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Question 401Question →

A practical nurse (PN) is assessing a client who is 6 hours postoperative following a total abdominal hysterectomy. The PN is evaluating the client's current clinical status. Which of the following findings indicates a potential life-threatening complication that requires the most urgent escalation to the registered nurse (RN)?

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Answer: The client's heart rate has progressively increased from 76 to 118 beats per minute over the past three hours, and the current blood pressure is 98/60 mm Hg.

Answer

The finding of a progressively increasing heart rate combined with borderline hypotension.
The correct answer identifies a trend of tachycardia (heart rate increasing from 76 to 118 bpm) paired with borderline hypotension (98/60 mm Hg). In a client who is 6 hours postoperative following major abdominal surgery, these are classic early compensatory signs of hypovolemic shock, most likely due to internal hemorrhage. The practical nurse must recognize this life-threatening trend immediately and escalate it to the registered nurse so that rapid interventions (such as fluid resuscitation, blood transfusion, or surgical re-exploration) can be initiated.

Step-by-Step Solution

1
Evaluate the clinical significance of the progressively increasing heart rate and borderline low blood pressure.
Identified as early compensatory signs of hypovolemic shock, likely from internal postoperative bleeding.
Recognizing early shock is critical for preventing irreversible organ damage and initiating rapid interventions.
2
Analyze the remaining assessment findings (WBC count, pain level, and positioning) to compare their clinical urgency.
Determined that mild leukocytosis, incisional pain with movement, and semi-Fowler's positioning are all expected findings after an abdominal hysterectomy.
Clinical prioritization requires distinguishing between normal postoperative expected outcomes and life-threatening emergencies.
3
Determine the required nursing action based on the practical nurse scope of practice.
The practical nurse must immediately escalate the signs of shock to the registered nurse.
The registered nurse and healthcare provider must intervene rapidly with fluid resuscitation, blood administration, or surgical re-exploration.

Key Concept

Recognizing Early Signs of Shock in the Postoperative Client
Question 402Question →

A practical nurse (PN) is collecting data on a client who is 4 hours post-operative following a total thyroidectomy. The client exhibits new-onset restlessness, a heart rate of 114 beats/min, and reports a tingling sensation around the lips. Which of the following actions should the PN take? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Examine the back of the client's neck and the surgical dressing for pooled blood.; Ensure that a tracheostomy tray and suction equipment are readily available at the bedside.; Notify the registered nurse (RN) immediately regarding the client's changing status.

Answer

The correct actions are to examine the neck for bleeding, ensure emergency airway equipment is at the bedside, and notify the RN immediately.
Following a thyroidectomy, clients are at severe risk for airway compression, hemorrhage, and hypocalcemia (tetany). The client's restlessness and tachycardia indicate potential internal bleeding or hypoxia, necessitating a check of the dependent area (back of the neck) for pooled blood. Perioral tingling is a classic sign of hypocalcemia. The PN must prioritize airway readiness by ensuring a tracheostomy tray is present and immediately escalate these unstable findings to the RN.

Step-by-Step Solution

1
Analyze the clinical cues from the data collection.
Restlessness and a heart rate of 114 beats/min are early signs of hypoxia, hemorrhage, or thyroid storm. Tingling around the lips indicates hypocalcemia caused by inadvertent damage to the parathyroid glands.
Recognizing the physiological significance of these symptoms dictates the urgency of the response.
2
Determine the highest priority interventions based on ABCs (Airway, Breathing, Circulation).
The risk of airway obstruction from a hematoma requires ensuring airway equipment is present and physically checking for concealed bleeding at the back of the neck.
Airway and circulation must be secured before addressing secondary concerns.
3
Apply the practical nurse (PN) scope of practice to the required interventions.
The PN must report these unstable findings to the RN immediately. The PN cannot administer IV push medications for the hypocalcemia.
Safe practice requires escalating acute status changes and operating strictly within legal licensure boundaries.

Key Concept

Post-Thyroidectomy Complications and PN Prioritization
Question 403Question →

A client is recovering in the orthopedic unit after undergoing a right total hip arthroplasty via a posterior approach. The client requires a fracture bedpan for elimination. Which technique should the practical nurse use to place the bedpan safely?

Show answer & explanation

Answer: Turn the client onto the unaffected left side while maintaining an abduction pillow between the legs, position the pan, and carefully roll the client back.

Answer

The nurse should place an abduction pillow between the client's legs, turn the client onto the unaffected left side, position the fracture pan, and roll the client back onto it.
Turning the client onto the unoperated (left) side while keeping an abduction pillow between the legs ensures that the right hip remains in a neutral, abducted position. This safely allows the nurse to position the fracture pan without causing adduction, internal rotation, or extreme flexion, which are all strictly contraindicated following a posterior hip replacement.

