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During a shift on an acute care medical-surgical unit, a practical nurse (PN) is tasked with managing care for several clients. Which of the following nursing actions demonstrate appropriate risk reduction and adherence to safe practice guidelines? (Select all that apply.)

Select all that apply

Implementing daily weights and strict intake and output monitoring for a client admitted with an acute exacerbation of heart failure.

Verifying the client's ability to swallow effectively before providing oral fluids following an acute ischemic stroke.

Accepting an assignment to independently manage a client who requires continuous titration of an intravenous (IV) antiarrhythmic medication.

Administering scheduled medications by relying solely on the client's verbal confirmation of their name when the unit's barcode scanner is broken.

Placing a laboratory report indicating a serum sodium level of 118 mEq/L in the chart for the provider to review during routine afternoon rounds.

Attributing a postoperative client's steadily increasing heart rate and borderline hypotension strictly to surgical pain without further escalation.

Show answer & explanation

Answer: Implementing daily weights and strict intake and output monitoring for a client admitted with an acute exacerbation of heart failure.; Verifying the client's ability to swallow effectively before providing oral fluids following an acute ischemic stroke.

Answer

The correct actions are implementing daily weights and strict intake/output monitoring for the client with heart failure, and verifying the swallowing ability of the client who experienced a stroke.

Safe risk reduction involves implementing evidence-based basic care (such as daily weights for heart failure to monitor fluid status) and preventing complications (such as assessing swallowing after a stroke to prevent aspiration). Both actions fall safely within the practical nurse's scope of practice and directly protect the client from harm.

Step-by-Step Solution

Evaluate the heart failure intervention.

Daily weights and intake/output monitoring are identified as appropriate.

These are standard, evidence-based practices to reduce the risk of fluid volume overload complications.

Evaluate the stroke intervention.

Verifying swallowing ability is identified as appropriate.

This is a necessary risk reduction measure to prevent aspiration before introducing oral intake.

Analyze the IV titration assignment.

Identified as an unsafe practice.

Managing continuous IV antiarrhythmic drips exceeds the practical nurse scope and requires RN-level monitoring.

Analyze the medication verification method.

Identified as a safety violation.

Using only one identifier (verbal name) breaches medication safety protocols; two distinct identifiers are always required.

Review the handling of the lab report.

Identified as a failure to escalate.

A sodium level of 118 mEq/L is critically low and requires immediate verbal notification, not passive charting.

Analyze the vital signs interpretation.

Identified as a missed clinical warning.

Tachycardia with borderline hypotension are early signs of shock and must be reported immediately, rather than assumed to be pain.

Key Concept

Identifying clinical risks and escalating care appropriately within the practical nurse scope of practice.

Question 482Question →

A practical nurse is providing oral care to a client who is unconscious and unable to swallow. Arrange the following nursing actions in the correct chronological sequence to ensure client safety and hygiene. (Place the first action at the top and the last action at the bottom.)

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence begins with protecting the airway by positioning the client in a side-lying position. Next, the nurse places a towel and emesis basin to catch fluids. The mouth is then safely opened using a padded tongue blade, followed by cleaning the oral cavity with a moistened sponge swab. Finally, the nurse applies a water-soluble lubricant to the client's lips.

Safety is the highest clinical priority when providing care to an unconscious client who has lost their protective swallow and gag reflexes. The nurse must first secure the airway by placing the client in a side-lying position to prevent aspiration. Once the airway is protected, the nurse prepares the immediate environment for cleanliness. The mouth is safely accessed using appropriate equipment (a padded tongue blade) to prevent injury, the hygiene is performed, and finally, comfort measures (lubricant) are applied to the lips.

Step-by-Step Solution

Position the client in a side-lying or lateral position.

The client's airway is protected from aspiration.

Gravity allows saliva and cleaning fluids to pool in the cheek and drain out of the mouth rather than sliding back into the pharynx.

Place a towel under the chin and position the emesis basin.

The area is prepared to manage fluid drainage.

This maintains cleanliness and dignity by preventing the client's gown and bed linens from becoming soiled during the procedure.

Open the mouth using a padded tongue blade.

The oral cavity is safely accessed.

Unconscious clients may have an unpredictable bite reflex. A padded blade protects both the client's oral mucosa and the nurse's fingers.

Swab the teeth, gums, and tongue.

The oral cavity is cleansed of debris and bacteria.

Regular cleaning prevents halitosis, oral infections, and the buildup of thick secretions.

Apply water-soluble lubricant to the lips.

The lips are moisturized and protected.

Unconscious clients often breathe through their mouths, leading to severely dry and cracked lips if not properly lubricated.

Key Concept

Oral Care for the Unconscious Client

Question 483Question →

A client diagnosed with bipolar disorder has been taking lithium carbonate for several months. During a clinic visit, the client reports experiencing persistent nausea, vomiting, and severe diarrhea for the past 48 hours. The practical nurse observes that the client is mildly disoriented and has a resting heart rate of 115 beats per minute. Which action should the practical nurse take first?

Withhold any upcoming doses of the medication and immediately inform the registered nurse of the client's status.

Proceed with administering the next dose alongside a full glass of water to address the client's dehydration.

Instruct the client to strictly limit their dietary sodium intake to prevent further gastrointestinal distress.

Tell the client that these are common, expected side effects of the medication and encourage them to rest.

Show answer & explanation

Answer: Withhold any upcoming doses of the medication and immediately inform the registered nurse of the client's status.

