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Question 501Question →

A practical nurse (PN) is assigned to a 78-year-old client who underwent an open reduction and internal fixation (ORIF) of a right femur fracture 24 hours ago. Which of the following actions by the PN demonstrate appropriate clinical judgment regarding the client's physiological adaptation? Select all that apply.

Select all that apply

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Answer: Report the sudden appearance of a petechial rash on the client's anterior chest to the registered nurse (RN).; Notify the RN if the client reports severe, progressive right leg pain that is unrelieved by the prescribed opioid analgesic.; Escalate a morning hemoglobin level of 7.1 g/dL (71 g/L) to the RN before attempting to ambulate the client.

Answer

The correct actions include reporting the petechial rash, notifying the RN about unrelenting severe pain, and escalating the critically low hemoglobin level.
The correct actions reflect sound clinical judgment by identifying classic signs of postoperative emergencies. A petechial rash is a hallmark of fat embolism syndrome. Severe pain unresponsive to opioid analgesics is a cardinal sign of acute compartment syndrome. A hemoglobin level of 7.1 g/dL indicates severe anemia and potential hemorrhage, making ambulation unsafe and requiring immediate RN notification for potential intervention.

Step-by-Step Solution

1
Analyze the client's postoperative risk profile.
The client is at high risk for complications such as fat embolism, compartment syndrome, and hemorrhage due to the femur fracture and recent surgery.
Identifying potential complications guides targeted data collection.
2
Evaluate each finding for signs of instability or systemic complications.
Petechiae, severe unrelenting pain, and a hemoglobin of 7.1 g/dL indicate critical physiological derangements.
The PN must differentiate between expected postoperative recovery and acute decompensation.
3
Apply the principles of prioritization.
Immediate escalation to the RN is required for findings involving airway/breathing (tachypnea), circulation (tachycardia, hypotension, low hemoglobin), and limb-threatening conditions (compartment syndrome).
Ensuring patient safety requires reporting critical findings before addressing secondary issues like routine incisional pain.

Key Concept

Recognition and prioritization of life-threatening postoperative complications following long bone fractures.
Question 502Question →

A practical nurse (PN) is assigned to collect a sterile urine specimen for culture and sensitivity from a client with a continuous indwelling urinary catheter. In what order should the PN perform the following actions to ensure specimen integrity and minimize the risk of infection? Arrange the steps in the correct chronological sequence.

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Answer

The correct sequence begins with clamping the tubing to collect fresh urine, followed by cleansing the port, aspirating the sample with a sterile syringe, transferring it to a sterile container, and finally unclamping the tubing to restore urinary flow.
Obtaining a sterile urine specimen from a closed drainage system requires a strict aseptic sequence to prevent catheter-associated urinary tract infections (CAUTIs) and ensure accurate laboratory results. The nurse must first clamp the tubing to allow fresh, uncontaminated urine to collect. Next, the port must be disinfected to prevent the introduction of pathogens. A sterile syringe is then used to safely aspirate the urine from the port. The sample is transferred to a sterile cup, and finally, the nurse must unclamp the tubing to prevent urinary retention and potential complications.

Step-by-Step Solution

1
Clamp the drainage tubing.
Fresh urine collects in the tubing.
Ensures the sample is recently produced rather than stagnant urine from the drainage bag.
2
Cleanse the collection port.
The external surface of the port is disinfected.
Prevents the introduction of bacteria into the closed catheter system.
3
Aspirate urine with a sterile syringe.
A sterile urine sample is obtained.
Maintains the closed drainage system integrity while safely extracting the specimen.
4
Transfer urine to a sterile container.
The sample is secured for transport.
Prevents contamination of the specimen en route to the laboratory.
5
Unclamp the drainage tubing.
Normal, continuous urine flow resumes.
Prevents dangerous bladder distention, discomfort, and potential renal complications.

Key Concept

Sterile Specimen Collection from a Closed Drainage System
Question 503Question →

A woman is resting in her hospital room a few hours after a right-sided modified radical mastectomy with axillary lymph node dissection. To promote optimal comfort and prevent complications, how should the practical nurse position the client's right arm?

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Answer: Elevated on a pillow so it rests above the level of the heart

Answer

The correct action is to keep the affected arm elevated on a pillow above the level of the heart.
Following a mastectomy with lymph node dissection, lymphatic drainage in the affected arm is significantly compromised. Elevating the arm on a pillow above the level of the heart uses gravity to promote lymphatic and venous return, thereby minimizing painful edema and enhancing client comfort.