Step-by-Step Solution

1
Identify the surgical approach and associated positioning precautions for the client.
The client had a posterior total hip arthroplasty, which requires avoiding hip flexion greater than 90 degrees, adduction (crossing the legs), and internal rotation.
Adhering strictly to joint precautions prevents the head of the femur from dislocating from the newly implanted acetabulum.
2
Select the appropriate elimination device and safe positioning technique.
A fracture bedpan is chosen because of its lower profile, and the client is logrolled onto the unaffected side using an abduction pillow.
The abduction pillow prevents the legs from crossing the midline, and rolling to the unaffected side protects the operative hip joint from dangerous rotational and pressure forces.

Key Concept

Postoperative Positioning and Joint Precautions
Question 404Question →

A practical nurse (PN) is assisting a client who is 2 days postoperative following an abdominal surgery. The client coughs forcefully and reports a sudden "popping" sensation. The PN observes that the surgical wound has completely separated and loops of bowel are protruding. In what order should the PN perform the following actions? Arrange the actions from first priority to last.

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Answer

The correct sequence for managing a wound evisceration is to first stay with the client and call for help, then position the client in low Fowler's with knees flexed, followed by covering the wound with sterile saline-soaked dressings, measuring vital signs, and finally documenting the event.
Wound evisceration is a medical emergency requiring rapid, sequential intervention. The absolute first priority is client safety, meaning the nurse must stay at the bedside and call for help to get the RN, surgeon, and necessary supplies (Step 1). To prevent further protrusion of the bowel, the nurse immediately positions the client in a low Fowler's position with the knees flexed to relax the abdominal muscles (Step 2). Once supplies arrive, the exposed organs must be covered with sterile, normal saline-soaked dressings to prevent tissue drying and necrosis (Step 3). After the organs are protected, the nurse obtains vital signs to monitor for impending shock (Step 4). Finally, once the client is fully stabilized and prepared for return to the operating room, the nurse documents the event (Step 5).

Step-by-Step Solution

1
Identify the immediate safety priority when an evisceration occurs.
The nurse stays with the client and calls for assistance.
The client is experiencing a surgical emergency and requires immediate advanced support and supplies, but leaving the client alone could compromise their safety.
2
Determine the physical action to prevent worsening of the condition.
The nurse places the client in a low Fowler's position with flexed knees.
This position reduces intra-abdominal pressure and tension on the suture line, preventing more bowel from protruding.
3
Identify the intervention to protect the exposed tissue.
The nurse covers the bowel with sterile, saline-moistened dressings.
Exposed internal organs can quickly dry out and become necrotic or infected; a moist, sterile environment preserves the tissue until surgery.
4
Determine the necessary clinical assessment.
The nurse obtains the client's vital signs.
Evisceration causes fluid shifts and immense physical stress, putting the client at high risk for shock. Monitoring vital signs detects this early.
5
Identify the final administrative responsibility.
The nurse documents the entire event.
Accurate charting is required for the medical record, but it must wait until the client's physiological safety is secured.

Key Concept

Prioritization of Wound Evisceration Management
Question 405Question →

A practical nurse is preparing to administer a morning dose of 10 units of regular insulin and 20 units of NPH insulin subcutaneously to a client with type 2 diabetes mellitus. Arrange the following steps for preparing and mixing these insulins in the correct chronological order.

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Answer

The correct sequence is to roll the NPH vial, inject air into the NPH vial, inject air into the regular vial, withdraw the regular insulin, and finally withdraw the NPH insulin.
The standard 'clear before cloudy' procedure ensures that the shorter-acting, clear regular insulin is not contaminated by the longer-acting, cloudy NPH insulin. Rolling the NPH gently prevents bubble formation while ensuring the suspension is properly mixed. Injecting air into both vials prevents a vacuum from forming, which ensures accurate dosing.

Step-by-Step Solution

1
Roll the NPH insulin vial between the palms.
The cloudy insulin suspension is evenly mixed without forming bubbles.
Shaking the vial can cause bubbles, which leads to inaccurate dosing.
2
Inject 20 units of air into the NPH vial and remove the syringe.
Pressure is equalized in the NPH vial.
Air must be injected to prevent a vacuum, but withdrawing medication now would contaminate the needle before it enters the regular insulin vial.
3
Inject 10 units of air into the regular insulin vial.
Pressure is equalized in the regular insulin vial.
This prepares the regular insulin vial for immediate medication withdrawal.
4
Withdraw 10 units of regular insulin.
The short-acting (clear) insulin is drawn into the syringe first.
Drawing the clear insulin first prevents it from being contaminated by the longer-acting NPH insulin.
5
Withdraw 20 units of NPH insulin.
The syringe now contains a total of 30 units of mixed insulin.
Drawing the cloudy insulin last completes the mixture safely without risking contamination of the regular insulin vial.

