Examkin

All practice questions

2933 questions

All types2,933Multiple choice1,506Multiple select653Numeric68Matching70Ordering636
Question 521Question →

A client is recovering from a subtotal thyroidectomy performed earlier in the day. During routine data collection, the practical nurse notes the client's heart rate is 108 beats/min and blood pressure is 102/64 mm Hg. The client states, "My neck feels very tight, and it is getting a little hard to swallow." Which action should the practical nurse take immediately?

Show answer & explanation

Answer: Inspect the surgical dressing and the back of the client's neck for swelling or excessive bleeding.

Answer

The practical nurse should immediately inspect the surgical dressing and the back of the client's neck for swelling or excessive bleeding.
After a thyroidectomy, a feeling of neck tightness, difficulty swallowing, tachycardia, and a dropping blood pressure are classic signs of a surgical site hemorrhage and expanding hematoma. This life-threatening emergency can quickly compress the trachea and block the airway. The practical nurse must immediately inspect the dressing and the back of the neck (where blood can pool dependently) to gather data before promptly notifying the registered nurse or rapid response team.

Step-by-Step Solution

1
Analyze the client's vital signs and reported symptoms.
The client has tachycardia (108 beats/min), borderline hypotension (102/64 mm Hg), neck tightness, and difficulty swallowing.
Identifying abnormal data is the critical first step in recognizing a sudden clinical change.
2
Correlate the findings with potential postoperative complications of a thyroidectomy.
These findings point to an expanding hematoma, which can cause both hypovolemic shock (tachycardia, low blood pressure) and airway compression (neck tightness, difficulty swallowing).
Connecting signs and symptoms to underlying pathophysiological complications determines the severity of the situation.
3
Determine the priority nursing action based on the Airway, Breathing, and Circulation (ABC) framework.
The immediate priority is to visually assess the surgical site for bleeding and swelling before quickly escalating to the RN or provider.
Focused data collection must occur to confirm the complication and guide life-saving emergency interventions.

Key Concept

Recognition of postoperative hemorrhage and airway compromise
Question 522Question →

A client arrives at the medical-surgical unit after undergoing a percutaneous liver biopsy. The registered nurse has completed the initial admission assessment and delegates ongoing care to the licensed practical nurse. Which actions are essential for the practical nurse to perform to minimize the risk of complications? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Position the client in a right lateral decubitus position using a small pillow or rolled towel under the costal margin.; Assess the client's vital signs every 15 minutes during the first hour and compare them to the pre-procedure baseline.; Inspect the biopsy puncture site and surrounding skin for overt bleeding or expanding hematoma during each assessment.

Answer

The correct actions include positioning the client on the right side to apply pressure to the liver, monitoring vital signs every 15 minutes initially, and frequently inspecting the puncture site for bleeding.
Following a percutaneous liver biopsy, the primary risk is hemorrhage because the liver is a highly vascular organ. Positioning the client on the right side compresses the liver capsule against the chest wall, promoting hemostasis. Frequent vital sign monitoring (every 15 minutes for the first hour) and direct inspection of the puncture site are critical to rapidly identify signs of bleeding or hypovolemic shock.

Step-by-Step Solution

1
Analyze the client's clinical situation and procedure.
The client has just undergone a percutaneous liver biopsy.
The liver is a highly vascular organ, making severe hemorrhage the most critical potential complication following a biopsy.
2
Evaluate each nursing action for its impact on reducing the risk of hemorrhage.
Right-sided positioning, frequent vital sign checks, and direct site inspection actively mitigate or detect bleeding.
Applying external pressure and closely monitoring for early signs of shock are evidence-based standards of care for this procedure.
3
Identify actions that fall outside the LPN scope of practice or actively increase risk.
Delegating the initial assessment to UAP, ignoring borderline vital signs, and placing the client in a high-Fowler's position are incorrect and unsafe actions.
These actions fail to appropriately monitor the client or position them to prevent bleeding.

Key Concept

Reduction of Risk Potential: Post-Procedure Liver Biopsy Care
Question 523Question →

A practical nurse is reinforcing teaching for a client who is non-weight-bearing on the right leg and is learning to ascend stairs using crutches without a handrail. In what order should the practical nurse instruct the client to perform the following actions? Arrange the actions in the correct chronological sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: Assume the tripod position, transfer body weight to the crutches, advance the unaffected leg up onto the step, shift body weight to the unaffected leg, and finally bring the affected leg and both crutches up to the step.
When ascending stairs with crutches, the standard safety protocol is 'up with the good, down with the bad.' The client must first establish balance in the tripod position and transfer weight to the crutches. This allows the unaffected (strong) leg to be lifted onto the step safely. Once the strong leg is on the step, the client shifts their weight onto it, using the strong leg to power the body upward while simultaneously bringing the crutches and the affected (weak) leg up to the same step.

