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Question 441Question →

A licensed practical nurse (LPN) is monitoring a client who underwent a percutaneous liver biopsy 22 hours ago. The client is resting quietly in the right lateral position. The LPN obtains the following current vital signs: blood pressure 108/66108/66 mm Hg, heart rate 104104 beats/min, and respiratory rate 2020 breaths/min. The client's pre-procedure vital signs were blood pressure 132/76132/76 mm Hg, heart rate 7474 beats/min, and respiratory rate 1616 breaths/min. Which action should the LPN take next?

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Answer: Notify the registered nurse (RN) immediately regarding the vital sign trends.

Answer

Notify the registered nurse (RN) immediately regarding the vital sign trends.
The client is exhibiting tachycardia and hypotension compared to their baseline, which are classic early signs of hypovolemic shock due to internal hemorrhage. Because the liver is a highly vascular organ, bleeding is a major and life-threatening complication following a liver biopsy. The LPN must immediately recognize this subtle deterioration and notify the RN so that prompt medical intervention, such as fluid resuscitation or surgical evaluation, can be initiated.

Step-by-Step Solution

1
Compare the client's current vital signs to their pre-procedure baseline.
The blood pressure has decreased significantly (from 132/76 to 108/66 mm Hg) and the heart rate has increased (from 74 to 104 beats/min).
Identifying trends and deviations from baseline is essential for recognizing early signs of clinical deterioration.
2
Analyze the clinical meaning of these physiological changes in the context of the recent procedure.
The combination of new-onset tachycardia and dropping blood pressure suggests early hypovolemic shock, likely due to internal bleeding from the highly vascular liver.
The liver is highly prone to hemorrhage after invasive procedures like a percutaneous biopsy.
3
Determine the most appropriate action within the LPN scope of practice.
The LPN must immediately escalate this critical finding to the RN.
The client requires urgent RN-level assessment and potential medical intervention to manage the suspected hemorrhage.

Key Concept

Early recognition of shock and appropriate escalation within the practical nursing scope of practice.
Question 442Question →

An 8-year-old child weighing 5555 lb is prescribed oral cefdinir. The prescribed dose is 1414 mg/kg/day, to be administered in two divided doses every 1212 hours. The pharmacy dispenses cefdinir oral suspension at a concentration of 250250 mg/55 mL. How many milliliters (mL) will the practical nurse administer for a single dose? Record your answer using one decimal place. Do not include units in your answer.

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Answer: 3.5

Answer

3.5
To find the correct single dose volume, the nurse first converts the child's weight to kilograms (55÷2.2=2555 \div 2.2 = 25 kg). Next, the total daily dose is calculated (14×25=35014 \times 25 = 350 mg). Since this daily dose is divided every 12 hours, the single dose is half of the total (350÷2=175350 \div 2 = 175 mg). Finally, using the available concentration of 250250 mg in 55 mL, the nurse determines the volume: 175250×5=3.5\frac{175}{250} \times 5 = 3.5 mL.

Step-by-Step Solution

1
Convert the client's weight from pounds to kilograms (55÷2.2=2555 \div 2.2 = 25).
25 kg
The prescribed medication dosage is based on kilograms (mg/kg/day).
2
Calculate the total daily dose in milligrams (14×25=35014 \times 25 = 350).
350 mg/day
Multiply the client's weight in kg by the prescribed daily dosage of 14 mg/kg/day.
3
Calculate the amount needed for a single dose (350÷2=175350 \div 2 = 175).
175 mg/dose
The prescription states the daily dose must be divided into two equal doses to be given every 12 hours.
4
Calculate the volume of liquid to administer per dose (175250×5=3.5\frac{175}{250} \times 5 = 3.5).
3.5 mL
Use dimensional analysis or the formula DesiredHave×Volume\frac{\text{Desired}}{\text{Have}} \times \text{Volume}.

Key Concept

Weight-based dosage calculation for divided pediatric doses
Question 443Question →

During a morning assessment, a client receiving continuous total parenteral nutrition (TPN) appears diaphoretic and exhibits sudden confusion. The client's capillary blood glucose level is 4242 mg/dL. The client's medication administration record includes a PRN prescription for 5050 mL of 50%50\% dextrose in water (D50W) intravenous (IV) push for severe hypoglycemia. Based on the practical nurse scope of practice, which action is most appropriate?

Show answer & explanation

Answer: Promptly notify the registered nurse to administer the prescribed intravenous push medication

Answer

The practical nurse should promptly notify the registered nurse to administer the prescribed intravenous push medication.
The client is experiencing a hypoglycemic emergency requiring immediate pharmacological intervention. Because the client has an altered mental status, oral intake is unsafe due to aspiration risks. The prescribed medication is an intravenous push, which is outside the scope of practice for a practical nurse. Therefore, the correct and safest action is to immediately notify the registered nurse, who can legally administer the IV push medication.