Key Concept

Safe preparation and mixing of short-acting (clear) and intermediate-acting (cloudy) insulins.
Question 406Question →

A practical nurse (PN) is reviewing the electronic health record of a client scheduled to receive a routine dose of oral warfarin. The client's morning International Normalized Ratio (INR) is 5.2. Current vital signs reveal a heart rate of 108 beats/min and a blood pressure of 96/58 mm Hg. Which action should the PN take to reduce the client's risk of complications?

Show answer & explanation

Answer: Withhold the scheduled dose of warfarin and immediately alert the registered nurse (RN).

Answer

The correct action is to withhold the scheduled dose of warfarin and immediately alert the registered nurse (RN).
The client presents with a critically elevated INR (therapeutic range for warfarin is generally 2.0 to 3.0) and borderline vital signs (tachycardia and hypotension) that strongly suggest active internal hemorrhage. The safest and most appropriate action for the practical nurse is to withhold the anticoagulant to prevent further bleeding and immediately alert the registered nurse or healthcare provider to initiate emergency interventions.

Step-by-Step Solution

1
Identify the critical laboratory value.
The client's INR is 5.2.
A normal therapeutic INR for a client on warfarin is typically 2.0 to 3.0. A value of 5.2 indicates a severe risk for bleeding.
2
Evaluate the current vital signs.
The heart rate is 108 beats/min and blood pressure is 96/58 mm Hg.
These borderline vital signs represent early physiological indicators of internal hemorrhage and hypovolemic shock.
3
Determine the priority nursing action within the PN scope of practice.
Withhold the medication and escalate to the RN.
This prevents further harm and ensures the client receives immediate advanced medical intervention.

Key Concept

Prioritization of Critical Laboratory Values and Early Signs of Shock
Question 407Question →

A 4-year-old pediatric client is admitted to the pediatric unit with a high fever. The healthcare provider prescribes ibuprofen 8 mg/kg8\text{ mg/kg} orally every 6 hours as needed for temperature greater than 101.5∘F101.5^\circ\text{F} (38.6∘C38.6^\circ\text{C}). The client's current weight is documented as 41.8 lbs41.8\text{ lbs}. The unit stocks ibuprofen oral suspension at a concentration of 100 mg/5 mL100\text{ mg}/5\text{ mL}. How many mL should be administered for one dose? Record the answer to the nearest tenth. Do not include units in the answer.

Show answer & explanation

Answer: 7.6

Answer

7.6
The correct dose is calculated by first converting the child's weight to kilograms (41.8 lbs÷2.2=19 kg41.8\text{ lbs} \div 2.2 = 19\text{ kg}). Next, the weight in kg is multiplied by the prescribed dose to find the desired amount (19 kg×8 mg/kg=152 mg19\text{ kg} \times 8\text{ mg/kg} = 152\text{ mg}). Finally, using the available medication concentration of 100 mg100\text{ mg} in 5 mL5\text{ mL}, the required volume is determined by dividing the desired dose by the available dose, then multiplying by the quantity (152 mg100 mg×5 mL=7.6 mL\frac{152\text{ mg}}{100\text{ mg}} \times 5\text{ mL} = 7.6\text{ mL}). The final answer is already at the tenths place, requiring no further rounding.

Step-by-Step Solution

1
Convert the client's weight from pounds (lbs) to kilograms (kg).
41.8 lbs÷2.2 lbs/kg=19 kg41.8 \text{ lbs} \div 2.2 \text{ lbs/kg} = 19 \text{ kg}
Weight-based medication dosages require the client's weight to be in kilograms for accurate calculation.
2
Calculate the total prescribed dose in milligrams (mg) using the client's weight in kilograms.
19 kg×8 mg/kg=152 mg19 \text{ kg} \times 8 \text{ mg/kg} = 152 \text{ mg}
The healthcare provider prescribed 8 mg per every 1 kg of body weight per dose.
3
Determine the volume of liquid medication to administer in milliliters (mL).
152 mg100 mg×5 mL=1.52×5 mL=7.6 mL\frac{152 \text{ mg}}{100 \text{ mg}} \times 5 \text{ mL} = 1.52 \times 5 \text{ mL} = 7.6 \text{ mL}
Using the dimensional analysis or the formula (Desired Dose / Available Dose) x Quantity calculates the exact volume of suspension needed to deliver the required milligrams.

Key Concept

Weight-based dosage calculation for pediatric pharmacology
Question 408Question →

An 80-year-old client is admitted to the medical-surgical unit with melena and a suspected upper gastrointestinal bleed. The practical nurse (PN) observes that the client has become suddenly restless, is attempting to get out of bed, and states, 'I have to go to work now.' The client's resting apical pulse is 114 beats/minute. Which action should the PN take first?

Show answer & explanation

Answer: Obtain the client's blood pressure and oxygen saturation.