Step-by-Step Solution

1
Assume the tripod position at the bottom of the stairs.
The client achieves a stable base of support.
Provides necessary balance before initiating any upward movement.
2
Transfer body weight entirely onto the crutches.
The legs are freed from bearing weight.
Allows the unaffected leg to be lifted without the client losing balance.
3
Advance the unaffected leg up onto the step.
The strong leg is positioned on the higher level.
The unaffected leg must lead when going up to provide the power to lift the body (often remembered as 'up with the good').
4
Shift body weight from the crutches to the unaffected leg.
The strong leg now supports the entire body weight.
Frees the arms and crutches so they can be lifted to the next step.
5
Bring the affected leg and both crutches up to the step.
The client successfully completes one step ascent.
Completes the motion while safely keeping the affected leg non-weight-bearing.

Key Concept

Ascending stairs with crutches (non-weight-bearing)
Question 524Question →

During morning rounds, a practical nurse (PN) evaluates a client who had an open appendectomy 6 hours earlier. The baseline vital signs recorded upon transfer from the post-anesthesia care unit were a blood pressure of 122/78 mm Hg and a heart rate of 76 beats/min. The current vital signs show a blood pressure of 100/64 mm Hg and a heart rate of 108 beats/min. The client complains of feeling slightly dizzy. Which action should the PN take first?

Show answer & explanation

Answer: Report the assessment findings to the supervising registered nurse (RN).

Answer

Report the assessment findings to the supervising registered nurse (RN).
The client is exhibiting early signs of compensatory shock, likely due to postoperative hemorrhage or hypovolemia. The combination of a decreasing blood pressure, an increasing heart rate, and dizziness requires immediate escalation to the RN or provider for further assessment and intervention to prevent clinical deterioration.

Step-by-Step Solution

1
Analyze the client's current vital signs compared to the baseline.
The blood pressure has dropped, and the heart rate has increased significantly.
Comparing current data to baseline helps identify downward trends.
2
Interpret the clinical significance of the findings.
Tachycardia, hypotension, and dizziness in a postoperative client are early indicators of hypovolemia or hemorrhage.
Recognizing postoperative complications is a key aspect of reducing risk potential.
3
Determine the appropriate scope of practice for the PN.
The PN must report these abnormal findings to the RN for comprehensive assessment and medical intervention.
Abnormal physiological trends that indicate instability require immediate escalation.

Key Concept

Early Recognition of Postoperative Hypovolemia
Question 525Question →

A practical nurse (PN) is reviewing the medication administration record for an adult client with a history of heart failure. The client is scheduled to receive oral digoxin and oral furosemide. Additionally, a new prescription for intravenous (IV) push furosemide was just added to the chart. The client's morning vital signs include a heart rate of 56 beats/min56\text{ beats/min} and a blood pressure of 118/74 mm Hg118/74\text{ mm Hg}. The morning serum potassium level is 3.1 mEq/L3.1\text{ mEq/L}. Which of the following actions should the PN take? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Withhold the scheduled dose of oral digoxin.; Notify the registered nurse (RN) regarding the client's vital signs and laboratory results.; Document the withheld medications and the clinical reasons for withholding them in the electronic health record.

Answer

The correct actions are to withhold the scheduled dose of oral digoxin, notify the registered nurse (RN) regarding the vital signs and laboratory results, and document the withheld medications and the reasons for withholding them in the electronic health record.
The practical nurse must apply clinical knowledge and strictly adhere to their scope of practice. Oral digoxin should be withheld because the client's heart rate is below 60 beats/min, and the presence of hypokalemia (potassium 3.1 mEq/L) dangerously increases the risk of digoxin toxicity. Oral furosemide must also be withheld because it is a potassium-wasting diuretic that would exacerbate the low potassium level. The RN must be immediately notified of these critical findings so the provider can adjust the treatment plan. Finally, standard nursing practice requires thorough documentation whenever a scheduled medication is withheld, including the rationale.

Step-by-Step Solution

1
Evaluate the client's vital signs against medication parameters.
The heart rate is 56 beats/min. Digoxin must be held for a heart rate less than 60 beats/min in an adult.
Digoxin has a negative chronotropic effect (slows heart rate) and could cause symptomatic bradycardia.
2
Evaluate the client's laboratory results against the scheduled medications.
The serum potassium is 3.1 mEq/L (normal: 3.5-5.0 mEq/L). Furosemide wastes potassium and must be held. Hypokalemia also increases the risk of digoxin toxicity.
Administering furosemide will exacerbate the hypokalemia, and the low potassium makes the heart muscle more sensitive to digoxin, increasing toxicity risk.
3
Determine the practical nurse's scope of practice for the new IV push prescription.
IV push furosemide cannot be administered by the PN.
The administration of IV push medications requires advanced assessment and clinical judgment reserved for the RN scope of practice.
4
Formulate a safe clinical response.
Hold the oral digoxin and furosemide, decline the IV push medication, notify the RN, and accurately document the withheld medications.
This comprehensively ensures client safety, maintains adherence to the scope of practice, and fulfills legal documentation standards.