Step-by-Step Solution

1
Analyze the client's clinical presentation and blood glucose results.
The client has symptomatic hypoglycemia, indicated by diaphoresis and confusion, with a critical blood glucose of 4242 mg/dL.
Identifying the clinical emergency is the first step in prioritizing care.
2
Evaluate the safety of oral versus parenteral interventions.
Oral carbohydrates are contraindicated because the client's sudden confusion creates a high risk for aspiration.
Airway protection must be prioritized in clients with altered mental status.
3
Determine the appropriate administration of the prescribed pharmacological therapy within the practical nurse scope of practice.
The prescribed treatment is IV push D50W, which requires a registered nurse's scope of practice to administer safely.
Practical nurses must not accept tasks or administer medications that exceed their legal scope of practice, such as IV push medications.
4
Select the action that ensures safe, immediate client care.
Escalating the situation to the registered nurse immediately ensures the client receives the necessary emergency medication.
Immediate collaboration with the registered nurse is required for critical interventions that fall outside the practical nurse's scope.

Key Concept

Practical Nurse Scope of Practice in Emergency Pharmacological Interventions
Question 444Question →

An outpatient clinic has requested a 24-hour urine collection for a client being evaluated for nephropathy. The client is currently staying in a short-term rehabilitation unit. How should the nurse sequence the steps to ensure an accurate specimen collection? Arrange the actions in the correct chronological order.

Drag items to arrange them in the correct order

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Answer

To properly execute a 24-hour urine collection, the nurse must first instruct the client to empty the bladder and discard that urine, document the start time immediately, collect all subsequent urine in a chilled container, obtain one final void exactly 24 hours later, and then promptly label and send the completed specimen to the laboratory.
A 24-hour urine collection requires precise timing and sequencing to accurately measure kidney function. The protocol must always begin with an empty bladder (by discarding the first void) so only newly produced urine is measured. The start time must be documented immediately. All subsequent urine is kept cold to preserve its chemical composition. Exactly 24 hours later, the client voids one last time to finalize the collection, after which the complete specimen is labeled and sent for analysis.

Step-by-Step Solution

1
Have the client void and discard the urine.
The bladder is emptied of preexisting urine.
Ensures the 24-hour period starts with no older urine in the bladder, which would skew the volume and analyte calculations.
2
Record the time of the discarded void.
The exact start time is established.
Provides a definitive, documented timestamp to calculate the 24-hour completion mark accurately.
3
Collect all subsequent urine and store it on ice or in a refrigerator.
All urine produced during the testing window is safely stored.
Cold storage preserves the specimen's integrity and prevents the breakdown of substances being measured.
4
Instruct the client to void exactly 24 hours after the start time and add this to the collection.
The final amount of urine produced in the period is captured.
Completes the physiological 24-hour cycle of urine production.
5
Label and transport the container.
The specimen reaches the lab safely and promptly.
Maintains specimen viability and ensures accurate patient identification for diagnostics.

Key Concept

24-Hour Urine Specimen Collection Protocol
Question 445Question →

A practical nurse (PN) is assisting a client who has a right-sided chest tube to change positions in bed. Suddenly, the chest tube is completely pulled out of the client's chest wall. Arrange the following immediate nursing actions in the correct chronological order.

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Answer

The correct sequence is to first instruct the client to exhale and bear down, cover the site with petroleum gauze, secure the tape on three sides, assess the respiratory status, and finally notify the healthcare team.
In any respiratory emergency where the pleural space is exposed to the atmosphere, the absolute first priority is to stop air entry (Airway/Breathing principle). Asking the client to exhale and bear down provides an immediate internal pressure block, allowing the nurse a few seconds to apply the physical petroleum gauze seal. Taping it on three sides is the standard of care to create a one-way flutter valve. Only after securing the airway and breathing mechanics should the nurse assess the physiological response and notify the team.

Step-by-Step Solution

1
Instruct the client to forcefully exhale and bear down.
Intrathoracic pressure immediately increases.
This prevents atmospheric air from entering the pleural cavity through the newly opened wound, which would collapse the lung.
2
Cover the insertion site with a sterile petroleum gauze.
An airtight seal is created over the wound.
The petroleum gauze acts as an immediate physical barrier to stop further air exchange between the atmosphere and the pleural space.
3
Secure the occlusive dressing with tape on three sides.
A flutter valve (one-way valve) is established.
Taping only three sides allows any trapped air to escape during exhalation but prevents outside air from being drawn in during inhalation, drastically reducing the risk of a tension pneumothorax.
4
Assess the client's respiratory rate and oxygen saturation.
Baseline respiratory data is obtained.
The nurse must evaluate if the client is experiencing respiratory distress, hypoxia, or signs of a developing pneumothorax after the acute intervention is applied.
5
Notify the registered nurse and healthcare provider.
The medical team is alerted to the critical event.
The client will likely require emergency medical intervention, such as a chest X-ray and the insertion of a new chest tube.