Answer

Obtain the client's blood pressure and oxygen saturation.
Sudden restlessness, acute confusion, and tachycardia in a client with a suspected gastrointestinal bleed are early compensatory signs of hypovolemic shock and cerebral hypoxia. The practical nurse must prioritize physiological data collection (Circulation and Breathing) to confirm these findings and immediately report them to the registered nurse.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has a history of GI bleeding, sudden onset of confusion, restlessness, and tachycardia.
Identifying all abnormal cues is the first step in clinical judgment.
2
Correlate the symptoms with potential complications.
These findings strongly suggest decreased cardiac output, hypovolemia, and resulting cerebral hypoxia.
Active bleeding reduces circulating volume, leading to compensatory tachycardia and decreased oxygen delivery to the brain.
3
Determine the immediate priority action for the practical nurse.
The PN must gather a complete set of vital signs, specifically blood pressure and oxygen saturation.
According to the ABCs (Airway, Breathing, Circulation) and the nursing process, acute physiological data collection takes precedence over secondary safety or behavioral interventions.

Key Concept

Early recognition of hypovolemic shock and prioritization of physiological data collection.
Question 409Question →

During morning care at a rehabilitation center, a practical nurse is providing care for a resident who underwent a right above-the-knee amputation three days ago. To prevent the development of a hip flexion contracture, which positioning strategy is most appropriate for the nurse to implement?

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Answer: Assist the resident into a prone position for 20 to 30 minutes several times a day.

Answer

The most appropriate strategy is to assist the resident into a prone position for 20 to 30 minutes several times a day.
Placing a client in the prone position for 20 to 30 minutes three to four times a day is a critical basic care intervention following a lower extremity amputation. This position fully extends the hip joint, safely stretching the flexor muscles and preventing the development of a flexion contracture, which would otherwise impede the future fitting and use of a prosthesis.

Step-by-Step Solution

1
Identify the primary mobility and comfort risk associated with the client's postoperative time frame.
Three days after an above-the-knee amputation, the priority concern is preventing hip flexion contractures.
Contractures severely limit mobility rehabilitation and the future ability to effectively use a prosthetic limb.
2
Determine the physiological effect of various positions on the hip joint.
Sitting, elevating the limb, and high-Fowler's positions all cause hip flexion. Prone positioning causes hip extension.
Extending the hip stretches the flexor muscles, directly counteracting the tendency for those muscles to shorten and permanently contract.
3
Select the nursing intervention that promotes therapeutic hip extension.
Placing the client in a prone position for 20 to 30 minutes multiple times daily is the correct intervention.
This specific positioning strategy is the standard of basic care to prevent joint complications in amputation recovery.

Key Concept

Post-amputation Positioning and Contracture Prevention
Question 410Question →

A practical nurse is preparing to administer a scheduled fentanyl transdermal patch to a client managing chronic pain. The client has an existing patch on their right upper chest that was applied 72 hours ago. Which sequence of actions by the nurse demonstrates the safest medication administration technique?

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Answer: Remove the existing patch, fold the adhesive sides together, discard it in a secured receptacle, and apply the new patch to a different hairless area.

Answer

The safest technique is to remove the existing patch, fold the adhesive sides together, discard it securely, and apply the new patch to a new, clean, hairless site.
Safe administration of transdermal fentanyl requires a strict sequence to prevent toxicity and diversion. The old patch must be removed first to ensure the client does not receive a double dose. Folding the patch in half with the adhesive sides together seals in the remaining active medication. Secure disposal (often in a sharps container or pharmaceutical waste bin, per facility policy) is required to prevent accidental exposure to staff or visitors. Finally, rotating to a new, hairless site prevents skin breakdown and ensures consistent absorption.

Step-by-Step Solution

1
Remove and properly dispose of the old patch.
The old patch is folded adhesive-side together and placed in a secure receptacle.
Fentanyl patches contain residual active medication even after 72 hours. Removing the old patch prevents an accidental overdose, and secure disposal prevents unauthorized access or accidental exposure to others.
2
Prepare a new application site.
A different, flat, hairless area of skin is selected and cleansed gently with water if needed.
Site rotation prevents skin breakdown. Avoiding alcohol or vigorous rubbing prevents increased skin permeability, which could cause rapid, dangerous absorption of the opioid.
3
Apply the new transdermal patch.
The new patch is applied and pressed firmly in place for 30 seconds.
Firm application ensures proper adhesion and consistent delivery of the medication.

Key Concept

Safe Administration of Transdermal Opioids
Question 411Question →

Morning rounds are being conducted on a medical unit for a client undergoing treatment for a deep vein thrombosis. The client is currently receiving a continuous infusion of unfractionated heparin. The client's most recent laboratory results reveal an activated partial thromboplastin time (aPTT) of 115 seconds. During data collection, the client's heart rate is noted at 102 beats per minute with a blood pressure of 98/60 mm Hg. What is the priority action for the practical nurse in this situation?

