the client securely in bed and protect the surgical site.

Ask the client, "Why do you think your children are at school? You are 75 and they are adults now."

Obtain a complete set of vital signs, including oxygen saturation, and report the findings to the registered nurse.

Show answer & explanation

Answer: Obtain a complete set of vital signs, including oxygen saturation, and report the findings to the registered nurse.

Answer

The correct action is to obtain a complete set of vital signs, including oxygen saturation, and report the findings to the registered nurse.

Sudden onset confusion and agitation in an older adult is a classic presentation of delirium, which is an acute medical emergency often triggered by physiological factors such as hypoxia, infection, or medication side effects. The practical nurse must prioritize obtaining baseline physiological data (vital signs and oxygen saturation) and immediately reporting these findings to the registered nurse so that the underlying cause can be promptly diagnosed and treated.

Step-by-Step Solution

Analyze the client's presentation to differentiate between expected aging transitions and acute pathological changes.

The sudden onset of agitation and disorientation in a previously alert older adult indicates delirium, not a normal developmental transition or expected aging process.

Recognizing that acute confusion is a physiological red flag ensures that life-threatening causes (such as hypoxia or infection) are prioritized over psychological reassurance.

Determine the priority intervention within the practical nurse's scope of practice.

The nurse must prioritize gathering objective physiological data (vital signs and oxygenation) and escalating the findings.

Delirium often has a reversible, underlying physiological cause. Collecting vital signs provides the registered nurse and primary care provider with essential data to direct immediate medical treatment.

Key Concept

Differentiating expected older adult developmental transitions from acute delirium

Question 2174Question →

A client who underwent a percutaneous liver biopsy one hour ago is currently resting in a right side-lying position. The client now reports a new onset of dull right shoulder pain. Upon assessment, the practical nurse notes a heart rate of $108\text{ beats/min}$ and a blood pressure of $106/62\text{ mm Hg}$ . The client's baseline vital signs prior to the procedure were a heart rate of $74\text{ beats/min}$ and a blood pressure of $132/82\text{ mm Hg}$ . Which action is the priority for the practical nurse to take next?

Administer the prescribed as-needed oral analgesic to treat the client's shoulder pain.

Document the assessment findings and repeat the vital signs in 30 minutes.

Assist the client into a supine position to relieve the pressure on the right side.

Immediately report the assessment findings to the supervising registered nurse.

Show answer & explanation

Answer: Immediately report the assessment findings to the supervising registered nurse.

Answer

The priority action is to immediately report the assessment findings to the supervising registered nurse, as the client is exhibiting classic signs of internal hemorrhage.

The client is demonstrating early signs of hemorrhagic shock (resting tachycardia and a significant drop in blood pressure) along with referred pain to the right shoulder, which occurs when blood accumulates under the diaphragm and irritates the phrenic nerve. Because bleeding is a major, life-threatening risk following a highly vascular procedure like a liver biopsy, the practical nurse must recognize these combined signs and immediately escalate the situation to the registered nurse for emergency intervention.

Step-by-Step Solution

Analyze the client's post-procedure symptoms.

The client has a new onset of dull right shoulder pain.

Right shoulder pain after a liver biopsy is a classic sign of referred pain caused by blood irritating the phrenic nerve under the diaphragm.

Compare the current vital signs to the client's pre-procedure baseline.

The heart rate has increased from

74

108\text{ beats/min}

(tachycardia), and the blood pressure has decreased from

132/82

106/62\text{ mm Hg}

(relative hypotension).

Trending vital signs is essential to identify early physiological deterioration.

Synthesize the clinical findings to determine the risk potential.

The combination of referred shoulder pain, tachycardia, and dropping blood pressure strongly indicates internal hemorrhage at the biopsy site.

The liver is a highly vascular organ, making hemorrhage the most significant immediate risk following a percutaneous biopsy.

Determine the most appropriate action within the practical nurse's scope of practice.

The nurse must prioritize circulation (ABCs) and immediately escalate the unstable findings to the registered nurse.

Unstable clients with signs of active bleeding require immediate RN and provider intervention; delaying escalation to administer pain medication or continuing routine monitoring could result in severe client harm.

Key Concept

Recognizing and Escalating Signs of Hemorrhage Post-Biopsy

Estimated Time:1m 30s

Question 2175Question →

Following a shift handoff on a medical-surgical unit, a practical nurse evaluates a client who was admitted for gastrointestinal bleeding 24 hours ago. The client's family member states that the client is unusually restless and seems disoriented this morning. The electronic health record shows a current heart rate of 114 bpm and a blood pressure of 98/60 mm Hg, compared to admission vital signs of 84 bpm and 134/78 mm Hg. Which action should the practical nurse take first?