Key Concept

Emergency Priority Management of an Accidentally Dislodged Chest Tube
Question 446Question →

A newly admitted client experiencing severe constipation is prescribed a warm tap water enema. The equipment has been gathered and the solution is prepared in the enema bag. Arrange the following steps in the correct chronological sequence to safely administer the enema.

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Answer

The correct sequence begins with proper positioning, followed by tube preparation, safe insertion, fluid instillation, and finally, managing potential complications like cramping.
Administering an enema requires sequential steps that prioritize safety, anatomical alignment, and client comfort. Proper left-sided positioning must occur first so gravity can assist fluid travel into the descending colon. Lubrication must happen before insertion to prevent mucosal damage. The tube is then inserted following the natural curve of the bowel (toward the umbilicus). Only after proper insertion should the clamp be opened to begin instillation. Finally, if the client experiences cramping during the procedure, the nurse must intervene by lowering the bag to reduce flow pressure.

Step-by-Step Solution

1
Assist the client into the left lateral Sims' position.
The client's descending colon is positioned optimally.
Gravity aids the flow of solution into the sigmoid and descending colon when the client is on their left side.
2
Lubricate the distal end of the enema tubing.
The tube tip becomes slick and smooth.
Lubrication prevents friction, discomfort, and trauma to the rectal mucosa.
3
Insert the tubing gently into the rectum angled toward the umbilicus.
The tube safely enters the lower bowel.
Angling toward the umbilicus aligns the tube with the anatomical contour of the rectum, minimizing the risk of bowel perforation.
4
Unclamp the tubing and allow the fluid to instill slowly.
The enema solution begins to flow into the client.
Slow instillation minimizes sudden bowel distention, which can cause intense cramping.
5
Lower the enema container if the client reports abdominal cramping.
The flow rate of the solution decreases.
Lowering the bag reduces hydrostatic pressure, alleviating cramps without having to remove the tube entirely.

Key Concept

Bowel Elimination and Enema Administration
Estimated Time:1m 0s
Question 447Question →

A practical nurse is preparing to administer prescribed oral acetaminophen to a pediatric client experiencing a fever. The healthcare provider has prescribed 240240 mg to be given every 66 hours as needed. The medication is available in a liquid concentration of 160160 mg/55 mL. Which action describes the safest and most appropriate procedure for the practical nurse to follow?

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Answer: Calculate the required dose as 7.57.5 mL, verify the client's identity using two distinct identifiers, and administer the medication.

Answer

Calculate the required dose as 7.57.5 mL, verify the client's identity using two distinct identifiers, and administer the medication.
The practical nurse correctly calculates the dose using the standard formula: 240 mg160 mg×5 mL=7.5 mL\frac{240 \text{ mg}}{160 \text{ mg}} \times 5 \text{ mL} = 7.5 \text{ mL}. Furthermore, the nurse safely adheres to strict medication administration protocols by using two distinct client identifiers prior to administering the drug.

Step-by-Step Solution

1
Calculate the correct medication dosage using the formula: DesiredHave×Volume\frac{\text{Desired}}{\text{Have}} \times \text{Volume}.
240 mg160 mg×5 mL=1.5×5 mL=7.5 mL\frac{240 \text{ mg}}{160 \text{ mg}} \times 5 \text{ mL} = 1.5 \times 5 \text{ mL} = 7.5 \text{ mL}.
Accurate calculation is the first step in ensuring the client receives the safe and therapeutic dose prescribed.
2
Identify the safety requirements for medication administration.
The nurse must use at least two distinct client identifiers (e.g., name and date of birth confirmed with an identification band) and must administer the medication personally.
Adhering to the 'rights of medication administration' prevents medication errors, and medication administration cannot be delegated to a UAP.
3
Select the option that combines the correct calculation with safe, within-scope nursing practice.
The option calculating 7.57.5 mL and verifying using two identifiers is the only comprehensively safe and correct choice.
It fulfills all pharmacological and patient safety standards within the practical nurse's scope.