Show answer & explanation

Answer: Promptly alert the registered nurse regarding the client's coagulation values and current vital signs.

Answer

Promptly alert the registered nurse regarding the client's coagulation values and current vital signs.
The client's aPTT of 115 seconds is critically elevated, placing them at severe risk for spontaneous bleeding. Furthermore, the client's mild tachycardia (102 beats per minute) and hypotension (98/60 mm Hg) are subtle but highly concerning indicators of early hemorrhagic shock. The practical nurse's priority is to immediately escalate these life-threatening findings to the registered nurse, who has the authority to halt the high-risk intravenous infusion and perform advanced interventions.

Step-by-Step Solution

1
Analyze the laboratory results.
The aPTT of 115 seconds is critically elevated beyond the therapeutic range (which is typically 1.5 to 2.5 times the normal control, up to about 70-80 seconds).
To determine if the continuous heparin infusion is maintaining safe and therapeutic anticoagulation.
2
Analyze the vital signs in the context of the laboratory data.
A heart rate of 102 beats per minute and a blood pressure of 98/60 mm Hg indicate mild tachycardia and hypotension, which are early signs of shock.
To identify if the client is actively experiencing a complication, such as internal hemorrhage, due to the toxic medication level.
3
Determine the appropriate scope of practice for intervention.
The practical nurse must immediately escalate these critical findings to the registered nurse.
To ensure immediate, safe intervention, as managing high-risk intravenous infusions and administering intravenous push antidotes are outside the practical nurse's scope.

Key Concept

Recognizing critical laboratory values and signs of shock, followed by immediate escalation to the registered nurse.
Estimated Time:1m 0s
Question 412Question →

A client is receiving care on an orthopedic unit following a closed pelvic fracture sustained in a fall. During evening rounds, the licensed practical nurse notes the following vital signs: blood pressure 96/62 mm Hg, heart rate 118 beats/min, respiratory rate 18 breaths/min, and oral temperature 98.8°F (37.1°C). Which nursing action is the most appropriate next step?

Show answer & explanation

Answer: Report the vital sign parameters to the registered nurse immediately.

Answer

The most appropriate next step is to report the vital sign parameters to the registered nurse immediately.
The correct action is to report the vital signs to the registered nurse immediately. Tachycardia (heart rate of 118 beats/min) and borderline hypotension (blood pressure of 96/62 mm Hg) in a client with a pelvic fracture are early clinical indicators of internal hemorrhage and hypovolemic shock. Pelvic fractures carry a high risk of significant concealed blood loss, requiring prompt RN assessment and provider notification to mitigate severe, life-threatening complications.

Step-by-Step Solution

1
Analyze the client's vital signs in the context of their injury.
The heart rate is significantly elevated (118 beats/min) and blood pressure is borderline low (96/62 mm Hg) for an adult.
Recognizing abnormal physiological parameters is the first step in clinical reasoning and risk reduction.
2
Correlate the findings with the client's diagnosis of a closed pelvic fracture.
Pelvic fractures carry a high risk of massive internal hemorrhage, which presents initially as compensatory tachycardia and hypotension.
Connecting the diagnosis to potential complications identifies the severe risk of hypovolemic shock.
3
Determine the appropriate scope of practice and priority action.
The practical nurse must immediately escalate these critical, unstable findings to the registered nurse.
Unstable clients with early signs of shock require RN-level assessment and rapid provider intervention.

Key Concept

Early recognition and escalation of hypovolemic shock indicators
Question 413Question →

An inpatient psychiatric unit receives morning laboratory results for a client managed on oral clozapine therapy. The report shows a white blood cell (WBC) count of 1,800/mm31,800/\text{mm}^3 and an absolute neutrophil count (ANC) of 400/mm3400/\text{mm}^3. Upon entering the room for morning care, the client complains of a painful sore throat and has an oral temperature of 100.8∘F100.8^\circ\text{F} (38.2∘C38.2^\circ\text{C}). Based on these findings, which action is most appropriate for the practical nurse to perform?

Show answer & explanation

Answer: Withhold the next dose of clozapine and urgently notify the registered nurse of the client's status.

Answer

Withhold the next dose of clozapine and urgently notify the registered nurse of the client's status.
Withholding the medication and notifying the registered nurse is the correct action because the client is exhibiting classic signs of agranulocytosis (critically low WBC/ANC, fever, sore throat), a life-threatening adverse effect of clozapine. The practical nurse's scope of practice dictates holding the offending agent and immediately escalating unstable or critical findings to the registered nurse.