Report the change in mental status and vital signs to the registered nurse immediately.

Reassure the family member that temporary disorientation is a normal reaction to hospitalization.

Document the vital signs in the chart and plan to recheck them during the next scheduled rounds.

Dim the room lights and close the door to provide a low-stimulation environment.

Show answer & explanation

Answer: Report the change in mental status and vital signs to the registered nurse immediately.

Answer

Report the change in mental status and vital signs to the registered nurse immediately.

The client is exhibiting early signs of hypovolemic shock (tachycardia, hypotension) and inadequate cerebral perfusion (restlessness, disorientation) stemming from the gastrointestinal bleeding. Within the practical nurse's scope of practice, recognizing acute physiological instability requires immediately notifying the registered nurse or provider so that rapid life-saving interventions can be initiated.

Step-by-Step Solution

Analyze the client's clinical presentation and vital sign trends.

The client has a new onset of restlessness, disorientation, tachycardia (114 bpm), and a decrease in blood pressure (98/60 mm Hg) compared to baseline.

Identifying deviations from baseline is critical for recognizing early physiological decompensation.

Correlate the findings with the client's admission diagnosis.

The symptoms indicate potential hypovolemic shock and inadequate cerebral perfusion due to active or worsening gastrointestinal bleeding.

Connecting symptoms to the underlying disease process determines the urgency of the situation.

Determine the most appropriate intervention within the practical nurse's scope of practice.

The immediate priority is to notify the registered nurse.

Acute, unstable changes require escalation for advanced assessment, fluid resuscitation, and potential medical intervention.

Key Concept

Early Recognition of Hypovolemic Shock

Question 2176Question →

A practical nurse is caring for a client who had a percutaneous liver biopsy 2 hours ago. The client's heart rate has increased from 80 to 118 beats per minute, and blood pressure has decreased from 122/76 mm Hg to 92/58 mm Hg. Which action should the practical nurse take first?

Notify the registered nurse (RN) immediately.

Document the vital signs and recheck them in 30 minutes.

Administer the prescribed as-needed pain medication.

Increase the rate of the maintenance intravenous fluids.

Show answer & explanation

Answer: Notify the registered nurse (RN) immediately.

Answer

Notify the registered nurse (RN) immediately.

The correct answer is to notify the RN immediately. A percutaneous liver biopsy involves inserting a needle into a highly vascular organ, putting the client at significant risk for internal bleeding. Tachycardia (increased heart rate) and hypotension (decreased blood pressure) are classic early signs of hemorrhage and hypovolemic shock. Because this is a life-threatening emergency, the practical nurse must escalate the findings immediately to the RN, who will coordinate with the healthcare provider for further interventions.

Step-by-Step Solution

Analyze the client's current vital signs compared to the baseline.

The heart rate has significantly increased (tachycardia) and the blood pressure has decreased (hypotension).

Identifying abnormal trends in vital signs helps recognize physiological deterioration.

Correlate the vital sign changes with the recent procedure.

A liver biopsy carries a high risk of hemorrhage. The vital sign changes strongly suggest active internal bleeding.

Understanding procedure-specific risks is essential for anticipating and identifying life-threatening complications.

Determine the priority action based on the practical nurse's scope of practice.

The client is experiencing a life-threatening complication that must be immediately reported to the RN for collaborative emergency management.

Prompt escalation ensures the client receives timely medical interventions.

Key Concept

Early recognition of shock and appropriate escalation within the practical nursing scope of practice.

Question 2177Question →

A client is recuperating on the medical unit after a diagnostic lumbar puncture. The individual complains of a mild throbbing headache. Which interventions should the practical nurse implement to promote comfort and safety? Select all that apply.

Select all that apply

Encourage the client to increase oral fluid intake as tolerated.

Keep the client lying flat in bed for the prescribed duration.

Provide a darkened, quiet environment in the client's room.

Elevate the head of the bed to a semi-Fowler's position to ease the headache.

Administer an intravenous push dose of a prescribed opioid analgesic.

Show answer & explanation

Answer: Encourage the client to increase oral fluid intake as tolerated.; Keep the client lying flat in bed for the prescribed duration.; Provide a darkened, quiet environment in the client's room.

Answer

The correct interventions are encouraging oral fluid intake, keeping the client flat in bed, and providing a darkened, quiet environment.