Key Concept

Medication Calculation and Administration Safety Principles
Question 448Question →

A 78-year-old client is recovering in the surgical unit six hours after a transurethral resection of the prostate (TURP). The practical nurse (PN) observes that the client is newly restless and asking repetitive questions about his location. Vital signs reveal a heart rate of 112 beats/min and a blood pressure of 98/62 mm Hg. The client's preoperative vital signs were a heart rate of 76 beats/min and a blood pressure of 138/82 mm Hg. Which action is the priority for the PN?

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Answer: Notify the registered nurse immediately regarding the changes in vital signs and cognition

Answer

The priority action is to notify the registered nurse immediately regarding the changes in vital signs and cognition.
The correct answer requires immediate escalation to the registered nurse. The client's new-onset confusion, restlessness, tachycardia, and drop in blood pressure are classic early indicators of hypovolemic shock, a serious potential complication of a transurethral resection of the prostate (TURP) due to bleeding. The practical nurse must recognize these systemic changes as a medical emergency and immediately communicate the findings so that life-saving interventions (such as IV fluids or blood products) can be initiated.

Step-by-Step Solution

1
Analyze the client's current vital signs and mental status against the baseline preoperative data.
The heart rate has significantly increased (tachycardia), blood pressure has decreased (hypotension), and mental status has acutely changed (restlessness, confusion).
Comparing current assessment data to baseline is essential to identify acute physiological deterioration.
2
Correlate the systemic findings with potential postoperative complications for a TURP procedure.
The combination of symptoms strongly suggests decreased tissue perfusion and early hypovolemic shock, likely resulting from postoperative hemorrhage.
Understanding the physiological meaning of the data guides clinical prioritization and safety.
3
Determine the priority nursing action within the PN scope of practice.
The priority is to immediately report the unstable findings to the supervising registered nurse (RN) or provider for advanced assessment and intervention.
A client exhibiting signs of shock is hemodynamically unstable and requires immediate escalation of care.

Key Concept

Recognizing early signs of hypovolemic shock and prioritizing escalation of care
Question 449Question →

A licensed practical nurse is evaluating an adolescent client who arrived on the surgical unit three hours ago following a tonsillectomy. The client is observed to be swallowing continuously. The current vital signs reveal a heart rate of 118118 beats per minute and a blood pressure of 102/64102/64 mm Hg. Which action is the priority for the nurse to take?

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Answer: Promptly notify the registered nurse about the continuous swallowing and the vital sign trends.

Answer

Promptly notify the registered nurse about the continuous swallowing and the vital sign trends.
Continuous swallowing after a tonsillectomy is a hallmark sign of active bleeding, as blood pools in the pharynx and stimulates the swallow reflex. The elevated heart rate of 118118 beats per minute is an early compensatory mechanism for hypovolemia. The practical nurse must prioritize client safety by immediately escalating these critical findings to the registered nurse for prompt surgical or medical intervention.

Step-by-Step Solution

1
Evaluate the clinical presentation of continuous swallowing and tachycardia.
Recognize these as classic signs of active postoperative bleeding.
Blood trickling down the back of the throat stimulates the swallow reflex, and the heart rate increases to compensate for ongoing fluid volume loss.
2
Identify the practical nurse's scope of practice in a potentially emergent situation.
Determine that an unstable client requires immediate registered nurse and provider intervention.
Practical nurses must escalate care for clients exhibiting signs of severe complications to ensure timely medical management and risk reduction.

Key Concept

Postoperative Hemorrhage Recognition and Escalation
Question 450Question →

A practical nurse is providing basic care for an older adult client who had a left-sided mastectomy with axillary lymph node dissection 24 hours ago. The client reports aching, a feeling of heaviness, and stiffness in the left arm. Which nonpharmacological action should the nurse take to promote comfort and reduce these symptoms?

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Answer: Elevate the client's left arm on pillows so it is positioned above the level of the heart.

Answer

Elevate the client's left arm on pillows so it is positioned above the level of the heart.
After a mastectomy with axillary lymph node dissection, lymphatic drainage is impaired, leading to edema, heaviness, and discomfort. Elevating the affected arm on pillows above the level of the heart promotes gravity-assisted venous and lymphatic return. This effectively reduces swelling and provides comfort without relying on pharmacological interventions.

Step-by-Step Solution

1
Analyze the client's procedure and symptoms.
The client had a left mastectomy with axillary lymph node dissection and is experiencing aching and heaviness in the left arm.
Axillary node removal disrupts normal lymphatic drainage, leading to localized fluid accumulation (lymphedema) and discomfort.
2
Identify the goal of basic care.
The nurse needs a nonpharmacological intervention to reduce swelling and promote comfort in the affected extremity.
Basic comfort measures should directly address the underlying cause of the discomfort, which is fluid pooling.
3
Evaluate the positioning options.
Elevating the arm above the heart uses gravity to drain fluid, whereas dependent positioning or lying on the arm will worsen the swelling.
Proper postoperative positioning is a fundamental nursing responsibility to prevent complications and maximize comfort.