Answer

The practical nurse should withhold any upcoming doses of the medication and immediately inform the registered nurse.

Lithium carbonate is a medication with a narrow therapeutic index. Conditions that cause dehydration and sodium depletion, such as severe vomiting and diarrhea, reduce the kidneys' ability to excrete lithium, rapidly leading to toxicity. The client's clinical presentation (tachycardia, gastrointestinal distress, and disorientation) strongly points to lithium toxicity and potential hypovolemia. The practical nurse must act safely by withholding the next dose and immediately escalating these critical findings to the registered nurse or healthcare provider for immediate medical intervention.

Step-by-Step Solution

Analyze the client's clinical presentation in the context of their medication therapy.

The client taking lithium has severe gastrointestinal fluid loss (vomiting, diarrhea), tachycardia, and disorientation.

Identifying abnormal findings is the first step in clinical data collection and determining client safety.

Correlate the symptoms with potential pharmacological complications.

Fluid and sodium loss lead to decreased renal excretion of lithium. The symptoms presented strongly indicate acute lithium toxicity.

Lithium has a very narrow therapeutic index, meaning the difference between a safe dose and a toxic dose is small.

Determine the safest, scope-appropriate action.

The nurse must withhold the dangerous medication and immediately escalate the critical findings to the RN or provider.

Practical nurses must prioritize client safety and recognize when a client's condition requires RN-level assessment and intervention.

Key Concept

Recognizing early signs of lithium toxicity and acting within the practical nursing scope of practice to ensure client safety.

Question 484Question →

A practical nurse (PN) is caring for a client who returned 2 hours ago from a diagnostic cardiac catheterization performed via the right femoral artery. The client's pre-procedure vital signs were a blood pressure of 138/76 mmHg and a heart rate of 72 beats/min. The client now reports a new onset of dull, aching pain in the lower right back. Current vital signs are blood pressure 102/58 mmHg, heart rate 108 beats/min, and respiratory rate 18 breaths/min. Which of the following actions is the priority for the PN to take?

Immediately report the assessment findings to the registered nurse.

Document the vital signs and continue to monitor the client every 15 minutes.

Assist the client into a high-Fowler's position to alleviate the back discomfort.

Perform a comprehensive physical assessment to determine the source of the back pain.

Show answer & explanation

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

Answer

Immediately report the assessment findings to the registered nurse.

The client's new-onset tachycardia, relative hypotension, and lower back pain strongly indicate retroperitoneal bleeding, a severe and potentially life-threatening complication of a femoral cardiac catheterization. The practical nurse must prioritize client safety by immediately reporting these alarming findings to the registered nurse so that timely medical intervention can be initiated.

Step-by-Step Solution

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

Blood pressure has dropped significantly from 138/76 to 102/58 mmHg, and heart rate has increased from 72 to 108 beats/min.

To identify early hemodynamic instability indicative of hypovolemia or shock.

Correlate the vital sign changes with the client's reported symptom of new lower right back pain.

The combination of back pain, hypotension, and tachycardia suggests retroperitoneal bleeding, a known and severe complication of femoral artery access.

Back or flank pain following a femoral catheterization is a classic clinical indicator of internal retroperitoneal hemorrhage.

Determine the appropriate action based on the PN scope of practice.

The PN must notify the registered nurse (RN) immediately rather than independently managing the complication.

The client is experiencing a potentially life-threatening complication that requires RN-level assessment, clinical judgment, and immediate provider notification.

Key Concept

Recognizing Complications of Diagnostic Procedures

Question 485Question →

An 80-year-old client is admitted to the medical-surgical unit with an acute gastrointestinal hemorrhage. The client has a peripheral intravenous line infusing 0.9% sodium chloride. Which actions by the practical nurse demonstrate safe and effective prioritization of the client's physiological adaptation? Select all that apply.

Select all that apply

Elevating the head of the bed and verifying airway patency if the client begins vomiting active red blood.

Notifying the registered nurse immediately when the client's resting heart rate increases to 112 beats/min with a blood pressure of 100/64 mm Hg.

Applying a pulse oximeter to check oxygen saturation when the client becomes newly restless and diaphoretic.

Administering a scheduled oral analgesic for chronic joint pain before assessing a new onset of rapid, shallow breathing.

Instructing the family that the client's sudden disorientation to person and place is a normal consequence of advanced age.

Continuing routine hourly observations without reporting a newly documented blood pressure of 96/60 mm Hg because the client is resting quietly.

Show answer & explanation

Answer: Elevating the head of the bed and verifying airway patency if the client begins vomiting active red blood.; Notifying the registered nurse immediately when the client's resting heart rate increases to 112 beats/min with a blood pressure of 100/64 mm Hg.; Applying a pulse oximeter to check oxygen saturation when the client becomes newly restless and diaphoretic.

Answer

The correct actions include elevating the head of the bed during vomiting, notifying the registered nurse of early shock vitals, and checking oxygen saturation for sudden restlessness.

The correct actions focus on maintaining airway patency during emesis, promptly recognizing and reporting early compensatory signs of hypovolemic shock (tachycardia, borderline hypotension), and assessing for hypoxia when neurological changes occur. These interventions align with the practical nurse's scope of practice for prioritizing physiological safety.

Step-by-Step Solution

Analyze the client's clinical condition and associated risks.