Appropriate basic care for a post-lumbar puncture headache includes promoting hydration to restore cerebrospinal fluid, maintaining a flat position to prevent further fluid leakage, and reducing environmental stimuli to ease discomfort.

Step-by-Step Solution

Analyze the client's clinical situation and current symptoms.

The client recently had a lumbar puncture and is experiencing a throbbing headache, a common complication caused by cerebrospinal fluid leakage.

Understanding the cause of the headache helps determine the appropriate non-pharmacological and physiological interventions.

Evaluate the options based on the principles of basic care, comfort, and the practical nurse's scope of practice.

Hydration, flat positioning, and a quiet environment are appropriate and within scope. Elevating the head worsens the condition, and IV push medications are out of scope.

Nursing actions must be safe, therapeutically effective for the specific condition, and legally permissible.

Key Concept

Basic care and comfort measures for a post-lumbar puncture client involve minimizing cerebrospinal fluid loss and providing a restful environment.

Question 2178Question →

An adult client is recovering on the medical-surgical unit 4 hours after an ultrasound-guided percutaneous liver biopsy. The client is currently positioned on their right side and reports new-onset right shoulder pain along with feeling 'anxious.' The practical nurse assesses the client and notes a heart rate of 112 bpm, blood pressure of 104/62 mm Hg, and a respiratory rate of 22 breaths per minute. Baseline vitals before the procedure were a heart rate of 76 bpm, blood pressure of 136/78 mm Hg, and a respiratory rate of 14 breaths per minute. Based on these findings, which action is the priority for the practical nurse?

Administer the prescribed as-needed analgesic to treat the client's right shoulder pain

Document the vital signs in the electronic health record and repeat the assessment in one hour

Immediately alert the registered nurse of the clinical changes to initiate emergency escalation

Reposition the client from the right lateral side to a semi-Fowler's position to alleviate anxiety

Show answer & explanation

Answer: Immediately alert the registered nurse of the clinical changes to initiate emergency escalation

Answer

Immediately alert the registered nurse of the clinical changes to initiate emergency escalation

The correct action involves notifying the registered nurse immediately because the client is exhibiting classic signs of internal hemorrhage and early hypovolemic shock. Following a liver biopsy, the organ is highly vascular and prone to bleeding. The new-onset right shoulder pain is referred pain resulting from blood pooling and irritating the phrenic nerve under the diaphragm. Combined with increasing restlessness, a rising heart rate, and a dropping blood pressure compared to the baseline, these findings require immediate emergency escalation rather than independent nursing interventions.

Step-by-Step Solution

Analyze the client's recent procedure (liver biopsy) and identify the primary post-procedure risk.

The highest risk following a percutaneous liver biopsy is internal hemorrhage due to the high vascularity of the liver.

Anticipating complications allows the nurse to interpret assessment data accurately.

Evaluate the new-onset symptoms of right shoulder pain and anxiety.

Anxiety is an early sign of hypoxia or shock. Right shoulder pain is referred pain caused by blood accumulating under the diaphragm and irritating the phrenic nerve.

Recognizing referred pain helps differentiate a severe complication from benign musculoskeletal discomfort.

Compare the current vital signs to the client's pre-procedure baseline.

The heart rate increased by 36 bpm and the systolic blood pressure dropped by 32 mm Hg. Combined with the symptoms, this indicates early compensatory hypovolemic shock.

Absolute vital sign numbers can be misleading; recognizing significant shifts from baseline is critical for detecting shock early.

Determine the safest and most appropriate intervention within the practical nurse's scope of practice.

The priority is to maintain the pressure-holding right lateral position and immediately escalate the critical findings to the registered nurse for emergency intervention.

The client requires rapid medical evaluation, fluid resuscitation, and potentially surgical intervention, which necessitates immediate escalation.

Key Concept

Identifying early signs of hemorrhage and hypovolemic shock following invasive procedures and prioritizing immediate escalation.

Question 2179Question →

During an outpatient clinic visit, a client who has been taking the monoamine oxidase inhibitor (MAOI) tranylcypromine for depression reports experiencing a sudden, throbbing headache and a "racing heart." The practical nurse obtains a blood pressure reading of $218/124 \text{ mmHg}$ and a heart rate of $112 \text{ beats/min}$ . Which of the following actions should the practical nurse take? (Select all that apply.)

Select all that apply

Stay with the client, place them in a semi-Fowler's position, and immediately notify the registered nurse or healthcare provider.

Collect data regarding the client's dietary intake of aged cheeses, cured meats, or draft beer over the last 24 hours.

Ask the client if they have used any over-the-counter nasal decongestants or cold medications recently.