Key Concept

Postoperative Comfort and Lymphedema Prevention
Question 451Question →

A practical nurse (PN) is caring for a client who is receiving a continuous intravenous (IV) infusion of Lactated Ringer's for fluid replacement. The healthcare provider's prescription is for 1,000 mL1,000 \text{ mL} to infuse over 12 hours. The primary IV tubing has a drop factor of 15 gtt/mL15 \text{ gtt/mL}. The registered nurse (RN) has initiated the infusion. At what rate, in drops per minute (gtt/min), should the PN verify the IV is infusing?

*Record your answer to the nearest whole number. Do not include units in your answer.*

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Answer: 21

Answer

21
To calculate the gravity flow rate in drops per minute, the nurse must first convert the total infusion time into minutes (12 hours * 60 = 720 minutes). Then, use the standard formula: (Total Volume / Total Time in minutes) * Drop Factor. Plugging in the values gives: (1,000 mL / 720 minutes) * 15 gtt/mL = 20.833 gtt/min. Because the nurse cannot administer a fraction of a drop, the final step is to round to the nearest whole number, which is 21.

Step-by-Step Solution

1
Convert the prescribed time to minutes
720 minutes
The gravity flow rate formula requires total time to be in minutes, but the prescription is given in hours.
2
Apply the IV flow rate formula
20.833 gtt/min
Multiply the volume over time by the drop factor to find the drops per minute.
3
Round to the nearest whole number
21
IV drip rates must be counted in whole drops.

Key Concept

Intravenous flow rate calculation (drops per minute) for a continuous fluid infusion.
Question 452Question →

A client is resting in bed recovering from a total abdominal hysterectomy performed earlier today. While providing routine comfort and hygiene measures, which actions should the nurse take? (Select all that apply)

Select all that apply

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Answer: Provide frequent oral hygiene using a soft-bristled toothbrush and a non-alcohol-based mouth rinse.; Encourage the client to keep their knees slightly flexed while resting in bed.; Offer a gentle back massage using warm lotion to promote relaxation.

Answer

The correct actions are providing oral hygiene with a non-alcohol rinse, encouraging slight knee flexion to reduce incisional tension, and offering a gentle back massage with warm lotion.
Providing a non-alcohol mouth rinse promotes oral hygiene without drying out mucous membranes. Encouraging slight knee flexion actively reduces physical tension on the abdominal incision, which minimizes pain and facilitates healing. Offering a gentle back massage stimulates localized circulation and acts as a foundational comfort measure for immobilized clients.

Step-by-Step Solution

1
Analyze the client's postoperative care needs.
The client requires interventions that manage pain, respect personal boundaries, and maintain hygiene without causing harm.
A total abdominal hysterectomy involves a major abdominal incision, making safe positioning and gentle comfort care critical.
2
Evaluate the positioning and hygiene options.
Slight knee flexion, gentle back massages, and non-drying oral care are appropriate; flat positioning is contraindicated.
Flat positioning stretches the abdominal wall, increasing incisional pain and compromising respiratory effort.
3
Assess the psychosocial and nutritional interventions.
Nontherapeutic 'why' questions and serving unverified animal products must be avoided.
These actions fail to respect the client's emotional boundaries and cultural dietary restrictions during basic care delivery.

Key Concept

Basic Comfort Measures and Postoperative Positioning
Question 453Question →

During evening rounds at a skilled nursing facility, a practical nurse (PN) evaluates a resident who is currently undergoing oral antibiotic treatment for bacterial pneumonia. Which clinical observation requires the most immediate escalation to the registered nurse?

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Answer: The resident exhibits sudden, severe agitation and continuously attempts to remove their clothing.

Answer

The resident exhibits sudden, severe agitation and continuously attempts to remove their clothing.
The correct answer identifies sudden, severe agitation. In a resident with pneumonia, an abrupt change in mental status, such as restlessness or combativeness, is frequently the earliest clinical indicator of hypoxia. The brain is highly sensitive to decreased oxygen levels, and this acute change takes precedence over all other findings as it directly threatens the resident's airway and breathing.

Step-by-Step Solution

1
Analyze the resident's current diagnosis and baseline condition.
The resident is being treated for bacterial pneumonia, placing them at high risk for respiratory compromise and hypoxia.
Understanding the primary diagnosis helps identify which complications are most likely to occur.
2
Evaluate each assessment finding using the Airway, Breathing, Circulation (ABC) prioritization framework.
Sudden agitation is a primary indicator of hypoxia (Breathing/Airway issue). Borderline vitals are a Circulation concern but are currently stable. Headache is a comfort issue. Baseline confusion is non-emergent.
The ABC framework dictates that physiological needs threatening oxygenation and perfusion must be addressed before basic comfort or chronic issues.
3
Select the finding that represents the most acute, life-threatening change.
The sudden onset of severe agitation requires immediate escalation, as it likely indicates rapidly deteriorating respiratory function.
Acute changes in mental status in a patient with a respiratory infection are often the first sign of inadequate oxygenation to the brain.