The client has a gastrointestinal hemorrhage, placing them at high risk for hypovolemic shock, airway compromise (from vomiting blood), and hypoxia.

Understanding the primary diagnosis helps the nurse anticipate potential life-threatening physiological complications.

Evaluate each nursing action against the ABC (Airway, Breathing, Circulation) priority framework.

Elevating the bed protects the airway; checking oxygenation prioritizes breathing; reporting tachycardia and borderline hypotension addresses circulation.

The ABC framework dictates the immediate survival priorities in acute physiological adaptation scenarios.

Differentiate expected baseline gerontological findings from signs of acute physiological deterioration.

Sudden confusion is an acute change indicating hypoxia or shock, not normal aging. Borderline low blood pressure is an early warning sign of hemorrhage, not an expected stable finding.

Failing to recognize subtle changes delays life-saving interventions and compromises client safety.

Key Concept

Prioritization of care and recognition of early signs of hypovolemic shock in a bleeding client.

Question 486Question →

During the first postoperative day after a right total hip arthroplasty (posterior approach), a client requires assistance with repositioning and morning hygiene. Which action by the practical nurse (PN) is most appropriate to promote safety and comfort?

Elevate the head of the bed to 90 degrees while the client consumes their morning meal.

Massage the client's bilateral calves to relieve postoperative muscle aching.

Maintain an abduction wedge between the client's legs when turning them onto their left side.

Direct the unlicensed assistive personnel (UAP) to perform the client's scheduled neurovascular checks.

Show answer & explanation

Answer: Maintain an abduction wedge between the client's legs when turning them onto their left side.

Answer

Maintain an abduction wedge between the client's legs when turning them onto their left side.

Following a total hip arthroplasty with a posterior approach, the client is at high risk for hip dislocation. Keeping the legs abducted using a wedge, especially when turning the client onto the unaffected side, prevents the operative leg from crossing the midline (adduction) and maintains proper joint alignment.

Step-by-Step Solution

Identify the surgical procedure and the associated physiological risks.

The client had a right total hip arthroplasty via a posterior approach, which carries a high risk of hip dislocation if the joint is flexed greater than 90 degrees or adducted.

Understanding specific postoperative mobility constraints is essential for providing safe basic care.

Evaluate each potential nursing intervention for safety and appropriateness.

Elevating the bed to 90 degrees causes dangerous flexion; massaging calves risks causing a pulmonary embolism; and delegating assessments is outside the UAP's scope of practice.

Actions that compromise safety, ABCs, or legal scope of practice must be eliminated.

Select the action that safely promotes comfort and mobility within the prescribed limits.

Using an abduction wedge while turning the client onto the unaffected side maintains proper joint alignment and prevents dislocation.

This action directly satisfies the requirement for safe positioning and comfort care.

Key Concept

Postoperative positioning and mobility precautions for total hip arthroplasty

Question 487Question →

A practical nurse is preparing to administer prescribed otic drops to an adult client diagnosed with otitis externa. Arrange the following actions for administering this medication in the correct chronological sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: Position the client laterally, straighten the auditory canal by pulling the pinna upward and backward, instill the drops, apply gentle pressure to the tragus, and instruct the client to remain in the lateral position.

The correct chronological sequence ensures patient safety, anatomical alignment, and maximum medication efficacy. First, positioning the client uses gravity to direct the drops. Second, pulling the adult pinna upward and backward properly straightens the naturally curved ear canal. Third, instilling the drops while avoiding physical contact maintains sterility. Fourth, pressing the tragus actively moves the fluid inward toward the tympanic membrane. Finally, having the client remain in position prevents the medication from prematurely leaking out of the ear.

Step-by-Step Solution

Establish the correct patient position.

The client is lying on their side with the affected ear facing the ceiling.

Gravity is required to keep the instilled liquid inside the ear canal.

Prepare the anatomical pathway.

The ear canal is straightened by pulling the pinna upward and backward.

Adult ear canals have a natural curve; straightening them ensures the medication reaches deep into the canal rather than resting on the outer walls.

Administer the medication.

The prescribed drops are instilled into the ear.

Instillation immediately follows anatomical preparation. Avoiding contact between the dropper and the ear prevents contamination.

Facilitate medication transit.

Gentle pressure is applied to the tragus.

This creates an inward pumping mechanism that moves the drops past any air pockets toward the eardrum.

Maintain medication placement.

The client remains on their side for several minutes.

This dwell time prevents the medication from leaking out when the client sits up.

Key Concept

Administration of Otic Medications in Adults

Question 488Question →

A client with severe generalized weakness is confined to bed. To promote physical comfort and prevent complications related to immobility, which positioning techniques should the practical nurse implement? (Select all that apply.)

Select all that apply

Maintain the client in a 30-degree lateral incline position when turning.

Support the calves with a cushion to completely suspend the heels off the mattress.

Position the client's weight directly on the hip bone when assisting them to a side-lying posture.

Place a firm, rolled towel directly under the popliteal space while the client rests on their back.

Restrict the upward angle of the bed's headrest to 30 degrees or lower except when eating.

Show answer & explanation

Answer: Maintain the client in a 30-degree lateral incline position when turning.; Support the calves with a cushion to completely suspend the heels off the mattress.; Restrict the upward angle of the bed's headrest to 30 degrees or lower except when eating.

Answer

The correct positioning techniques include maintaining a 30-degree lateral incline, supporting the calves to suspend the heels, and restricting the headrest angle to 30 degrees or lower.