Step-by-Step Solution

1
Identify the physiological impact of the specific surgical procedure.
The client underwent a right-sided mastectomy with axillary lymph node dissection, which disrupts normal lymphatic drainage pathways in the right arm.
Understanding the anatomical changes guides strategies for comfort and complication prevention.
2
Determine the mechanical goal for positioning the affected limb.
Gravity must be utilized to assist interstitial fluid and venous blood in returning from the right arm back toward the central circulation.
Preventing fluid accumulation (lymphedema) reduces tissue tension, minimizes pain, and promotes healing.
3
Select the positioning technique that best achieves this gravitational goal.
Elevating the entire right arm on a pillow so that it rests above the level of the client's heart is the most effective intervention.
This specific elevation angle creates a downward gradient for optimal fluid drainage.

Key Concept

Post-mastectomy lymphedema prevention through therapeutic positioning
Question 504Question →

A practical nurse (PN) is preparing to administer a scheduled dose of oral cephalexin to a client in an acute care facility. Upon entering the room, the PN observes that the client is not wearing an identification wristband. The client is alert, oriented, and states, 'I took the band off because it was scratching my arm.' Which action should the PN take?

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Answer: Obtain and apply a new identification wristband before administering the medication.

Answer

The nurse should obtain and apply a new identification wristband before administering the medication.
According to national patient safety standards, a nurse must verify a client's identity using two approved identifiers that match the client's physical identification band and the medication administration record. If the band is missing, it must be replaced before any medication is administered to ensure accurate verification and to comply with institutional barcode administration protocols.

Step-by-Step Solution

1
Assess the situation regarding patient identification requirements.
The client is missing their physical identification wristband.
Safe medication administration requires two patient identifiers verified against an official ID band and the medication administration record.
2
Determine the safest and most appropriate intervention to resolve the missing band.
A new identification band must be generated and applied to the client.
Facility policies require the ID band for barcode scanning and to prevent medication errors. Verbal confirmation alone is not a substitute for standard safety protocols.

Key Concept

Medication Rights Verification
Question 505Question →

A client with stable angina is prescribed a daily nitroglycerin transdermal patch. Place the following steps for applying the patch in the correct sequential order. (Move the steps into the correct order, starting with the first action.)

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Answer

The correct sequence is: put on gloves, remove the old patch, clean and dry a new site, label the new patch, and apply the new patch.
The correct sequence strictly adheres to safety protocols for transdermal medication administration. It begins with self-protection (gloves), prioritizes client safety by preventing overdose (removing the old patch), ensures optimal drug delivery (cleaning a new site), establishes accurate communication (labeling), and concludes with the actual administration (applying the patch).

Step-by-Step Solution

1
Put on clean gloves.
The nurse's hands are protected.
Nitroglycerin is readily absorbed through the skin and can cause adverse effects like headaches or hypotension in the nurse if handled with bare hands.
2
Remove the old patch and discard it properly.
The continuous delivery of the previous dose is stopped.
Failing to remove the old patch before applying a new one can lead to nitroglycerin toxicity and severe hypotension.
3
Cleanse and dry a new site.
A fresh, hairless area is prepared for the new medication.
Site rotation prevents skin breakdown, and a clean, dry surface is required for the adhesive to stick securely.
4
Label the new patch with date, time, and initials.
The patch is properly identified.
Labeling provides a clear timeline for medication administration and ensures the next nurse knows when the patch is due for removal.
5
Apply the new patch firmly to the skin.
The medication delivery process begins.
Pressing the patch firmly ensures it adheres fully and delivers the correct therapeutic dose.

Key Concept

Safe administration of transdermal medications requires protecting the nurse from exposure, preventing client toxicity by removing prior doses, and ensuring proper site rotation and documentation.
Question 506Question →

A practical nurse is preparing to transfer a client with right-sided weakness (hemiparesis) from the bed to a wheelchair. Arrange the following nursing actions in the correct sequence to ensure a safe transfer.

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Answer

The correct sequence for a safe transfer is: Position the wheelchair on the unaffected (left) side, lock the brakes on the bed and wheelchair, assist the client to sit on the edge of the bed, apply a transfer belt, and finally, instruct the client to bear weight on the strong leg and pivot.
A safe wheelchair transfer relies on proper preparation, biomechanics, and equipment safety. First, the environment must be prepared by placing the wheelchair on the client's unaffected (strong) side to maximize their participation. Next, all equipment brakes must be locked to prevent accidental movement. The client is then assisted to a sitting position to ensure hemodynamic stability and prevent orthostatic hypotension. Once the client is stable, a gait belt is applied to provide the nurse with a secure hold. Finally, the client uses their strong leg to pivot safely into the wheelchair.