Key Concept

Early Recognition of Hypoxia and Delirium in Pneumonia
Question 454Question →

A practical nurse (PN) is caring for a client who is 4 hours postoperative following an open reduction and internal fixation (ORIF) of a fractured right femur. The client reports increasing incisional pain. The PN obtains the following vital signs: temperature 98.8°F (37.1°C), heart rate 110 beats/min, respiratory rate 20 breaths/min, and blood pressure 102/64 mm Hg. Which action should the PN take first?

Show answer & explanation

Answer: Notify the registered nurse immediately to evaluate the client for potential hypovolemia.

Answer

Notify the registered nurse immediately to evaluate the client for potential hypovolemia.
Following a major orthopedic surgery such as a femur fracture repair, clients are at a high risk for significant blood loss. A heart rate of 110 beats/min combined with a blood pressure of 102/64 mm Hg, particularly when the client is experiencing pain (which typically elevates blood pressure), represents borderline vital signs that strongly indicate early hypovolemic shock. The practical nurse must immediately escalate these findings to the registered nurse for comprehensive assessment and intervention.

Step-by-Step Solution

1
Analyze the client's surgical history and postoperative timeframe.
The client had a femur ORIF 4 hours ago, a procedure associated with significant vascularity and a high risk of postoperative blood loss.
Identifying the client's specific surgical risks helps prioritize potential physiological complications.
2
Evaluate the current vital signs against expected physiological responses.
The heart rate is elevated (110 beats/min) and the blood pressure is on the lower end (102/64 mm Hg).
Pain typically causes an increase in both heart rate and blood pressure. A low-normal blood pressure accompanied by tachycardia is a red flag for volume depletion.
3
Determine the appropriate scope of practice and necessary escalation.
The practical nurse must report these early signs of potential hypovolemic shock directly to the registered nurse.
The RN is responsible for performing a comprehensive assessment to diagnose hemorrhage and coordinating appropriate medical interventions with the provider.

Key Concept

Early recognition of hypovolemic shock and appropriate escalation within the practical nursing scope of practice.
Question 455Question →

A practical nurse is assessing a client who returned from an esophagogastroduodenoscopy (EGD) with a biopsy 2 hours ago. The client reports a mild sore throat but now states, "My stomach feels really tight and painful." The nurse notes the client's abdomen is firm and distended. The current vital signs are: blood pressure 104/58 mmHg104/58\text{ mmHg}, heart rate 112 beats/min112\text{ beats/min}, respiratory rate 22 breaths/min22\text{ breaths/min}, and temperature 37.4∘C37.4^\circ\text{C} (99.3∘F99.3^\circ\text{F}). Which action should the practical nurse take first?

Show answer & explanation

Answer: Notify the registered nurse (RN) immediately about the assessment findings.

Answer

Notify the registered nurse (RN) immediately about the assessment findings.
The correct action is to notify the registered nurse immediately. A firm, distended abdomen combined with new-onset severe pain, tachycardia, and borderline hypotension following an EGD with biopsy are classic signs of a perforation. This is a life-threatening emergency that requires immediate advanced assessment by the RN and intervention by the healthcare provider to prevent severe peritonitis and shock.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has a firm, distended abdomen, new severe pain, tachycardia (112 beats/min), and borderline low blood pressure (104/58 mmHg) following an invasive gastrointestinal procedure.
Identifying abnormal findings is the first step in recognizing postoperative complications.
2
Correlate the findings with potential procedural complications.
These signs strongly suggest an esophageal or gastric perforation, which can lead to rapid peritonitis and hypovolemic shock.
Understanding the risk factors of an EGD with biopsy helps in anticipating life-threatening events.
3
Determine the appropriate nursing intervention within the LPN scope of practice.
The practical nurse must immediately escalate these critical findings to the RN for advanced assessment and collaboration with the healthcare provider.
Acting within the legal scope of practice ensures client safety during a rapidly evolving emergency.

Key Concept

Recognizing and Escalating Complications of Invasive Procedures
Question 456Question →

A pediatric client weighing 3333 lb is prescribed ibuprofen oral suspension 250250 mg every 66 hours for a fever. The established safe pediatric dosage range for this medication is 55 to 1010 mg/kg/dose. The pharmacy provides ibuprofen in a concentration of 100100 mg/55 mL. Based on this information, which action should the nurse perform?