Key Concept

Medication administration safety, LPN/VN scope of practice, and critical lab value interpretation
Question 526Question →

A practical nurse (PN) is collecting data on an 82-year-old client who is receiving intravenous antibiotics for severe pyelonephritis. Which of the following assessment findings should the PN identify as early indicators of systemic decompensation and potential septic shock that require immediate notification to the registered nurse (RN)? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Heart rate of 118 beats per minute; New-onset confusion and restlessness; Respiratory rate of 28 breaths per minute

Answer

The findings that indicate early systemic decompensation and require immediate RN notification are a heart rate of 118 beats per minute, new-onset confusion and restlessness, and a respiratory rate of 28 breaths per minute.
In the early (compensatory) stages of septic shock and systemic inflammatory response syndrome (SIRS), the body attempts to maintain cardiac output and oxygen delivery to tissues. This physiological adaptation results in an increased heart rate (tachycardia) and an increased respiratory rate (tachypnea). Additionally, older adults are highly sensitive to slight decreases in cerebral oxygenation and perfusion, making new-onset confusion or restlessness one of the earliest and most reliable indicators of systemic deterioration. These findings require immediate intervention to prevent irreversible organ damage.

Step-by-Step Solution

1
Identify the client's current diagnosis and primary risks.
The client has severe pyelonephritis (a kidney infection), which places them at high risk for systemic inflammatory response syndrome (SIRS) and septic shock.
Understanding the clinical context helps distinguish between expected disease symptoms and life-threatening complications.
2
Evaluate the assessment findings to distinguish between localized expected symptoms and systemic emergency signs.
Flank pain and cloudy urine are expected local signs. Tachycardia, tachypnea, and altered mental status are abnormal systemic signs.
The PN must differentiate baseline or expected disease manifestations from acute changes that indicate deterioration.
3
Prioritize the findings based on Airway, Breathing, and Circulation (ABC) principles.
The elevated heart rate, elevated respiratory rate, and new-onset confusion represent early circulatory and respiratory compromise (shock) and must be reported immediately.
Systemic shock is a life-threatening emergency that takes precedence over expected localized infection signs or routine pain management.

Key Concept

Early Recognition of Septic Shock and SIRS
Estimated Time:1m 30s
Question 527Question →

A practical nurse is caring for a client with atrial fibrillation who is prescribed a daily dose of oral warfarin. The client is also scheduled to receive a seasonal influenza vaccine. Upon reviewing the morning laboratory results, the nurse notes an international normalized ratio (INR) of 6.56.5. Which of the following actions is the priority for the practical nurse?

Show answer & explanation

Answer: Withhold the scheduled oral warfarin and immediately report the INR result to the registered nurse.

Answer

The priority action is to withhold the scheduled oral warfarin and immediately report the critical INR result to the registered nurse.
The client's international normalized ratio (INR) of 6.56.5 is significantly elevated above the standard therapeutic range of 2.0 to 3.0 for a client with atrial fibrillation, indicating a critical risk for hemorrhage. The priority action for the practical nurse is to ensure client safety by withholding the scheduled warfarin and immediately escalating this critical laboratory value to the registered nurse or provider for further medical orders.

Step-by-Step Solution

1
Evaluate the client's morning laboratory results against the scheduled medications.
The INR of 6.5 is identified as critically high compared to the normal therapeutic range.
Safe medication administration requires verifying that relevant laboratory values are within safe limits prior to administration.
2
Determine the appropriate clinical intervention based on the abnormal finding.
The scheduled dose of warfarin must be withheld.
Administering additional warfarin would further increase the INR and place the client at an extreme risk for spontaneous hemorrhage.
3
Identify the correct action within the practical nurse scope of practice.
The nurse must report the critical value to the supervising registered nurse or provider.
Practical nurses are responsible for monitoring client data, recognizing critical abnormalities, and escalating them appropriately to ensure client safety.

Key Concept

Monitoring for adverse effects and escalating critical laboratory values associated with pharmacological therapies.
Question 528Question →

During the evening shift, a practical nurse answers a call light for a client who underwent a subtotal thyroidectomy earlier that morning. The client is experiencing mild incisional aching and requests assistance with getting comfortable for sleep. Which nursing action is the priority for ensuring this client's safety and comfort?