Step-by-Step Solution

1
Position the wheelchair on the unaffected side.
The client will be able to reach for the chair with their strong arm.
Transferring toward the strong side ensures the client can support their own weight safely and maintain balance.
2
Lock the brakes on all equipment.
The bed and wheelchair are completely immobilized.
Unsecured equipment can roll backward during the transfer, causing a severe fall.
3
Assist the client to sit on the edge of the bed.
The client is in a seated position with feet on the floor.
Allows the client to regain equilibrium and prevents dizziness from orthostatic hypotension.
4
Apply the transfer belt.
The nurse has a secure grip on the client's waist.
Protects the client from falls and prevents the nurse from pulling on the client's weakened shoulder.
5
Pivot the client into the chair.
The client safely transitions from the bed to the wheelchair.
Using a pivot technique on the strong leg minimizes lifting for the nurse and promotes client independence.

Key Concept

Safe Client Transfer and Mobility Principles
Question 507Question →

A client who is three days postoperative following an abdominal laparotomy suddenly reports a "popping" sensation after a forceful cough. The practical nurse examines the surgical site and observes that the incision has separated and a loop of bowel is protruding. In which order should the nurse perform the following actions? (Arrange from first action to last)

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Answer

The correct sequence is to first stay with the client and call for help, then position them in low Fowler's with flexed knees, followed by covering the wound with sterile saline-moistened dressings, assessing vital signs, and finally documenting the event.
The correct sequence logically follows the principles of emergency nursing care: secure assistance without abandoning the client (call for help), immediately stabilize the mechanical threat using positioning (low Fowler's with bent knees), protect the compromised biological tissue (sterile moist dressings), monitor for systemic decompensation (vital signs), and conclude with accurate administrative recording (documentation).

Step-by-Step Solution

1
Recognize the medical emergency (wound evisceration).
Immediate identification that the client's internal organs are exposed and vulnerable to injury and infection.
Rapid recognition dictates that the client must not be left alone, necessitating a call for help as the absolute first action.
2
Implement immediate mechanical protection without requiring supplies.
The client is placed in low Fowler's position with knees flexed.
This specific position minimizes tension on the abdominal musculature, halting the further evisceration of the bowel.
3
Apply localized tissue protection once supplies are brought to the bedside.
The eviscerated bowel is covered with sterile, saline-moistened dressings.
Moist sterile dressings preserve tissue viability, prevent cellular necrosis, and form a barrier against environmental pathogens.
4
Assess systemic physiological adaptation and stability.
Vital signs are measured to establish a baseline during the acute event.
Monitoring blood pressure and pulse identifies the onset of hypovolemic shock or severe physiological distress.
5
Complete legal and medical record requirements.
The emergency event, interventions, and client status are documented.
Documentation must reflect chronological facts but is prioritized last to ensure direct client care is not delayed.

Key Concept

Prioritization of Nursing Interventions for Surgical Evisceration
Question 508Question →

An adult client is transferred to the step-down unit after undergoing a diagnostic cardiac catheterization utilizing the right femoral artery approach. When managing the client's basic care and comfort during the immediate recovery phase, which positioning intervention should the practical nurse implement?

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Answer: Maintain the client in a supine position with the right leg kept completely straight.

Answer

Maintain the client in a supine position with the right leg kept completely straight.
Following a femoral artery catheterization, the most critical intervention is maintaining the affected extremity straight and keeping the client supine (or with the head elevated no more than 30 degrees, depending on facility policy). The femoral artery is a major vessel under high pressure. Flexing the hip or knee can alter the tension on the puncture site, dislodge the newly formed clot, and lead to sudden, life-threatening internal or external arterial hemorrhage.

Step-by-Step Solution

1
Identify the specific procedure and access site from the clinical scenario.
The client had a cardiac catheterization via the right femoral artery.
Different vascular access sites require entirely different postoperative positioning protocols.
2
Determine the necessary positioning requirements for a femoral artery puncture.
The client must remain on strict bed rest with the affected extremity kept entirely extended (straight) and the head of the bed flat or minimally elevated.
Arterial pressure is high. Keeping the leg straight and the hip unflexed prevents dislodgment of the clot at the femoral site, preventing life-threatening hemorrhage.