Show answer & explanation

Answer: Withhold the medication and clarify the prescription with the healthcare provider.

Answer

Withhold the medication and clarify the prescription with the healthcare provider.
The correct action is to withhold the medication because the prescribed dose exceeds the safe maximum limit. The child's weight is 1515 kg (33÷2.233 \div 2.2). Based on the provided parameter of 55 to 1010 mg/kg/dose, the safe range for this child is 7575 mg to 150150 mg per dose. The ordered dose of 250250 mg is a significant overdose. The practical nurse must withhold the drug and immediately notify the provider.

Step-by-Step Solution

1
Convert the client's weight from pounds to kilograms.
33 lb÷2.2 lb/kg=15 kg33 \text{ lb} \div 2.2 \text{ lb/kg} = 15 \text{ kg}
Weight-based pediatric dosage parameters are calculated using kilograms.
2
Calculate the safe minimum and maximum dosage range for this specific client.
Minimum: 15 kg×5 mg/kg=75 mg/dose15 \text{ kg} \times 5 \text{ mg/kg} = 75 \text{ mg/dose}. Maximum: 15 kg×10 mg/kg=150 mg/dose15 \text{ kg} \times 10 \text{ mg/kg} = 150 \text{ mg/dose}.
This establishes the acceptable therapeutic window to evaluate the provider's order.
3
Compare the prescribed dose to the calculated safe range.
The prescribed dose is 250250 mg. The maximum safe dose is 150150 mg. The order is therefore unsafe.
Administering a dose above the calculated safe range can cause severe toxicity and adverse effects.
4
Determine the appropriate nursing intervention within the LPN/LVN scope of practice.
Withhold the medication and contact the healthcare provider to clarify the order.
Nurses have a legal and ethical duty to withhold unsafe orders, and only the provider can write or modify a prescription.

Key Concept

Pediatric Dosage Verification and Safe Medication Administration
Estimated Time:1m 30s
Question 457Question →

A practical nurse (PN) is preparing to remove an indwelling urinary catheter from an adult female client. Arrange the following actions in the correct sequence to reduce the risk of trauma and potential complications.

Drag items to arrange them in the correct order

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Answer

The correct sequence is: position the client and place a pad, attach the syringe to the port, withdraw all fluid from the balloon, instruct the client to exhale while withdrawing the catheter, and finally inspect the catheter tip.
The correct sequence ensures client comfort, prevents environmental contamination, and minimizes the risk of urethral trauma or retained foreign bodies. Proper preparation, complete balloon deflation, and post-removal inspection are key risk reduction strategies.

Step-by-Step Solution

1
Position the client supine with knees flexed and place a waterproof pad under the buttocks.
The client is appropriately positioned, and the environment is protected.
Optimal visualization of the meatus and protection of bed linens are necessary first steps.
2
Attach a designated syringe to the catheter's balloon inflation port.
The syringe is securely connected.
A secure connection is required to draw back the fluid anchoring the catheter.
3
Withdraw the entire volume of sterile water from the balloon.
The balloon is completely deflated.
Failing to remove all fluid before pulling will cause significant urethral trauma and pain.
4
Instruct the client to take a deep breath and exhale while smoothly withdrawing the catheter.
The catheter is safely removed from the urethra.
Exhaling relaxes the pelvic floor sphincter muscles, reducing resistance during removal.
5
Inspect the catheter tip to ensure it is completely intact.
The tip is verified to be whole.
A retained catheter fragment can lead to bladder infection, obstruction, or calculi formation.

Key Concept

Indwelling Urinary Catheter Removal Sequence
Question 458Question →

A practical nurse (PN) and an unlicensed assistive personnel (UAP) are preparing to move a partially dependent client up in bed using a draw sheet. In what order should the nurse direct these actions? Arrange the steps from first to last.

Drag items to arrange them in the correct order

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Answer

The correct sequence is: 1) Position the bed flat and raise the bed height, 2) Remove the pillow and place it against the headboard, 3) Instruct the client to fold their arms and bend their knees, 4) Grasp the draw sheet close to the client, and 5) Shift weight to move the client on the count of three.
To safely move a client up in bed, the nurse must first prioritize environmental safety and ergonomics by flattening and raising the bed. Next, the client's head is protected by placing the pillow against the headboard. The client is then positioned to minimize friction and assist with the move (arms folded, knees bent). Finally, the caregivers establish a secure, close grip on the draw sheet and use a coordinated weight-shifting technique to execute the movement safely.