Show answer & explanation

Answer: Arrange the bed in a semi-seated posture and use pillows to continuously support the head and neck in a neutral alignment.

Answer

The correct action is to place the client in a semi-seated position while using pillows to strategically maintain the head and neck in a neutral alignment.
Following a thyroidectomy, maintaining a semi-seated position (such as semi-Fowler's) with meticulous head and neck support is essential. This neutral alignment minimizes mechanical tension on the suture line, facilitates venous drainage to decrease tissue edema, and prevents both flexion and hyperextension. Ultimately, this basic care measure is the most effective way to secure the airway and provide comfort.

Step-by-Step Solution

1
Analyze the surgical procedure and identify its inherent postoperative risks.
A thyroidectomy involves an incision in the anterior neck, placing the client at high risk for localized tissue edema, hematoma formation, and subsequent respiratory distress.
Understanding the anatomical location of the surgery highlights the immediate threats to airway patency.
2
Determine the optimal basic care intervention that addresses both comfort and safety.
Positioning the client upright (semi-Fowler's) with the head and neck carefully supported in a neutral position is identified as the priority nursing action.
This alignment prevents both hyperextension (which stretches the fresh incision) and severe flexion (which compresses the trachea), thereby decreasing edema and protecting the airway.
3
Evaluate the distractors against foundational nursing safety principles.
The alternative actions involve dangerous hyperextension, neglecting the airway to prioritize medication, or offering non-therapeutic false reassurance.
Systematically ruling out unsafe actions confirms the absolute priority of mechanical airway protection in postoperative basic care.

Key Concept

Post-Thyroidectomy Care and Airway Protection
Question 529Question →

A practical nurse (PN) is preparing to perform open tracheostomy suctioning for a stable adult client. In what order should the PN perform the following actions to reduce the risk of hypoxia and airway trauma? Arrange the steps in the correct chronological sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence for tracheostomy suctioning is: Assess baseline respiratory status, hyperoxygenate the client, insert the catheter without suction, apply intermittent suction during withdrawal, and finally reassess the respiratory status.
Safe tracheostomy suctioning follows a strict protocol to mitigate risks such as hypoxia and tissue trauma. The process begins with a baseline assessment to ensure the procedure is necessary and to provide comparative data. Next, hyperoxygenation is mandatory to build the client's oxygen reserve. The catheter is then carefully inserted without suction to protect the delicate tracheal mucosa. Active, intermittent suction is applied only while withdrawing the catheter (typically for 10 seconds or less) to safely clear the secretions. Finally, a post-procedure reassessment is conducted to ensure the intervention was successful and the client has stabilized.

Step-by-Step Solution

1
Assess the client's baseline respiratory rate, breath sounds, and oxygen saturation.
Establishes baseline clinical data.
Provides a baseline to compare against after the procedure and confirms that suctioning is indicated.
2
Hyperoxygenate the client.
Increases oxygen reserves in the lungs and bloodstream.
Compensates for the oxygen that will be removed from the airway along with secretions during active suctioning.
3
Insert the sterile suction catheter without applying suction.
Safely advances the catheter to the appropriate depth.
Applying suction during insertion aggressively pulls on the tracheal lining, causing mucosal damage and bleeding.
4
Apply intermittent suction while rotating and withdrawing the catheter.
Removes mucus and secretions from the airway.
Intermittent suction combined with rotation clears all sides of the airway safely while limiting the duration of oxygen deprivation.
5
Reassess the client's respiratory status.
Determines the clinical outcome of the procedure.
Verifies that the airway is clear and confirms the client has returned to or improved beyond baseline oxygenation.

Key Concept

Airway Management and Hypoxia Prevention
Question 530Question →

During afternoon rounds, a 71-year-old client hospitalized for bacterial pneumonia suddenly becomes restless, rubs their chest, and asks to speak with a deceased relative. The client's family states the client was completely lucid just an hour ago. Current vital signs reveal a heart rate of 114 beats per minute, a respiratory rate of 26 breaths per minute, and a blood pressure of 102/60 mm Hg. Which action should the nurse prioritize?

Show answer & explanation

Answer: Measure the client's oxygen saturation and evaluate respiratory effort

Answer

The correct action is to measure the client's oxygen saturation and evaluate respiratory effort.
The correct answer addresses the most critical physiological need first. In older adults, acute hypoxia often manifests as sudden confusion, agitation, or restlessness. Given the client's diagnosis of bacterial pneumonia and vital signs indicating tachycardia and tachypnea, assessing oxygenation status (Airway and Breathing) is the immediate priority.