Key Concept

Post-cardiac catheterization positioning for femoral access
Question 509Question →

Fifteen minutes after receiving an intramuscular injection of ceftriaxone for a respiratory infection, a client suddenly reports feeling dizzy and extremely restless. The practical nurse assesses the client and notes a heart rate of 122122 beats per minute and a blood pressure of 84/50 mmHg84/50\text{ mmHg}. Which action should the nurse take first?

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Answer: Activate the rapid response team and remain with the client to monitor their airway and breathing.

Answer

The correct action is to activate the rapid response team and remain with the client to monitor their airway and breathing.
The client's sudden onset of restlessness, dizziness, tachycardia, and hypotension shortly after receiving an antibiotic injection are classic signs of anaphylactic shock. Anaphylaxis is a life-threatening allergic reaction. According to the ABC (Airway, Breathing, Circulation) framework, the nurse must prioritize airway and circulation. The immediate and most appropriate action is to activate the rapid response team or emergency medical services while staying with the client to maintain the airway and provide support until advanced help arrives.

Step-by-Step Solution

1
Analyze the client's presentation and vital signs following the medication administration.
The client has developed tachycardia (122122 beats per minute), hypotension (84/50 mmHg84/50\text{ mmHg}), dizziness, and restlessness.
Identifying abnormal clinical data is the foundational step in recognizing an adverse pharmacological reaction.
2
Correlate the clinical findings with potential complications of the administered antibiotic.
The acute onset of these symptoms indicates anaphylactic shock, a severe and life-threatening allergic reaction to the ceftriaxone.
Antibiotics are a common cause of anaphylaxis, which rapidly compromises circulation and the airway.
3
Determine the priority nursing intervention based on the practical nurse scope of practice and the ABC framework.
The nurse must immediately call for emergency assistance while staying with the client to maintain airway patency.
In emergent situations, securing advanced medical help while providing basic life support is the highest priority.

Key Concept

Recognizing and responding to severe adverse medication reactions using the Airway, Breathing, Circulation (ABC) prioritization framework.
Estimated Time:1m 30s
Question 510Question →

A client who underwent a left total knee replacement yesterday requires assistance with morning care and positioning. Which actions by the practical nurse demonstrate correct understanding of postoperative comfort and safety measures? Select all that apply.

Select all that apply

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Answer: Place a rolled towel under the left lower leg to keep the heel completely suspended off the mattress.; Instruct the client to perform active ankle dorsiflexion and plantar flexion exercises hourly while awake.; Apply a cold therapy pack to the surgical site for 20-minute intervals as prescribed.

Answer

The correct actions are placing a towel under the lower leg to suspend the heel, instructing the client to perform active ankle exercises, and applying a cold therapy pack to the surgical site.
Appropriate postoperative care for a total knee replacement focuses on preventing venous stasis, protecting the skin, minimizing edema, and ensuring the knee heals in an extended position. Suspending the heel prevents pressure injuries while maintaining knee extension. Ankle exercises stimulate blood flow, reducing the risk of a deep vein thrombosis. Cold therapy causes local vasoconstriction, which decreases swelling and provides non-pharmacological pain relief.

Step-by-Step Solution

1
Analyze the client's postoperative status
The client is recovering from a left total knee replacement.
Understanding the specific surgical procedure is essential to determine safe joint positioning and expected basic care needs.
2
Evaluate each nursing intervention for appropriateness
Interventions that maintain knee extension, promote circulation, and reduce edema are appropriate. Interventions that promote knee flexion or are designed for different surgeries are inappropriate.
Proper postoperative positioning prevents severe complications such as joint contractures, deep vein thrombosis, and pressure injuries.
3
Select the correct basic care measures
Suspending the heel, performing ankle exercises, and applying cold therapy are the correct and safe measures.
These actions align with evidence-based practices for basic care and comfort following joint replacement surgery.

Key Concept

Postoperative Positioning and Basic Care for Total Knee Arthroplasty
Question 511Question →

A practical nurse is conducting a postoperative assessment on a 76-year-old client who underwent a total abdominal hysterectomy four hours ago. Which assessment findings should the nurse identify as expected physiological responses that can be managed with routine ongoing monitoring? Select all that apply.