Step-by-Step Solution

1
Prepare the environment for safe ergonomics.
The bed is flattened and raised to waist level.
Minimizes the need for the caregivers to reach or bend at the waist, reducing back strain and preventing gravity from working against the movement.
2
Protect the client from potential injury.
The pillow is placed against the headboard.
Provides a soft barrier that prevents the client's head from striking the hard surface of the headboard during the upward motion.
3
Prepare the client for movement.
The client's arms are folded and knees are bent.
Folding the arms reduces friction against the bed linens. Bending the knees allows the client to push with their heels, actively assisting the caregivers and reducing lifting requirements.
4
Establish a secure grip for the transfer.
The draw sheet is rolled and grasped close to the client's body.
Holding the sheet close to the client keeps the weight close to the caregivers' center of gravity, which is essential for safe body mechanics.
5
Execute the movement synchronously.
Caregivers shift their weight and the client is moved up in bed.
Moving on a unified count ensures smooth motion, evenly distributes the workload, and prevents jerky movements that could cause pain or injury.

Key Concept

Proper body mechanics and safety principles during client positioning and bed transfers.
Estimated Time:1m 15s
Question 459Question →

A practical nurse (PN) is caring for an older adult client who was admitted with a severe urinary tract infection. The client suddenly becomes highly restless, exhibits a respiratory rate of 28 breaths/min, and has a blood pressure that decreased from 132/80 mm Hg to 96/58 mm Hg. Which actions should the PN take in this situation? Select all that apply.

Select all that apply

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Answer: Notify the registered nurse (RN) immediately regarding the client's change in status.; Verify the patency of the client's existing intravenous (IV) access.; Prepare to administer supplemental oxygen as prescribed.

Answer

The correct actions are to notify the RN immediately, verify IV access patency, and prepare to administer supplemental oxygen.
The client is demonstrating early signs of septic shock, including restlessness (decreased cerebral perfusion), tachypnea, and a dropping blood pressure. The PN must immediately prioritize Airway, Breathing, and Circulation (ABC) while rapidly escalating care. Notifying the RN facilitates prompt medical intervention, checking IV patency prepares the client for emergent fluid or medication administration, and providing oxygen supports systemic tissue perfusion.

Step-by-Step Solution

1
Analyze the client's changing clinical data.
The client has a severe infection and now presents with restlessness, tachypnea (28 breaths/min), and a dropping blood pressure (96/58 mm Hg).
Recognizing trends in vital signs and mental status is essential for identifying early septic shock.
2
Prioritize interventions based on the ABC (Airway, Breathing, Circulation) framework.
The PN must address the client's systemic circulatory and respiratory compromise before addressing localized symptoms like pain.
Acute physiological deterioration requires immediate stabilizing care and escalation to prevent mortality.
3
Select the appropriate actions within the PN scope of practice.
The PN should prepare oxygen (Breathing), check IV patency for fluids (Circulation), and notify the RN for advanced orders (Escalation).
These actions are safe, immediate, and fall directly within the expected response protocols for a PN.

Key Concept

Early recognition and prioritization of care for septic shock.
Question 460Question →

An older adult client is hospitalized for the medical management of a bleeding gastric ulcer. The client is receiving a continuous intravenous infusion of normal saline. During morning rounds, the practical nurse assesses a heart rate of 118 beats per minute, a blood pressure of 92/58 mm Hg, and notes that the client appears pale and reports feeling dizzy. Which action should the practical nurse take first?

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Answer: Place the client in a supine position and immediately report the assessment findings to the supervising registered nurse.

Answer

The correct action is to position the client supine to promote blood flow to the brain and immediately notify the registered nurse of the significant vital sign changes.
The correct answer addresses the immediate threat to circulation (hypovolemia from bleeding) by placing the client in a supine position to enhance venous return and cerebral perfusion, while correctly acting within the practical nurse scope by immediately notifying the registered nurse of the client's deterioration.

Step-by-Step Solution

1
Analyze the clinical data.
The client has a history of a bleeding ulcer and now presents with tachycardia (118 bpm), hypotension (92/58 mm Hg), pallor, and dizziness.
Recognizing abnormal vital signs is the essential first step in clinical judgment.
2
Interpret the meaning of the findings.
These findings are classic early signs of hypovolemic shock caused by internal bleeding.
The body compensates for fluid loss by increasing the heart rate to maintain cardiac output and perfuse vital organs.
3
Determine the priority nursing intervention within the practical nurse scope of practice.
The most appropriate action is to protect the client's safety (supine position) and immediately escalate the critical findings to the registered nurse for further medical intervention.
Practical nurses must recognize complications and communicate urgent changes to the healthcare team while staying within their designated scope of practice.

Key Concept

Early Recognition and Escalation of Hypovolemic Shock
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