Administer a prescribed as-needed oral dose of acetaminophen to treat the client's severe headache.

Prepare to independently administer a rapid-acting intravenous push antihypertensive medication to lower the blood pressure.

Quickly administer an available oral antihypertensive medication without checking the client's identification band due to the emergent situation.

Show answer & explanation

Answer: Stay with the client, place them in a semi-Fowler's position, and immediately notify the registered nurse or healthcare provider.; Collect data regarding the client's dietary intake of aged cheeses, cured meats, or draft beer over the last 24 hours.; Ask the client if they have used any over-the-counter nasal decongestants or cold medications recently.

Answer

The correct actions are to stay with the client and notify the registered nurse, assess for recent tyramine consumption, and ask about the use of over-the-counter sympathomimetic medications.

The client is experiencing an MAOI-induced hypertensive crisis, a medical emergency characterized by extreme blood pressure elevation and a throbbing headache. The practical nurse must prioritize safety by staying with the client, positioning them safely, and notifying the provider. Furthermore, gathering data about tyramine intake and over-the-counter sympathomimetic drugs is essential, as these are the primary triggers for this drug interaction.

Step-by-Step Solution

Analyze the client's clinical presentation and current medications.

The client is taking an MAOI and presenting with a severely elevated blood pressure, tachycardia, and a throbbing headache, which strongly indicates a hypertensive crisis.

Recognizing the pattern of a critical adverse drug reaction is the first step in prioritizing care.

Determine appropriate immediate interventions within the practical nurse scope.

The nurse must stay with the client, elevate the head of the bed to reduce intracranial pressure, and escalate the emergency to the registered nurse or healthcare provider.

A hypertensive crisis is a life-threatening event requiring advanced medical intervention beyond the practical nurse's independent scope.

Identify data collection priorities to find the cause of the crisis.

The nurse should ask the client about common triggers, specifically the consumption of tyramine-rich foods or sympathomimetic medications (like decongestants).

Identifying the trigger helps the healthcare team confirm the diagnosis and prevent future occurrences once the client is stabilized.

Recognize and avoid unsafe or out-of-scope practices.

The nurse must not bypass safety protocols (like patient identification) or attempt to administer intravenous push medications.

Maintaining fundamental safety standards and adhering to scope of practice prevents further harm to the client.

Key Concept

MAOI Hypertensive Crisis and Practical Nurse Scope of Practice

Question 2180Question →

A 74-year-old client with profound vision loss is admitted to the medical unit for treatment of pneumonia. During the night shift, the client awakens in a darkened room, becomes acutely agitated, and claims that the shadows on the wall are intruders. The client attempts to climb over the bed rails. Which action should the practical nurse (PN) take first?

Turn on a soft room light, approach the client calmly, introduce oneself, and provide verbal reorientation.

Ask the client, "Why do you believe there are intruders in here when the hospital doors are closed?"

Document the acute agitation as an expected symptom of normal aging and monitor the client from a distance.

Apply bilateral soft wrist restraints immediately to ensure physical safety and prevent a fall from the bed.

Show answer & explanation

Answer: Turn on a soft room light, approach the client calmly, introduce oneself, and provide verbal reorientation.

Answer

The correct action is to turn on a soft room light, approach the client calmly, introduce oneself, and provide verbal reorientation.

The client is experiencing a visual illusion triggered by sensory deprivation (profound vision loss) combined with a dark, unfamiliar environment. The priority PN action is to decrease the sensory misperception by modifying the environment (turning on a soft light to eliminate shadows) and providing immediate reality orientation using a calm, non-threatening approach. This promotes client safety, reduces anxiety, and builds trust without resorting to restrictive measures.

Step-by-Step Solution

Analyze the client's presentation and environmental factors.

The client has a sensory deficit (vision loss) and is in a dark, unfamiliar room, leading to a sensory illusion (misinterpreting shadows as intruders) and acute agitation.

Identifying the root cause of the perceptual alteration is necessary to select the most effective and least restrictive intervention.

Determine the immediate priority of care.

The priority is to maintain client safety and de-escalate the acute confusion without utilizing restrictive measures.

Client safety is always the highest priority during an acute perceptual crisis or delirium episode.

Select the most appropriate nursing intervention within the PN scope of practice.

Turning on a soft light removes the environmental trigger (shadows), while a calm introduction and verbal reorientation establish trust and ground the client in reality.

Environmental modification and therapeutic communication are the standard first-line treatments for sensory illusions and acute confusion.

Key Concept

Sensory and Perceptual Alterations

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