Select all that apply

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Answer: Hypoactive bowel sounds auscultated in all four abdominal quadrants; Scant amount of dark red drainage on the intact surgical dressing; Client report of surgical site pain rated as a 4 on a 0 to 10 numeric scale

Answer

The expected postoperative findings that require only routine monitoring are hypoactive bowel sounds, a scant amount of dark red surgical drainage, and mild to moderate localized surgical site pain.
Following a major abdominal surgery, hypoactive bowel sounds are an expected physiological adaptation due to the effects of anesthesia and bowel manipulation. A scant amount of dark red (sanguineous) drainage is typical in the first few hours postoperatively. Mild to moderate localized incisional pain is also anticipated and can be managed with prescribed analgesics without requiring emergency escalation.

Step-by-Step Solution

1
Analyze the clinical scenario and the specific question being asked.
The client is 4 hours post-op from a major abdominal surgery. The question asks to identify expected, stable findings.
Understanding the timeline and surgical type is necessary to differentiate normal physiological adaptation from acute complications.
2
Evaluate each assessment finding against normal postoperative parameters.
Hypoactive bowel sounds, scant sanguineous drainage, and moderate pain are normal. Confusion, tachycardia with hypotension, and hypoxia are abnormal.
Systematic evaluation ensures critical signs of deterioration are not overlooked.
3
Select the options that represent expected, non-emergent findings.
The correct selections are the bowel sounds, the scant drainage, and the expected pain level.
These findings reflect appropriate physiological adaptation to surgery and can be safely managed with routine nursing care.

Key Concept

Differentiating expected postoperative physiological adaptations from early signs of acute complications in the older adult client.
Question 512Question →

An older adult client is recovering in the ambulatory care unit immediately following the surgical removal of a cataract in the right eye. To promote optimal comfort and prevent an increase in intraocular pressure, which positioning intervention should the practical nurse implement?

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Answer: Adjust the bed to a Semi-Fowler's position and assist the client to rest on their left side or back.

Answer

Adjust the bed to a Semi-Fowler's position and assist the client to rest on their left side or back.
Following cataract surgery, it is critical to prevent an increase in intraocular pressure. Adjusting the bed to a Semi-Fowler's position (head elevated 30 to 45 degrees) promotes venous drainage from the head, which naturally lowers pressure. Additionally, positioning the client either supine or on the non-operative side (the left side, since the right eye was operated on) prevents direct mechanical pressure on the delicate surgical site.

Step-by-Step Solution

1
Identify the surgical procedure and the affected side.
The client had a cataract removed from the right eye.
Knowing the operative side is essential for determining safe postoperative positioning and preventing direct pressure.
2
Determine the physiological goals following eye surgery.
The primary goals are to prevent an increase in intraocular pressure (IOP) and avoid direct physical contact with the surgical site.
Increased IOP or direct pressure can cause hemorrhage or disrupt the surgical incision, leading to severe complications.
3
Select the position that achieves these goals.
A Semi-Fowler's position facilitates venous drainage, and resting on the back or non-operative (left) side avoids direct pressure on the right eye.
This specific combination of bed elevation and side-lying protects the surgical eye while promoting comfort and safety.

Key Concept

Postoperative Positioning for Eye Surgery
Question 513Question →

A practical nurse (PN) is assigned to care for a client who is 24 hours postoperative following abdominal surgery and has a closed-wound drainage system (Jackson-Pratt drain). The PN is preparing to empty the drainage device. Arrange the following actions in the correct sequence to safely perform this procedure.

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Answer

The correct sequence is to first perform hand hygiene and don gloves, then unplug the port, pour the drainage into a measuring container, compress the empty bulb, and finally replace the plug while maintaining compression.
Maintaining a closed-wound drainage system requires strict adherence to infection control and the physical principles of negative pressure. Hand hygiene and gloving are the initial steps to prevent the introduction of pathogens. Opening the port allows the fluid to be emptied and measured, which is an essential nursing responsibility for monitoring postoperative bleeding or fluid shifts to reduce risk potential. Finally, squeezing the bulb and sealing it creates a vacuum, which restores the gentle, continuous suction needed to remove fluid from the surgical site, thereby reducing the risk of hematoma formation and promoting wound healing.

Step-by-Step Solution

1
Perform hand hygiene and put on clean gloves.
Pathogen transmission risk is minimized.
Standard precautions must always be the first step when preparing to handle bodily fluids or invasive devices.
2
Unplug the drainage port on the collection bulb.
The sealed vacuum is released.
The system must be opened to allow the accumulated fluid to be emptied.
3
Pour drainage into a graduated measuring container.
Fluid is collected for accurate measurement.
Careful monitoring of postoperative drainage volume is required to assess for risk of bleeding or excessive fluid loss.
4
Compress the empty bulb fully.
Air is expelled from the bulb.
The bulb must be flattened to prepare for re-establishing negative pressure.
5
Replace the plug into the drainage port while the bulb is compressed.
Negative pressure suction is re-established.
Sealing the flattened bulb creates the gentle vacuum needed to continuously draw fluid away from the surgical site.