Proper positioning aims to minimize pressure, friction, and shear forces that lead to skin breakdown and circulatory impairment. A 30-degree lateral incline effectively shifts body weight off the greater trochanter and onto the gluteal muscles. Suspending the heels removes all pressure from a highly vulnerable bony prominence. Limiting the headrest elevation to 30 degrees prevents the client from sliding downward, thereby reducing severe shearing forces on the sacrum.

Step-by-Step Solution

Analyze the goal of positioning an immobile client.

The primary goals are to distribute weight evenly, avoid pressure on bony prominences, minimize shearing forces, and maintain unobstructed circulation.

Immobility greatly increases the risk of pressure injuries and deep vein thrombosis without proper intervention.

Evaluate each positioning strategy against safety and comfort standards.

The 30-degree lateral incline, heel suspension, and low head-of-bed angle effectively reduce shear and localized pressure. Direct hip pressure and popliteal rolls cause tissue and circulatory harm.

Identifying interventions that prevent complications is within the practical nursing scope of basic care and comfort.

Key Concept

Prevention of Complications of Immobility

Question 489Question →

A practical nurse (PN) is collecting data on a client who is 6 hours postpartum following an uncomplicated vaginal delivery. Which finding is the priority to report to the registered nurse immediately?

A gradual increase in heart rate from 78 to 112 beats/minute and a blood pressure decrease from 122/76 to 104/62 mm Hg.

Saturation of one perineal pad over a three-hour period with dark red lochia.

Intense uterine cramping that worsens while the client is breastfeeding the newborn.

An oral temperature of 100.1°F (37.8°C) accompanied by mild diaphoresis.

Show answer & explanation

Answer: A gradual increase in heart rate from 78 to 112 beats/minute and a blood pressure decrease from 122/76 to 104/62 mm Hg.

Answer

The finding that requires immediate reporting is the gradual increase in heart rate accompanied by a decrease in blood pressure.

The correct answer identifies subtle but progressive vital sign changes (tachycardia and mild hypotension), which are early, critical indicators of compensatory hypovolemic shock. In a postpartum client, this strongly suggests an undetected hemorrhage. The PN must prioritize this finding and report it immediately to the RN for further assessment and medical intervention, as it directly impacts the client's circulation (ABCs).

Step-by-Step Solution

Analyze the client's current clinical status and the timeframe.

The client is 6 hours postpartum, a high-risk period for hemorrhage and physiological fluid shifts.

Establishing the timeframe helps differentiate between normal expected adaptations and acute complications.

Evaluate each data finding against expected normal postpartum physiological adaptations.

Saturating one pad in three hours, afterpains during breastfeeding, and a slight temperature elevation up to 100.4°F (38.0°C) are all normal, expected findings.

Normal findings reflect expected healing and hormonal changes, and they do not require immediate urgent reporting to the RN.

Identify any findings that compromise Airway, Breathing, or Circulation (ABCs).

The steadily rising heart rate and falling blood pressure indicate a serious circulation issue, specifically compensatory hypovolemia.

Prioritization questions require focusing on ABCs; early signs of shock must be escalated immediately to prevent severe cardiovascular collapse.

Key Concept

Early recognition of hypovolemic shock in the postpartum period

Estimated Time:1m 0s

Question 490Question →

Four hours following an uncomplicated vaginal delivery, a postpartum client reports feeling unusually tired. Upon evaluation, the nurse observes that the client has completely saturated a perineal pad with dark red blood within the last 45 minutes. The current assessment shows a heart rate of 106 beats/minute and a blood pressure of 104/68 mm Hg, a change from the baseline of 82 beats/minute and 126/78 mm Hg. Which action should the nurse take first?

Massage the uterine fundus and urgently notify the supervising registered nurse.

Record the assessment findings in the electronic health record and reassess in one hour.

Explain to the client that this volume of blood loss is a normal part of the recovery process.

Place the client in an upright, seated position to facilitate the drainage of accumulated blood.

Show answer & explanation

Answer: Massage the uterine fundus and urgently notify the supervising registered nurse.

Answer

Massage the uterine fundus and urgently notify the supervising registered nurse.

The correct answer addresses the immediate physical need by massaging the fundus to promote uterine contraction while simultaneously escalating the critical situation to the registered nurse. The client's saturated pad and vital sign changes indicate postpartum hemorrhage and early hypovolemic shock, requiring urgent collaborative intervention.

Step-by-Step Solution

Evaluate the perineal pad saturation rate.

The pad is saturated in 45 minutes, indicating excessive bleeding.

Saturating a pad in less than one hour is a clinical indicator of postpartum hemorrhage.

Analyze the vital sign trends.

Heart rate increased by 24 beats/minute and blood pressure decreased.

Tachycardia and mild hypotension are early compensatory signs of hypovolemic shock due to blood loss.

Determine the priority nursing intervention.

Initiate fundal massage and escalate to the RN.

Fundal massage is the immediate action for uterine atony, and the RN must be notified for collaborative management of hemorrhage.

Key Concept

Early recognition and escalation of postpartum hemorrhage

Question 491Question →

A practical nurse is assigned to care for a client who returned to the surgical unit 2 hours ago following a subtotal thyroidectomy. The client reports mild incisional discomfort. Which positioning intervention should the nurse implement to promote comfort and minimize tension on the surgical site?