Step-by-Step Solution

1
Analyze the laboratory data and vital signs.
The WBC count (1,800/mm31,800/\text{mm}^3) and ANC (400/mm3400/\text{mm}^3) are critically low. The fever and sore throat are clinical signs of an active infection in an immunocompromised client.
Recognizing life-threatening adverse effects of pharmacological therapies is essential for safe client care.
2
Determine the pharmacological implications.
Clozapine is an atypical antipsychotic with a known, severe risk of drug-induced agranulocytosis (severe neutropenia).
The medication must be stopped immediately to prevent further bone marrow suppression and potentially fatal sepsis.
3
Apply the practical nurse scope of practice.
The practical nurse must withhold the scheduled medication and escalate the critical findings to the registered nurse or healthcare provider.
While practical nurses gather data and recognize abnormalities, they must report critical, unstable findings to the registered nurse for comprehensive assessment and medical intervention.

Key Concept

Clozapine Adverse Effects and LPN Scope of Practice
Question 414Question →

A practical nurse is providing basic care for a client who is on strict bed rest following a carotid endarterectomy complicated by an ischemic stroke with left-sided hemiparesis. Which of the following actions should the nurse include in the client's daily care? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Support the client's affected left arm with pillows while they are resting in bed.; Assist the client in performing active range-of-motion exercises on their unaffected right arm and leg.; Perform thorough oral hygiene for the client before and after they consume their meals.

Answer

The correct actions are supporting the affected left arm with pillows, assisting with active range-of-motion exercises on the unaffected right extremities, and performing oral hygiene before and after meals.
Appropriate basic care for a client with hemiparesis includes supporting the affected limb to prevent shoulder subluxation, maintaining oral hygiene to clear pocketed food and prevent aspiration, and encouraging active use of unaffected extremities to preserve strength.

Step-by-Step Solution

1
Analyze the client's clinical condition and associated risks.
The client has left-sided hemiparesis and is on strict bed rest post-procedure, creating high risks for aspiration, deep vein thrombosis, and joint contractures.
Identifying specific physiological risks determines which basic care and comfort measures are safe.
2
Evaluate the feeding and positioning interventions.
Feeding the client at a 30-degree angle is unsafe due to the high aspiration risk. Placing a blanket tightly under the knees improperly restricts venous return.
Comfort measures must not compromise the client's airway (ABC priorities) or cardiovascular circulation.
3
Identify the appropriate basic care actions.
Supporting the flaccid arm, performing active movement on the healthy limbs, and maintaining strict oral hygiene are safe and necessary interventions.
These actions prevent common stroke complications like shoulder subluxation and aspiration while safely promoting comfort.

Key Concept

Basic care and comfort for a client with hemiparesis focuses on preventing complications such as aspiration, joint subluxation, and impaired circulation through proper positioning and meticulous hygiene.
Question 415Question →

While conducting hourly rounds, a practical nurse (PN) responds to a call light from the spouse of an 84-year-old client being treated for pneumonia. The spouse reports the client has suddenly become disoriented and is trying to remove their intravenous line. The PN notes the client is extremely restless, with a heart rate of 110 bpm and a blood pressure of 98/60 mm Hg. Which action should the PN take first?

Show answer & explanation

Answer: Verify the client's oxygen saturation level and ensure airway patency.

Answer

The priority action is to verify the client's oxygen saturation level and ensure airway patency.
Sudden onset of confusion, agitation, and restlessness in a client with pneumonia, accompanied by tachycardia and borderline hypotension, strongly suggests acute hypoxia or early shock. Using the ABC (Airway, Breathing, Circulation) framework, the priority is to immediately assess the client's oxygenation and airway status before intervening for other potential issues.

Step-by-Step Solution

1
Analyze the clinical cues presented by the client.
The client exhibits sudden disorientation, restlessness, tachycardia (110 bpm), and borderline hypotension (98/60 mm Hg).
Identifying abnormal findings is the first step in recognizing physiological decompensation.
2
Correlate the clinical cues with potential pathophysiological processes.
In an elderly client with pneumonia, these sudden changes strongly indicate potential respiratory compromise (hypoxia) or cardiovascular instability (early shock).
Understanding the underlying cause of the symptoms dictates the urgency and type of intervention required.
3
Apply the ABC (Airway, Breathing, Circulation) prioritization framework.
Evaluating the airway and oxygenation status takes precedence over secondary assessments or routine documentation.
Securing airway and breathing is the most critical initial action to prevent irreversible tissue damage or cardiac arrest.

Key Concept

Prioritization of Airway, Breathing, and Circulation (ABC) during acute physiological decompensation.
Question 416Question →

A practical nurse (PN) is preparing to administer a scheduled hepatitis B vaccine intramuscularly to a 6-month-old infant. The infant's parent reports that the child started taking a prescribed oral antibiotic yesterday for a mild ear infection, although the infant currently has no fever. What is the most appropriate action by the PN?

Show answer & explanation

Answer: Scan the client's identification band, verify the infant's name and date of birth with the parent, and administer the vaccine.