Key Concept

Maintaining and Emptying Closed-Wound Drainage Systems
Question 514Question →

An adult client is receiving a scheduled course of subcutaneous enoxaparin. During data collection, the client reports passing dark, tarry stools. The practical nurse notes that the client's latest laboratory results show a platelet count of 82,000/mm382,000/\text{mm}^3, and current vital signs include a heart rate of 112 beats/min112\text{ beats/min} and a blood pressure of 94/58 mmHg94/58\text{ mmHg}. Which of the following is the priority action for the practical nurse?

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Answer: Withhold the enoxaparin dose and urgently notify the registered nurse of the assessment findings.

Answer

The correct action is to withhold the enoxaparin dose and urgently notify the registered nurse of the assessment findings.
The correct answer demonstrates the practical nurse's responsibility to recognize critical pharmacological safety concerns and act strictly within their scope of practice. The client's dark, tarry stools, tachycardia, hypotension, and thrombocytopenia (82,000/mm382,000/\text{mm}^3) are classic signs of gastrointestinal hemorrhage and a severe adverse reaction to enoxaparin. The absolute priority is to withhold the anticoagulant to prevent worsening the hemorrhage and to immediately alert the registered nurse so that emergency medical interventions can be initiated.

Step-by-Step Solution

1
Analyze the client's clinical presentation and laboratory data.
The client presents with dark, tarry stools (melena), tachycardia, borderline hypotension, and a low platelet count (82,000/mm382,000/\text{mm}^3).
Identifying abnormal assessment findings is essential to determine the safety of continuing a prescribed pharmacological therapy.
2
Evaluate the mechanism and adverse effects of the prescribed medication.
Enoxaparin is an anticoagulant; known severe adverse effects include hemorrhage and heparin-induced thrombocytopenia (HIT).
Connecting the medication's physiological effects to the client's symptoms reveals an active, life-threatening complication.
3
Determine the appropriate nursing intervention within the practical nurse's scope of practice.
The practical nurse must withhold the contraindicated medication and immediately escalate the critical findings to the registered nurse or provider.
Practical nurses cannot alter prescribed doses or ignore critical signs of shock; ensuring immediate client safety and proper escalation is the top priority.

Key Concept

Recognizing adverse effects of anticoagulants (active bleeding and thrombocytopenia) and applying appropriate LPN scope of practice actions.
Question 515Question →

A client is recovering in the surgical unit 88 hours after a right total knee arthroplasty. The practical nurse evaluates the client and records a heart rate of 114114 beats/min, a blood pressure of 94/5694/56 mm Hg, and a respiratory rate of 1818 breaths/min. The client states their pain is currently manageable. Based on these findings, which of the following actions should the practical nurse take? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Inspect the surgical dressing and portable wound suction device for excessive blood accumulation.; Escalate the clinical assessment findings to the supervising registered nurse without delay.; Check the client's postoperative laboratory results for recent hemoglobin and hematocrit values.

Answer

The correct actions are to inspect the surgical dressing and wound suction device for bleeding, escalate the findings to the supervising registered nurse without delay, and check the postoperative hemoglobin and hematocrit laboratory results.
The client's tachycardia and hypotension postoperatively are early indicators of hypovolemia or internal bleeding. The practical nurse must prioritize client safety by assessing the surgical site for active bleeding, reviewing recent hemoglobin and hematocrit levels to evaluate blood loss, and immediately escalating these critical findings to the registered nurse for further medical management.

Step-by-Step Solution

1
Analyze the client's vital signs and postoperative timeline.
A heart rate of 114 beats/min and blood pressure of 94/56 mm Hg at 8 hours postoperative indicate potential early hypovolemic or hemorrhagic shock.
Tachycardia and mild hypotension are initial compensatory mechanisms when fluid or blood volume is actively being lost.
2
Determine the priority nursing interventions for suspected hypovolemia.
The nurse must identify the source of potential fluid loss by assessing the surgical site and gathering relevant laboratory data.
Assessing the surgical site for active bleeding and reviewing blood counts (Hgb/Hct) provide crucial data about the severity of blood loss.
3
Evaluate the role and scope of the practical nurse in this scenario.
The practical nurse must report these abnormal, potentially critical findings directly to the registered nurse.
Initiating emergency protocols and modifying the overall medical plan of care falls under the registered nurse's scope, requiring immediate collaboration.