Keep the client flat on their back with a rolled towel placed directly beneath the cervical spine.

Adjust the bed to a semi-Fowler's angle and stabilize the head and neck using supportive pillows.

Turn the client into a side-lying alignment with the bed positioned completely flat.

Sit the client straight up at a 90-degree angle with the chin resting toward the chest.

Show answer & explanation

Answer: Adjust the bed to a semi-Fowler's angle and stabilize the head and neck using supportive pillows.

Answer

Adjust the bed to a semi-Fowler's angle and stabilize the head and neck using supportive pillows.

Adjusting the bed to a semi-Fowler's angle (approximately 30 to 45 degrees) utilizes gravity to decrease swelling at the surgical site. Stabilizing the head and neck with pillows prevents hyperextension or hyperflexion, keeping the neck in a neutral position. This combination ensures optimal airway patency, reduces tension on the surgical incision, and maximizes client comfort.

Step-by-Step Solution

Identify the surgical procedure and its anatomical location.

The client had a subtotal thyroidectomy, which involves an incision in the anterior neck.

Understanding the surgical site is essential for determining the correct positioning to prevent complications.

Determine the primary physiological risks associated with the immediate postoperative period.

Risks include localized edema causing airway obstruction, and tension on the suture line causing hemorrhage.

Nursing interventions must be chosen to mitigate these specific, life-threatening complications.

Select the position that addresses these risks while promoting client comfort.

A semi-Fowler's position with the head and neck supported in a neutral alignment.

Elevation reduces swelling via gravity, and firm support prevents flexion or hyperextension of the neck.

Key Concept

Postoperative Positioning and Airway Protection

Practice More

Review the early signs of respiratory distress and hypocalcemia following a thyroidectomy.

Alternative Method

When thinking about post-neck surgery care, remember the 'E and N' rule: Elevate (to reduce swelling) and Neutral (to prevent suture tension).

Estimated Time:1m 0s

Question 492Question →

While reviewing the morning chart for a client treated for heart failure, a practical nurse notes a serum potassium result of $3.0$ mEq/L (reference range: $3.5$ to $5.0$ mEq/L). The medication record indicates upcoming scheduled doses of oral furosemide and oral potassium chloride. Which step is most appropriate for the nurse to take?

Hold the furosemide dose, give the potassium chloride supplement, and alert the supervising registered nurse.

Give both scheduled medications since the prescribed potassium will naturally resolve the electrolyte deficit.

Agree to a provider's telephone request to deliver a rapid bolus of intravenous potassium.

Bypass the electronic barcode verification process to expedite the delivery of the diuretic.

Show answer & explanation

Answer: Hold the furosemide dose, give the potassium chloride supplement, and alert the supervising registered nurse.

Answer

The nurse must withhold the furosemide, administer the potassium chloride, and notify the registered nurse.

Holding the furosemide prevents further depletion of the client's already low potassium levels. Administering the potassium chloride addresses the deficit, and notifying the registered nurse ensures proper escalation of a critical laboratory finding.

Step-by-Step Solution

Evaluate the morning laboratory results against normal reference ranges.

The client's serum potassium is

3.0

mEq/L, which indicates hypokalemia (normal is

3.5

5.0

mEq/L).

Identifying abnormal laboratory values is essential before administering medications that affect fluid and electrolyte balance.

Analyze the pharmacological effects of the scheduled medications on the abnormal lab value.

Furosemide is a loop diuretic that causes the kidneys to excrete potassium, which would worsen the hypokalemia. Potassium chloride will help correct the deficit.

Understanding the mechanism of action prevents the administration of a drug that could cause immediate client harm.

Determine the appropriate nursing intervention within the practical nurse scope of practice.

The nurse must hold the furosemide, proceed with the potassium supplement, and report the abnormal finding to the registered nurse.

Practical nurses must advocate for client safety by withholding harmful medications and escalating critical clinical data.

Key Concept

Monitoring adverse effects of pharmacological therapies and safe medication administration.

Question 493Question →

The practical nurse (PN) is providing care for a group of clients on a medical-surgical unit. Which of the following actions by the PN demonstrate appropriate risk reduction and safe clinical practice? Select all that apply.

Select all that apply

Notifying the registered nurse (RN) immediately regarding a client receiving a loop diuretic whose morning serum potassium level is 2.8 mEq/L (2.8 mmol/L).

Administering a prescribed intravenous push (IVP) analgesic to a client experiencing acute postoperative pain.

Documenting a new-onset resting heart rate of 114 bpm and a blood pressure of 88/56 mm Hg as expected findings for an older adult.

Verifying the client's name and date of birth using the identification band prior to providing scheduled oral medications.

Identifying a client for a procedure by relying on visual recognition because the client has been on the unit for several weeks.

Placing a client with right-sided weakness on a scheduled toileting protocol to prevent unassisted ambulation attempts.

Show answer & explanation

Answer: Notifying the registered nurse (RN) immediately regarding a client receiving a loop diuretic whose morning serum potassium level is 2.8 mEq/L (2.8 mmol/L).; Verifying the client's name and date of birth using the identification band prior to providing scheduled oral medications.; Placing a client with right-sided weakness on a scheduled toileting protocol to prevent unassisted ambulation attempts.

Answer

The correct actions are notifying the RN of the critically low potassium level, verifying two client identifiers before medication administration, and implementing a scheduled toileting protocol for a client with weakness.