Answer

The practical nurse should proceed with standard medication rights, including scanning the identification band and verifying two identifiers, and administer the vaccine. Mild illness and antibiotic use are not contraindications.
The correct action demonstrates knowledge that mild acute illness (such as otitis media) and concurrent antibiotic therapy do not contraindicate the administration of standard childhood vaccines like the hepatitis B vaccine. Furthermore, it adheres to the universal standard of verifying at least two patient identifiers (e.g., ID band scan and parent's verbal confirmation) prior to any pharmacological intervention.

Step-by-Step Solution

1
Evaluate the parent's report of the infant's ear infection and antibiotic use against established immunization guidelines.
Recognize that mild acute illnesses, even those being treated with concurrent antibiotic therapy, are not contraindications for receiving scheduled vaccines.
To ensure the safety and appropriateness of administering the pharmacological agent before proceeding.
2
Identify the standard protocol for safe medication administration.
Determine that two client identifiers and barcode scanning (if available) are required before giving the injection.
To comply with the rights of medication administration and prevent critical errors.

Key Concept

Safe Medication Administration and Immunization Guidelines
Question 417Question →

A client recovering from an ischemic stroke is receiving a continuous enteral tube feeding. The client suddenly develops a forceful cough, perioral cyanosis, and audible wheezing. In what order should the practical nurse (PN) perform the following actions? (Arrange the items in the correct chronological sequence from first to last.)

Drag items to arrange them in the correct order

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Answer

The correct sequence of actions is to first stop the enteral feeding, then elevate the head of the bed, obtain vital signs and oxygen saturation, auscultate lung sounds, and finally notify the RN.
In an acute respiratory emergency involving enteral feedings, the practical nurse must follow the ABCs (Airway, Breathing, Circulation) framework and the nursing process. The immediate threat is ongoing aspiration, so the feeding must be stopped first to secure the airway. Next, positioning the client upright supports breathing and ventilation. Only after these immediate interventions should the nurse gather assessment data (vital signs followed by focused auscultation) to prepare a complete clinical report. Finally, the nurse escalates the situation by notifying the RN with the collected data.

Step-by-Step Solution

1
Stop the continuous enteral feeding pump.
Prevents further formula from entering the client's lungs.
Addresses the immediate root cause threatening the client's airway (Airway priority).
2
Position the client in a high-Fowler's position.
Maximizes lung expansion and utilizes gravity.
Supports effective breathing and oxygenation (Breathing priority).
3
Obtain the client's oxygen saturation and vital signs.
Provides immediate objective hemodynamic and respiratory data.
Quantifies the severity of the client's physiological distress to establish a baseline.
4
Auscultate the client's anterior and posterior lung sounds.
Identifies specific adventitious breath sounds such as wheezing or crackles.
Provides focused clinical assessment data necessary for formulating an accurate clinical picture.
5
Notify the registered nurse (RN) about the change in condition.
Escalates the client's care to the appropriate clinical leader.
Ensures the client receives necessary advanced medical interventions based on the gathered assessment data.

Key Concept

When a client experiences sudden respiratory distress during an enteral feeding, the practical nurse must prioritize interventions using the airway, breathing, and circulation (ABC) framework: first stop the feeding (airway), optimize positioning (breathing), gather physiological data, and then escalate care.
Question 418Question →

Two hours after a right femoral cardiac catheterization, a client reports a new onset of dull lower back pain. The practical nurse notes the right groin dressing is dry and intact with no visible hematoma, and distal pulses remain equal bilaterally. The client's vital signs are: temperature 98.6°F (37°C), heart rate 108/min, respirations 18/min, and blood pressure 104/62 mm Hg. Baseline vital signs prior to the procedure were heart rate 74/min and blood pressure 128/78 mm Hg. What is the most appropriate next action for the practical nurse?

Show answer & explanation

Answer: Notify the supervising registered nurse immediately regarding the assessment changes.

Answer

The most appropriate action is to notify the supervising registered nurse immediately regarding the assessment changes.
The client is exhibiting signs of retroperitoneal bleeding, a critical and potentially life-threatening complication of femoral cardiac catheterization. The combination of new-onset back pain (due to blood pooling in the retroperitoneal space) and shifting vital signs (tachycardia and borderline hypotension compared to baseline) strongly indicates internal hemorrhage, even when the external insertion site appears dry and intact. The practical nurse must immediately escalate these findings to the registered nurse for urgent medical evaluation.

Step-by-Step Solution

1
Analyze the client's symptoms and vital sign trends.
The client has a new onset of back pain accompanied by an increasing heart rate (74 to 108/min) and decreasing blood pressure (128/78 to 104/62 mm Hg).
Comparing current assessment data to baseline is essential for identifying post-procedural complications.
2
Correlate the findings with potential procedural complications.
The combination of back pain and early signs of shock after a femoral approach indicates possible retroperitoneal bleeding, despite the external insertion site being dry.
Internal bleeding is not always visible on the surface dressing and requires clinical deduction.
3
Determine the safest nursing action within the practical nurse scope.
The nurse must immediately alert the registered nurse (RN) or healthcare provider.
Recognizing a life-threatening complication requires immediate escalation for advanced clinical judgment and intervention.