Key Concept

Early recognition of hypovolemic shock and appropriate escalation within the practical nursing scope of practice.
Question 516Question →

While coordinating care on a busy inpatient unit, a practical nurse performs several medication-related tasks throughout the shift. Which of the following actions reflect adherence to established pharmacological safety standards and the appropriate scope of practice? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Verifying a client's most recent serum potassium level prior to dispensing an oral loop diuretic.; Withholding a scheduled dose of metoprolol and notifying the registered nurse when the client's apical pulse is 48 beats per minute.; Asking a client to state their full name and comparing it with their identification band prior to handing them their pills.

Answer

The actions that demonstrate safe pharmacological practice are: verifying the potassium level before giving a loop diuretic, withholding metoprolol for a low heart rate and notifying the RN, and having the client state their name while checking their identification band.
Safe pharmacological therapy requires the practical nurse to operate within their defined scope of practice while strictly adhering to safety checks. This includes verifying relevant lab values (like potassium for diuretics), checking vital signs and knowing when to withhold medication (like heart rate for beta-blockers), and strictly using two acceptable patient identifiers (like asking the client to state their name and checking the ID band).

Step-by-Step Solution

1
Evaluate each action against the 'rights of medication administration' and safety protocols.
Checking identifiers (name/ID band) and verifying relevant lab values (potassium) align with the rights of medication administration.
Standard safety protocols require two active identifiers and pre-administration assessment of pertinent labs.
2
Determine if each action falls within the legal scope of practice for a practical nurse.
Withholding medication for abnormal vitals and reporting to the RN is within scope. Administering IV push medications is out of scope.
Practical nurses must recognize when to hold a medication based on vital sign parameters but are restricted from performing IV push administrations in most jurisdictions.
3
Assess pre-administration screening practices.
Failing to check for allergies before giving a vaccine is a major safety violation.
Immunization protocols mandate allergy screening to prevent anaphylactic reactions.

Key Concept

Medication Safety and Practical Nurse Scope of Practice
Estimated Time:1m 30s
Question 517Question →

A practical nurse is providing basic care for an adolescent client who is on strict bed rest following a spinal fusion surgery for scoliosis. Which of the following actions should the nurse implement to promote comfort and safety? Select all that apply.

Select all that apply

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Answer: Keep the client's spine in a straight, neutral alignment during routine care.; Utilize the logrolling technique with the assistance of additional staff when turning the client.; Offer a fracture bedpan for elimination needs to minimize movement of the lower back.

Answer

The appropriate actions are to keep the spine in a straight alignment, utilize the logrolling technique with additional staff assistance, and offer a fracture bedpan.
Following a spinal fusion, it is essential to maintain the spine in a neutral, straight alignment to prevent injury to the surgical site and promote proper healing. Utilizing the logrolling technique with multiple staff members allows the entire body to turn as a single unit, completely avoiding any twisting of the spine. Furthermore, using a fracture bedpan is appropriate for basic care because its flat lip requires significantly less lifting of the pelvis, minimizing stress on the lower back during elimination.

Step-by-Step Solution

1
Analyze the client's condition and post-operative requirements.
The client had a spinal fusion and is on strict bed rest, requiring maintenance of spinal alignment to prevent hardware failure and spinal cord injury.
Spinal fusion requires the vertebral column to remain immobilized and straight during the initial healing phase.
2
Evaluate each intervention for safety, proper body mechanics, and scope of practice.
Logrolling, keeping the spine neutral, and using a fracture bedpan maintain proper alignment. High-Fowler's position, twisting, and delegating assessment are contraindicated.
Improper positioning compromises the surgical site; additionally, assessing incisions falls strictly outside the scope of unlicensed assistive personnel.

Key Concept

Post-operative basic care, positioning, and safety following spinal fusion surgery.
Question 518Question →

During a shift, a practical nurse reviews the medication administration record for a client being treated for a pulmonary embolism. The client weighs 165 lb165\text{ lb}. The provider has prescribed a subcutaneous injection of enoxaparin sodium at 1 mg/kg1\text{ mg/kg} every 12 hours12\text{ hours}. The medication is supplied in a prefilled syringe containing 100 mg/1 mL100\text{ mg}/1\text{ mL}. How many mL\text{mL} should the nurse administer? Record your answer to the nearest hundredth. Do not include units in your answer.