The correct choices reflect safe clinical practice strictly within the practical nurse scope. Escalating a critically low hypokalemia value, adhering to mandatory two-identifier verification, and implementing proactive fall prevention strategies all directly reduce the risk of harm to vulnerable clients.

Step-by-Step Solution

Analyze the PN scope of practice regarding medication administration and delegation constraints.

Intravenous push (IVP) medications require RN-level assessment and are outside the standard PN scope.

Accepting tasks beyond legal scope increases the risk of client harm and violates professional licensure standards.

Evaluate vital signs and laboratory data to differentiate between expected variations and critical abnormalities.

A potassium level of 2.8 mEq/L and vital signs showing tachycardia with hypotension are critical findings.

These findings indicate severe physiological compromise (hypokalemia and potential shock) requiring immediate medical or RN intervention.

Review standard safety protocols for client identification and fall prevention.

Checking two distinct identifiers and implementing scheduled toileting are mandated safety practices.

Visual recognition bypasses safety checks, leading to medication errors, while unassisted ambulation in weak clients leads to falls. Proper protocols reduce these risks.

Key Concept

Scope of Practice and Clinical Prioritization in Risk Reduction

Question 494Question →

A client with a spinal cord injury at the T4 level reports a sudden, severe pounding headache and blurred vision. The practical nurse (PN) notes the client is profusely sweating and has a flushed face. The client's blood pressure is 208/112 mm Hg. In what order should the PN perform the following actions? Arrange the actions from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first elevate the head of the bed, then check the urinary catheter for kinks, notify the registered nurse, and finally monitor the blood pressure frequently.

In the event of autonomic dysreflexia, the primary life-threatening risk is a severe hypertensive crisis that can lead to a stroke. The very first action must always be to elevate the head of the bed to a sitting (high Fowler's) position, as this uses gravity to immediately lower the blood pressure (orthostatic hypotension). Once the client is safely positioned, the practical nurse must quickly assess for and remove the noxious stimulus, which is most commonly a distended bladder caused by a kinked catheter. After these immediate independent bedside interventions are completed, the nurse must notify the registered nurse to coordinate potential pharmacological treatment. Finally, the nurse continues to monitor the blood pressure every 10 to 15 minutes to evaluate the effectiveness of the interventions.

Step-by-Step Solution

Elevate the head of the bed to a high Fowler's (sitting) position.

The client is in a sitting position, which promotes orthostatic hypotension.

This is the most rapid and immediate action to lower the dangerously high blood pressure and prevent a cerebrovascular accident (stroke).

Check the client's urinary catheter tubing for kinks or obstruction.

The most common noxious stimulus is assessed and potentially resolved.

Bladder distention is the leading cause of autonomic dysreflexia. Removing the stimulus helps resolve the physiological cascade.

Notify the registered nurse (RN) of the client's acute symptoms.

The RN is informed of the medical emergency.

The RN and healthcare provider need to be aware, as pharmacological intervention may be required if nursing actions do not relieve the symptoms.

Monitor the client's blood pressure every 10 to 15 minutes.

Continuous assessment of the client's hemodynamic status is established.

Frequent monitoring is necessary to determine if the interventions are effective and to ensure the blood pressure is stabilizing.

Key Concept

Prioritization of care for autonomic dysreflexia involves immediate blood pressure reduction through positioning, followed by elimination of the triggering stimulus.

Question 495Question →

The healthcare provider prescribes oral ibuprofen for a toddler who weighs $33$ pounds and has a temperature of $101.2^\circ\text{F}$ ( $38.4^\circ\text{C}$ ). The prescribed dosage is $10\text{ mg/kg}$ per dose. The available medication is an oral suspension labeled $100\text{ mg}/5\text{ mL}$ . How many milliliters should the nurse administer for a single dose?

Record your answer to the nearest tenth. Do not include units in the answer.

Show answer & explanation

Answer: 7.5

Answer

7.5

To find the correct administration volume, the practical nurse must systematically process the data. First, the toddler's weight is converted to standard metric units by dividing by

2.2

(

33 \text{ lbs} \div 2.2 = 15\text{ kg}

). Next, the weight is multiplied by the ordered weight-based dose to find the target milligrams (

15\text{ kg} \times 10\text{ mg/kg} = 150\text{ mg}

). Finally, the nurse calculates the required volume using the supplied concentration:

(150\text{ mg} \div 100\text{ mg}) \times 5\text{ mL} = 7.5\text{ mL}

Step-by-Step Solution

Convert the toddler's weight from pounds to kilograms.

33 \text{ lbs} \div 2.2 \text{ lbs/kg} = 15 \text{ kg}

Weight-based medication dosages must be calculated using kilograms to ensure safe administration limits.

Calculate the total required dose in milligrams.

15 \text{ kg} \times 10 \text{ mg/kg} = 150 \text{ mg}

The prescription specifies a weight-based dose of 10 mg for every kilogram of body weight.

Calculate the administration volume using the available suspension concentration.

(150 \text{ mg} \div 100 \text{ mg}) \times 5 \text{ mL} = 7.5 \text{ mL}

Applying the desired over have formula determines the exact liquid volume needed to deliver the prescribed milligram dose.

Key Concept

Weight-based dosage calculation and liquid medication volume conversion

Question 496Question →

An older adult client is prescribed oral digoxin $0.125$ mg once daily. The unit's automated medication dispenser supplies digoxin in scored tablets of $0.25$ mg. Prior to administration, the practical nurse assesses the client's apical pulse and obtains a rate of $74$ beats per minute. Which action should the practical nurse take?