Key Concept

Recognition and Escalation of Post-Procedural Hemorrhage
Question 419Question →

A practical nurse (PN) is preparing to administer a scheduled dose of oral furosemide to a client admitted with heart failure exacerbation. The client's morning vital signs include a blood pressure of 94/56 mm Hg and a heart rate of 112 beats/min. A recent laboratory report indicates a serum potassium level of 2.6 mEq/L. Which action is the priority for the PN?

Show answer & explanation

Answer: Withhold the dose of furosemide and immediately notify the registered nurse (RN).

Answer

The correct action is to withhold the dose of furosemide and immediately notify the registered nurse (RN).
Furosemide is a potent loop diuretic that promotes the excretion of fluid and electrolytes, including potassium. A serum potassium level of 2.6 mEq/L is critically low (normal range is 3.5 to 5.0 mEq/L) and places the client at immediate risk for life-threatening cardiac dysrhythmias. Furthermore, the client's borderline hypotension and tachycardia suggest hypovolemia. Administering furosemide would exacerbate both the potassium depletion and the fluid volume deficit. The priority action to reduce risk potential is to withhold the medication and escalate these critical findings to the RN.

Step-by-Step Solution

1
Evaluate the client's laboratory results against normal reference ranges.
The serum potassium level of 2.6 mEq/L is critically low (normal is 3.5 to 5.0 mEq/L).
Identifying abnormal labs is essential before administering medications that can further alter those levels.
2
Analyze the client's vital signs.
The blood pressure (94/56 mm Hg) is low and the heart rate (112 beats/min) is elevated.
Tachycardia combined with hypotension often indicates fluid volume deficit (hypovolemia) or early shock.
3
Determine the pharmacological effects of furosemide.
Furosemide is a loop diuretic that causes the kidneys to excrete excess fluid and potassium.
Understanding the drug's mechanism reveals that giving it will worsen both the hypokalemia and the hypovolemia.
4
Select the safest nursing action within the PN scope of practice.
The medication must be withheld, and the abnormal findings must be escalated to the RN for immediate intervention.
The PN must reduce risk potential by preventing medication-induced complications and ensuring timely collaborative care.

Key Concept

Prioritizing client safety by recognizing critical laboratory values and vital signs that contraindicate scheduled medication administration.
Question 420Question →

A practical nurse (PN) is caring for a 78-year-old client who is prescribed daily oral digoxin and furosemide for the management of heart failure. During the morning assessment, the PN notes the client has become acutely restless and reports seeing "yellow halos" around the room lights. The client's morning laboratory results reveal a serum potassium level of 3.1 mEq/L (3.1 mmol/L), and the current apical pulse is 56 beats/minute. Which of the following is the priority action for the PN to take?

Show answer & explanation

Answer: Withhold both the digoxin and furosemide and immediately notify the supervising registered nurse of the findings.

Answer

The priority action is to withhold both medications and immediately notify the supervising registered nurse.
The correct action is to withhold both the digoxin and furosemide and immediately notify the RN. The client is displaying classic, life-threatening signs of digoxin toxicity (bradycardia, visual halos, and restlessness). Furthermore, the potassium level of 3.1 mEq/L indicates hypokalemia. Because potassium and digoxin bind to the same receptors in the heart, low potassium increases digoxin binding, causing toxicity even at normal doses. Furosemide is a potassium-wasting diuretic that would further deplete the client's potassium. Immediate escalation is critical and directly within the practical nurse's scope of practice.

Step-by-Step Solution

1
Analyze the client's vital signs and clinical presentation.
The client has an apical pulse of 56 beats/minute, acute restlessness, and reports visual yellow halos.
These findings represent classic cardiovascular, neurological, and visual signs of digoxin toxicity.
2
Evaluate the morning laboratory results.
The serum potassium level is 3.1 mEq/L, which indicates hypokalemia (normal is typically 3.5 to 5.0 mEq/L).
Hypokalemia increases the sensitivity of the myocardium to digoxin, making it a primary precipitating factor for digoxin toxicity.
3
Determine the appropriate intervention within the practical nurse scope of practice.
The nurse must withhold the scheduled digoxin and furosemide and immediately escalate the critical findings to the RN or provider.
Administering digoxin would worsen the toxicity, and administering furosemide (a potassium-wasting diuretic) would further lower the potassium level. Rapid escalation is required for life-threatening toxicity.

Key Concept

Digoxin Toxicity and Hypokalemia Management
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