Show answer & explanation

Answer: 0.75

Answer

0.75
To determine the correct volume to administer, first convert the client's weight to kilograms (165÷2.2=75 kg165 \div 2.2 = 75\text{ kg}). Next, determine the total dose required by multiplying the weight by the prescribed rate (75×1=75 mg75 \times 1 = 75\text{ mg}). Finally, divide the required dose by the available concentration to find the volume in milliliters (75÷100=0.75 mL75 \div 100 = 0.75\text{ mL}).

Step-by-Step Solution

1
Convert the client's weight to kilograms
75 kg75\text{ kg}
The prescription is weight-based in kilograms, so the pounds must be converted (165÷2.2=75165 \div 2.2 = 75).
2
Calculate the required medication dose
75 mg75\text{ mg}
Multiply the client's weight in kilograms by the prescribed dosage rate (75×1=7575 \times 1 = 75).
3
Calculate the volume to administer
0.75 mL0.75\text{ mL}
Divide the desired dose by the available concentration to find the required liquid volume (75÷100×1=0.7575 \div 100 \times 1 = 0.75).

Key Concept

Weight-based medication dosage and volume calculation
Question 519Question →

A practical nurse receives a client who just returned to the nursing unit following a diagnostic lumbar puncture. To prevent a common post-procedure complication and promote client comfort, which positioning action should the nurse implement?

Show answer & explanation

Answer: Maintain the client in a flat, supine position for several hours.

Answer

The client should be maintained in a flat, supine position for several hours following a lumbar puncture.
Following a lumbar puncture, the client must remain flat in a supine position for a prescribed period, usually 4 to 8 hours. This neutral, horizontal alignment prevents the leakage of cerebrospinal fluid (CSF) from the puncture site, which is the primary cause of severe, debilitating spinal headaches.

Step-by-Step Solution

1
Identify the procedure the client just underwent.
The client had a diagnostic lumbar puncture.
Different diagnostic procedures require specific postoperative positioning to prevent complications.
2
Determine the primary post-procedure complication associated with a lumbar puncture.
The main complication is a post-dural puncture headache (spinal headache) caused by cerebrospinal fluid (CSF) leakage.
Understanding the physiological risk guides the choice of nursing interventions.
3
Select the appropriate positioning to prevent this complication.
Keeping the client flat and supine helps maintain equalized pressure in the central nervous system, minimizing CSF leakage.
Gravity causes more CSF to leak from the puncture site if the head is elevated.

Key Concept

Post-procedure Positioning for Lumbar Puncture
Estimated Time:1m 0s
Question 520Question →

While performing an afternoon assessment on a client who underwent a total thyroidectomy earlier in the day, the licensed practical nurse notes the client has become visibly restless. The client's voice is increasingly hoarse, and they mention a new sensation of tightness in the anterior neck area. Current vital signs show a heart rate of 114 beats/min and a respiratory rate of 24 breaths/min. Which action should the nurse take first?

Show answer & explanation

Answer: Alert the registered nurse immediately and verify that an emergency tracheostomy tray is at the bedside.

Answer

The nurse should immediately alert the registered nurse and ensure emergency airway equipment is present.
Following a thyroidectomy, a new sensation of neck tightness, hoarseness, restlessness, tachycardia, and tachypnea are classic early indicators of a developing hematoma or laryngeal edema. This is a life-threatening complication that can rapidly occlude the airway. The practical nurse must prioritize airway management by immediately escalating these findings to the registered nurse and ensuring emergency equipment (such as a tracheostomy tray) is readily available to mitigate the risk of respiratory arrest.

Step-by-Step Solution

1
Analyze the client's new symptoms: restlessness, hoarseness, neck tightness, tachycardia (114 beats/min), and tachypnea (24 breaths/min).
Recognize these findings as indicative of a developing neck hematoma or laryngeal edema.
Following a thyroidectomy, bleeding into the tissue spaces can rapidly compress the trachea, presenting initially as local pressure and subtle respiratory distress.
2
Determine the appropriate priority intervention based on the practical nursing scope of practice.
Identify that the situation represents a life-threatening airway emergency requiring immediate escalation.
Airway compromise requires advanced assessment, potential rapid response team activation, and possible emergency surgical intervention.
3
Select the action that protects the client's safety.
Notify the RN immediately and confirm the availability of a tracheostomy tray.
This action ensures the team is aware of the critical change and is prepared for immediate advanced airway management.

Key Concept

Recognizing and Escalating Early Signs of Postoperative Complications
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