Step-by-Step Solution

1
Analyze the client's baseline versus current presentation.
The client transitioned from lucid to suddenly restless and confused, alongside an increased heart rate (114) and respiratory rate (26).
Identifying sudden deviations from baseline helps determine if the situation is acute and life-threatening.
2
Apply prioritization frameworks (ABCs and Maslow's Hierarchy).
The most immediate life-threatening physiological need is adequate oxygenation (Airway and Breathing).
Infection (pneumonia) impairs gas exchange. Hypoxia often presents as new-onset restlessness, anxiety, and confusion in older adults.
3
Select the nursing action that directly addresses the highest priority need.
Assessing oxygenation status (pulse oximetry and respiratory effort) is the priority over addressing pain or reorienting the client.
Without adequate oxygenation, all other interventions will fail to stabilize the client.

Key Concept

Prioritizing ABCs and recognizing hypoxia-induced delirium in older adults.
Estimated Time:1m 0s
Question 531Question →

While walking past a client's room, a practical nurse observes a client who is receiving continuous enteral tube feeding suddenly coughing vigorously and struggling to breathe. Which sequence of actions should the practical nurse implement? Arrange the actions in the correct order from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The practical nurse should first stop the enteral feeding, followed by elevating the head of the bed, then obtaining vital signs and oxygen saturation, and finally notifying the supervising registered nurse.
According to the airway, breathing, and circulation (ABC) prioritization framework, the practical nurse must first stop the immediate threat to the airway (the continuous enteral feeding). Next, positioning the client upright facilitates breathing and lung expansion. Once the client's airway and breathing are stabilized, the nurse collects objective clinical data (vital signs and oxygen saturation) before notifying the supervising registered nurse to escalate care.

Step-by-Step Solution

1
Stop the continuous enteral feeding infusion.
Halts the infusion of formula.
Protects the airway by eliminating the immediate source of suspected aspiration.
2
Elevate the head of the bed to a high Fowler's position.
Places the client in an upright position.
Facilitates lung expansion, decreases work of breathing, and uses gravity to prevent further reflux or aspiration.
3
Obtain the client's oxygen saturation and vital signs.
Gathers objective clinical data.
Establishes a baseline for the acute event and determines the severity of respiratory distress and hypoxia.
4
Notify the supervising registered nurse.
Escalates the client's care.
Ensures the registered nurse and healthcare provider can initiate further collaborative interventions, such as oxygen therapy or diagnostic imaging.

Key Concept

Prioritization in acute respiratory compromise involves addressing the airway first (stopping the immediate threat and positioning), breathing/circulation next (data collection), and then communicating findings to the team.
Question 532Question →

Following a right-sided carotid endarterectomy, a client requires careful positioning to ensure physiological safety and comfort. Which basic care actions should the practical nurse take to support this client? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Elevate the head of the bed to a 30-degree angle to promote venous drainage.; Support the client's head in a neutral, midline alignment using small pillows.; Apply a prescribed cold compress over the neck dressing to minimize localized swelling.

Answer

The nurse should elevate the head of the bed to a 30-degree angle, support the head in a neutral midline alignment, and apply a prescribed cold compress over the neck dressing.
Following a carotid endarterectomy, proper positioning is critical for airway protection and comfort. Elevating the head of the bed 30 degrees promotes venous drainage and minimizes edema. Maintaining the head in a neutral, midline position prevents tension on the incision and avoids airway compression. Applying a cold compress is an effective nonpharmacological comfort measure that reduces localized swelling.

Step-by-Step Solution

1
Assess the client's postoperative orders regarding positioning and comfort measures.
The nurse identifies the need to prevent neck edema and protect the airway.
Carotid endarterectomy involves an incision in the neck, making the airway highly vulnerable to swelling and improper alignment.
2
Adjust the bed and support the client's head.
The head of the bed is elevated 30 degrees, and the head is kept in a neutral position.
Elevation promotes venous drainage to reduce edema, while neutral alignment prevents airway compression and incision tension.
3
Implement nonpharmacological comfort measures.
A prescribed cold compress is applied to the neck.
Cold application constricts blood vessels, effectively reducing swelling and providing pain relief.

Key Concept

Basic Care and Comfort - Postoperative Positioning
Question 533Question →

A licensed practical nurse (LPN) is caring for a client who is 6 hours postoperative following a total abdominal hysterectomy. The client reports feeling dizzy. The LPN assesses the client and notes a blood pressure of 96/58 mm Hg and a heart rate of 112 beats/minute. The client's preoperative baseline blood pressure was 132/74 mm Hg and heart rate was 76 beats/minute. Which of the following actions should the LPN take next?

Show answer & explanation

Answer: Notify the registered nurse (RN) immediately about the changes in the client's condition.