Administer one-half of the scored tablet after verifying two client identifiers.

Administer one whole tablet because the client's apical pulse is greater than

60

beats per minute.

Verify the client's room number and administer one-half of the tablet to expedite morning care.

Ask the registered nurse to administer the dose because managing cardiac glycosides is outside the practical nurse scope.

Show answer & explanation

Answer: Administer one-half of the scored tablet after verifying two client identifiers.

Answer

The practical nurse should administer one-half of the scored tablet after verifying two appropriate client identifiers.

The correct action combines accurate dosage calculation, appropriate assessment, and strict adherence to medication rights. The prescribed dose is

0.125

mg, and the available tablet is

0.25

mg. Calculating the dose (

0.125 \div 0.25

) yields

0.5

, meaning one-half of a scored tablet is required. An apical pulse of

74

beats per minute is safely above the standard withholding threshold of

60

beats per minute for digoxin, making it appropriate to administer. Finally, verifying two distinct client identifiers (such as name and date of birth) is a mandatory safety standard before giving any medication.

Step-by-Step Solution

Assess the client's heart rate against the medication administration parameters.

The apical pulse is

74

beats per minute, which is safely above the standard threshold of

60

beats per minute for withholding digoxin.

Digoxin decreases heart rate, making it dangerous to administer to a client with bradycardia without further medical evaluation.

Calculate the correct medication dosage.

The prescribed dose is

0.125

mg. The available tablet is

0.25

mg. Using the formula

0.125 \div 0.25 = 0.5

, one-half of the scored tablet is needed.

Ensures the client receives the exact prescribed dose and prevents medication errors such as toxicity.

Ensure strict adherence to medication administration rights.

The nurse must verify the client using two acceptable identifiers, such as the client's name and date of birth.

Bypassing identification rights or using unacceptable identifiers like a room number can lead to severe medication administration errors.

Key Concept

Safe medication administration involves accurate dosage calculation, pre-administration physical assessment, and verifying two unique client identifiers.

Question 497Question →

A practical nurse is providing care for a 75-year-old client who had a bowel resection two days ago. The client's morning vital signs were: blood pressure 104/68 mm Hg, heart rate 96 beats/min, respirations 20 breaths/min, and oxygen saturation 94% on room air. Two hours later, the client suddenly becomes highly restless, confused, and attempts to climb out of bed. Which action should the practical nurse take first?

Dim the room lights, speak softly, and provide a calming environment

Document the change in mental status as expected postoperative delirium

Obtain a current set of vital signs including oxygen saturation

Assess the client for incisional pain and administer a prescribed analgesic

Show answer & explanation

Answer: Obtain a current set of vital signs including oxygen saturation

Answer

The priority action is to obtain a current set of vital signs including oxygen saturation.

Sudden restlessness and confusion in a postoperative client are classic early signs of hypoxia, hemorrhage, or hypovolemic shock. Because the morning vital signs were already borderline (heart rate of 96 beats/min and oxygen saturation of 94%), the nurse must first collect current physiologic data to determine if the client is rapidly decompensating. This objective data is essential before notifying the registered nurse or the healthcare provider.

Step-by-Step Solution

Analyze the baseline clinical data.

The morning vital signs showed a high-normal heart rate and low-normal oxygen saturation, indicating the client was in a borderline compensated state.

Establishing a baseline helps identify subtle trends that precede sudden clinical deterioration.

Interpret the new onset of symptoms.

Sudden restlessness and confusion in an older adult are often the first signs of impaired tissue perfusion (shock) or hypoxia.

The brain is highly sensitive to drops in oxygenation and blood flow, presenting as altered mental status before other overt signs appear.

Determine the priority nursing intervention.

The practical nurse must first collect objective data regarding airway, breathing, and circulation (vital signs).

According to ABC prioritization, verifying physiologic stability is required before implementing comfort measures or behavioral interventions.

Key Concept

Prioritization of Care and Acute Shock Recognition

Estimated Time:1m 0s

Question 498Question →

A licensed practical nurse is caring for an adult client who underwent an open reduction and internal fixation of a right femur fracture 8 hours ago. During the current assessment, the nurse notes a heart rate of 118 beats/minute, a blood pressure of 96/62 mm Hg, and a respiratory rate of 22 breaths/minute. Additionally, the surgical dressing exhibits a newly formed, 4-cm diameter area of sanguineous drainage. What is the priority action for the nurse to take?

Trace the outline of the drainage on the dressing and reassess the client in one hour.

Administer the prescribed as-needed oral opioid analgesic for postoperative pain.

Increase the continuous intravenous fluid infusion rate to stabilize the blood pressure.

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

Immediately report the assessment findings to the supervising registered nurse.

The client is demonstrating early signs of hypovolemic shock, likely due to postoperative hemorrhage, evidenced by tachycardia, borderline hypotension, and new sanguineous drainage. In the practical nursing scope of practice, recognizing an acute deterioration in client stability requires immediate escalation to the registered nurse or healthcare provider so that emergent interventions (such as fluid resuscitation or surgical evaluation) can be initiated.

Step-by-Step Solution

Analyze the client's vital signs and physical assessment findings.

The client has tachycardia (118 beats/minute), borderline hypotension (96/62 mm Hg), and new sanguineous drainage on the surgical dressing.