Answer

The LPN should immediately notify the registered nurse (RN) about the changes in the client's condition, as the vital signs indicate potential hypovolemia or hemorrhage.
The correct answer indicates immediate escalation to the registered nurse. The client is exhibiting tachycardia (heart rate of 112 beats/minute), hypotension (blood pressure of 96/58 mm Hg), and dizziness, which are classic early signs of hypovolemia or hemorrhage following major surgery. Recognizing these subtle signs of shock and promptly notifying the RN is essential for patient safety and falls strictly within the risk reduction responsibilities of the LPN.

Step-by-Step Solution

1
Analyze the current vital signs compared to the preoperative baseline.
The blood pressure has dropped significantly from 132/74 to 96/58 mm Hg, and the heart rate has increased from 76 to 112 beats/minute.
Identifying significant trends is necessary to detect early postoperative complications.
2
Interpret the clinical significance of these findings in a postoperative client.
Tachycardia combined with hypotension and reports of dizziness are classic early indicators of hypovolemia or internal bleeding.
Early recognition of shock is critical for risk reduction.
3
Determine the appropriate action within the LPN/LVN scope of practice.
The LPN must escalate these critical findings to the RN for further assessment and intervention.
LPNs are responsible for recognizing abnormalities and promptly notifying the RN or healthcare provider to ensure client safety.

Key Concept

Postoperative shock recognition and LPN scope of practice
Question 534Question →

A practical nurse (PN) is reviewing the morning laboratory results for several assigned clients on a medical-surgical unit. Which of the following laboratory findings indicate an immediate risk for complications and should be reported to the registered nurse (RN) without delay? Select all that apply.

Select all that apply

Show answer & explanation

Answer: A client receiving oral furosemide who has a serum potassium level of 2.8 mEq/L.; A client prescribed warfarin for atrial fibrillation who has an International Normalized Ratio (INR) of 5.5.; A client receiving a continuous heparin infusion who has a platelet count of 75,000/mm³.

Answer

The correct options are the client with a potassium level of 2.8 mEq/L, the client with an INR of 5.5, and the client with a platelet count of 75,000/mm³.
The correct options represent critical laboratory values that place the clients at immediate risk for severe, life-threatening complications. A potassium level of 2.8 mEq/L is critically low and can cause fatal cardiac dysrhythmias. An INR of 5.5 is significantly supratherapeutic and places the client at high risk for spontaneous hemorrhage. A platelet count of 75,000/mm³ in a client on a heparin infusion indicates severe thrombocytopenia and raises suspicion for heparin-induced thrombocytopenia (HIT), a dangerous complication requiring immediate intervention.

Step-by-Step Solution

1
Evaluate the serum potassium level of the client taking furosemide.
The value of 2.8 mEq/L is identified as critically low.
Furosemide is a potassium-wasting diuretic, and severe hypokalemia can lead to life-threatening cardiac dysrhythmias, making this an immediate priority.
2
Analyze the BUN, WBC count, and HbA1c results.
These values are abnormal but expected based on the clients' respective diagnoses (chronic kidney disease, pneumonia, and diabetes).
Expected abnormal findings in chronic or resolving conditions do not require immediate emergency escalation to the RN.
3
Assess the INR and platelet count for the clients receiving anticoagulants.
The INR of 5.5 is significantly above the therapeutic range, and the platelets of 75,000/mm³ indicate severe thrombocytopenia.
Both of these findings pose a high, immediate risk for hemorrhage or heparin-induced complications, requiring urgent notification.

Key Concept

Evaluating laboratory values to identify acute, life-threatening complications requiring immediate escalation versus expected baseline abnormalities.
Question 535Question →

A practical nurse is caring for a 78-year-old client who was admitted with severe gastroenteritis and prolonged vomiting. The client is receiving continuous intravenous fluids. Which assessment findings should the nurse identify as early indications that the client is developing hypovolemic shock? Select all that apply.

Select all that apply

Show answer & explanation

Answer: A resting heart rate of 108 beats per minute; New onset of unexplained restlessness and anxiety; A urine output of 15 mL over the past hour

Answer

The correct findings are a resting heart rate of 108 beats per minute, new onset of unexplained restlessness and anxiety, and a urine output of 15 mL over the past hour.
In the early (compensatory) stage of hypovolemic shock, the body activates the sympathetic nervous system to maintain cardiac output and tissue perfusion. This results in tachycardia (heart rate over 100 beats per minute) and decreased renal blood flow, causing oliguria (urine output less than 30 mL/hr). Furthermore, the brain's high sensitivity to slight decreases in oxygen delivery causes early neurological changes, most commonly presenting as unexplained restlessness, anxiety, or agitation.