Identifying abnormal clinical data is the first step in recognizing potential complications.

Correlate the findings with potential postoperative complications.

The combination of elevated heart rate, decreasing blood pressure, and fresh bleeding indicates a high risk for hypovolemic shock due to hemorrhage.

Connecting isolated vital sign changes to underlying physiological processes determines the urgency of the situation.

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

The nurse must escalate the findings to the registered nurse or healthcare provider immediately rather than attempting independent, out-of-scope interventions or delaying care.

Practical nursing standards require reporting acute changes in a client's condition that indicate instability to the supervising RN or provider.

Key Concept

Recognition and escalation of early shock indicators in postoperative clients

Question 499Question →

A practical nurse (PN) is caring for a client with osteoporosis who is scheduled to receive a weekly dose of oral risedronate. Which of the following actions must the PN take to safely administer this medication and reinforce client teaching? Select all that apply.

Select all that apply

Confirm the client's identity using two distinct identifiers prior to providing the medication.

Instruct the client to swallow the tablet whole with a full glass of plain water upon waking.

Administer the medication alongside the client's morning calcium carbonate supplement to maximize bone absorption.

Ensure the client maintains an upright seated or standing posture for at least 30 minutes after taking the dose.

Allow the client to return to a supine position in bed immediately if they report morning fatigue.

Accept a delegated task from the registered nurse to crush the tablet for administration via a nasogastric tube.

Show answer & explanation

Answer: Confirm the client's identity using two distinct identifiers prior to providing the medication.; Instruct the client to swallow the tablet whole with a full glass of plain water upon waking.; Ensure the client maintains an upright seated or standing posture for at least 30 minutes after taking the dose.

Answer

The correct actions include confirming the client's identity with two identifiers, instructing the client to swallow the tablet whole with a full glass of plain water upon waking, and ensuring the client remains upright for at least 30 minutes.

Risedronate is a bisphosphonate that must be taken in the morning on an empty stomach with 6 to 8 ounces of plain water to ensure proper gastrointestinal absorption. The client must remain upright for a minimum of 30 minutes to prevent the tablet from causing severe esophageal irritation or ulceration. Verifying two distinct client identifiers is a universal safety standard for all medication administration.

Step-by-Step Solution

Identify the pharmacological classification of risedronate.

Risedronate is recognized as a bisphosphonate used for osteoporosis.

Understanding the drug class dictates the specific administration and monitoring rules.

Determine the required safety protocols for bisphosphonate administration.

The medication requires an empty stomach, plain water, and an upright posture post-administration.

These strict parameters prevent poor drug absorption and severe esophageal ulceration.

Evaluate the distractors against LPN scope of practice and medication rights.

Identify that crushing the medication, co-administering with calcium, and allowing a supine position violate safe administration principles.

Safe practice requires recognizing dangerous drug interactions and inappropriate delegation.

Key Concept

Bisphosphonate Administration Principles and Scope of Practice

Question 500Question →

An individual is recovering in the surgical unit 48 hours after undergoing a right below-the-knee amputation. As part of basic care and comfort, which of the following interventions should be implemented? Select all that apply.

Select all that apply

Place the client in a prone position for 20 to 30 minutes multiple times a day.

Prop the right residual limb on a stack of pillows to continually minimize swelling.

Apply physical restraints immediately if the client becomes confused and reaches for the surgical dressing.

Assist the client with active range-of-motion exercises for the left leg and upper extremities.

Examine the skin around the residual limb carefully for early signs of pressure or breakdown.

Show answer & explanation

Answer: Place the client in a prone position for 20 to 30 minutes multiple times a day.; Assist the client with active range-of-motion exercises for the left leg and upper extremities.; Examine the skin around the residual limb carefully for early signs of pressure or breakdown.

Answer

The appropriate interventions include placing the client in a prone position, assisting with range-of-motion exercises for the unaffected extremities, and examining the skin around the residual limb.

The correct options focus on maintaining mobility and preventing complications. Placing the client in a prone position several times a day stretches the flexor muscles and prevents hip flexion contractures. Assisting with active range-of-motion exercises on unaffected limbs maintains muscle strength essential for future ambulation and transfers. Examining the skin around the surgical site is a vital basic care measure to detect early signs of breakdown and maintain tissue integrity.

Step-by-Step Solution

Analyze the client's postoperative timeframe (48 hours) and procedure (below-the-knee amputation) to identify specific mobility and skin care needs.

Determined that the initial 24-hour acute phase has passed, shifting focus to contracture prevention and mobility preservation.

Postoperative guidelines change based on the time elapsed since surgery, particularly regarding elevation.

Evaluate the positioning options against the risk of flexion contractures.

Identified that prone positioning prevents contractures, while prolonged pillow elevation causes them.

Preventing contractures is crucial for ensuring the client can successfully use a prosthesis in the future.

Review the safety and comfort measures regarding confusion and skin integrity.

Recognized that skin inspection is mandatory, while immediate physical restraint violates safety protocols.

Nurses must prioritize least restrictive measures for confusion and proactively monitor for pressure injuries.

Select all options that promote safe recovery, maintain unaffected muscle strength, and adhere to appropriate positioning guidelines.

Selected the options for prone positioning, range-of-motion exercises, and skin inspection.

These actions collectively support the objective of basic care and comfort within the practical nurse's scope.

Key Concept

Postoperative Positioning and Mobility for Amputations

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