Step-by-Step Solution

1
Analyze the clinical scenario and the client's risk factors.
The client is an older adult with severe fluid loss from prolonged vomiting, placing them at high risk for hypovolemic shock.
Identifying the primary risk factor directs the focus toward complications related to fluid volume deficit.
2
Identify the early compensatory mechanisms of hypovolemic shock.
The body attempts to maintain perfusion by increasing heart rate (tachycardia) and shunting blood away from non-vital organs (causing oliguria).
Recognizing early physiological adaptation prevents progression to irreversible shock.
3
Evaluate neurological changes associated with altered perfusion.
Decreased oxygen delivery to the brain manifests early as mild confusion, restlessness, or anxiety.
The brain is highly sensitive to subtle drops in oxygenation, making neurological status a critical early indicator of shock.
4
Rule out expected findings and normal parameters.
Normal blood pressure, expected localized pain (cramping), and normal sleep patterns are eliminated as indicators of acute shock.
Distinguishing between baseline or expected disease symptoms and emergent acute complications is essential for safe nursing practice.

Key Concept

Early Recognition of Hypovolemic Shock
Question 536Question →

A practical nurse is caring for an adult client who is prescribed daily oral furosemide and a daily oral potassium chloride supplement. While reviewing the morning laboratory results, the nurse notes a serum potassium level of 6.2 mEq/L (mmol/L). Which of the following is the most appropriate action for the nurse to take?

Show answer & explanation

Answer: Withhold the scheduled potassium chloride dose and promptly notify the registered nurse.

Answer

Withhold the scheduled potassium chloride dose and promptly notify the registered nurse.
The correct action is to withhold the medication and notify the registered nurse. The normal range for serum potassium is 3.5 to 5.0 mEq/L. A level of 6.2 mEq/L indicates severe hyperkalemia. Administering a potassium supplement in this state could induce fatal cardiac dysrhythmias. The practical nurse must recognize this critical value, intervene by holding the drug, and escalate the situation to the RN for further medical management.

Step-by-Step Solution

1
Evaluate the client's morning laboratory results against normal physiological reference ranges.
The serum potassium level of 6.2 mEq/L is identified as critically high (hyperkalemia), as the normal adult range is 3.5 to 5.0 mEq/L.
Identifying abnormal laboratory values is a crucial safety step before administering medications that directly affect those specific electrolyte levels.
2
Determine the appropriate clinical intervention based on the critical laboratory finding and the practical nurse scope of practice.
The nurse decides to withhold the potassium chloride supplement and immediately escalate the finding to the registered nurse.
Administering additional potassium to a client who is already experiencing severe hyperkalemia can precipitate life-threatening cardiac dysrhythmias. Immediate reporting is required for prompt medical intervention.

Key Concept

Pre-administration safety checks and interpretation of critical laboratory values
Question 537Question →

An older adult client admitted with community-acquired pneumonia has a scheduled dose of intravenous levofloxacin. The medication arrives from the pharmacy as a 500 mg500 \text{ mg} dose premixed in a 100 mL100 \text{ mL} bag of 5% Dextrose5\% \text{ Dextrose} in Water (D5W\text{D}_5\text{W}). According to the administration instructions, the medication must infuse steadily over 9090 minutes.

At what rate, in mL/hr\text{mL/hr}, should the infusion pump be programmed?

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

Show answer & explanation

Answer: 66.7

Answer

The infusion pump should be programmed to a rate of 66.766.7.
To determine the correct IV pump setting in mL/hr\text{mL/hr}, the total volume of the infusion (100 mL100 \text{ mL}) must be divided by the total time in minutes (9090 minutes) and then multiplied by 6060 (the number of minutes in an hour). This yields 66.666... mL/hr66.666... \text{ mL/hr}. Rounding to the nearest tenth provides the final correct value of 66.766.7.

Step-by-Step Solution

1
Identify the total volume to be infused.
The total fluid volume is 100 mL100 \text{ mL}.
The rate calculation relies on the total fluid volume of the IV bag, not the mass of the medication.
2
Identify the designated infusion time.
The infusion time is 9090 minutes.
This determines the duration over which the volume must be delivered.
3
Set up the standard formula for an IV pump rate.
100 mL90 minutes×60 minutes/hour\frac{100 \text{ mL}}{90 \text{ minutes}} \times 60 \text{ minutes/hour}
Infusion pumps are programmed in milliliters per hour (mL/hr\text{mL/hr}), so the time in minutes must be converted.
4
Calculate the continuous rate.
1.111...×60=66.666... mL/hr1.111... \times 60 = 66.666... \text{ mL/hr}
This provides the exact hourly rate required to deliver the medication over the specified timeframe.
5
Apply the rounding instructions.
66.766.7
The prompt explicitly requires rounding to the nearest tenth for safe and accurate pump programming.

Key Concept

Intravenous Infusion Rate Calculation
Question 538Question →

A licensed practical nurse (LPN) enters a client's room and observes them beginning to experience a generalized tonic-clonic seizure while sitting in a bedside armchair. Arrange the following nursing actions in the correct sequence of priority.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence prioritizes immediate physical safety, followed by airway management, observation, and post-seizure assessment.
In any acute physiological emergency, the nurse must follow the framework of Safety first, followed immediately by Airway, Breathing, and Circulation (ABCs). When a client seizes in a chair, the most imminent threat is a traumatic fall. Guiding them to the floor secures safety. Next, the airway is at risk due to loss of muscle control and excess secretions, making the side-lying position critical. Loosening clothing further assists breathing. Only after these immediate life-preserving steps are taken should the nurse focus on observing the specific details of the seizure. Finally, physical assessment data like vital signs require the client to be relatively still, which is only possible in the post-ictal state.

Step-by-Step Solution

1
Guide the client to the floor.
The client is moved from a precarious position in the chair to a safe, flat surface.
Prevents severe trauma from falling or hitting the extremities against the chair structure.
2
Place the client in a side-lying position.
The client's airway remains clear of the tongue and accumulating saliva or emesis.
Airway protection (the 'A' in ABCs) is the highest physiological priority once the client is protected from immediate mechanical injury.
3
Loosen restrictive clothing.
Neckties, tight collars, or belts are unfastened.
Facilitates unimpeded breathing and venous return.
4
Note the time and characteristics of the seizure.
Crucial clinical data is gathered regarding the onset, type of movements, and duration.
This data collection is essential for the provider to determine the type of seizure and appropriate pharmacological intervention.
5
Obtain vital signs.
Post-ictal heart rate, respiratory rate, blood pressure, and oxygen saturation are recorded.
Provides baseline data on the client's physiological recovery after the acute hypermetabolic state of the seizure has ended.

Key Concept

Prioritization of Care During a Seizure (Safety and ABCs)
Question 539Question →

A practical nurse (PN) is preparing to collect a sterile urine specimen for culture and sensitivity from a client who has a closed indwelling urinary catheter system. After performing hand hygiene and donning clean gloves, in what order should the PN perform the following actions to reduce the risk of infection and ensure an accurate laboratory sample? (Arrange the steps in the correct sequence from first to last.)

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: Clamp the tubing below the port, scrub the sampling port, withdraw urine with a sterile syringe, transfer the urine to a sterile container, and finally unclamp the drainage tubing.
The correct sequence ensures that a fresh, uncontaminated sample is collected directly from the closed urinary system while minimizing the risk of introducing pathogens. Clamping allows fresh urine to gather, proper disinfection prevents CAUTI, aseptic withdrawal and transfer maintain sample integrity, and unclamping is essential to prevent severe physical complications from urinary retention.

Step-by-Step Solution

1
Clamp the drainage tubing just below the sampling port for 15 to 30 minutes.
Freshly produced urine collects in the tubing.
Urine in the main drainage bag is stagnant and not suitable for accurate culture due to potential bacterial overgrowth at room temperature.
2
Scrub the needleless sampling port vigorously with an antimicrobial swab.
The access site is disinfected.
Disinfecting the port prevents the introduction of outside microorganisms into the sterile closed urinary system.
3
Attach a sterile syringe to the sampling port and withdraw the required volume of urine.
A sterile sample is securely obtained.
Using a sterile syringe ensures the sample remains uncontaminated during withdrawal.
4
Transfer the collected urine from the syringe into a sterile specimen container.
The sample is safely prepared for laboratory transport.
The laboratory requires a sterile container to ensure that any bacterial growth in the culture originates from the client's urinary tract, not the environment.
5
Unclamp the catheter drainage tubing to restore continuous gravity flow.
Normal urinary drainage resumes.
Prevents dangerous complications such as bladder distention, retrograde infection, and autonomic dysreflexia.

Key Concept

Reduction of Risk Potential: Infection Control and Complication Prevention
Estimated Time:1m 15s
Question 540Question →

Following a surgical repair of a fractured tibia 24 hours ago, a 65-year-old client suddenly develops severe restlessness and acute confusion. The client's respiratory rate has increased to 24 breaths per minute. Which action should the practical nurse take first?

Show answer & explanation

Answer: Obtain a pulse oximetry reading and auscultate the client's breath sounds

Answer

The practical nurse should first obtain a pulse oximetry reading and auscultate the client's breath sounds.
In any sudden clinical deterioration, the nurse must prioritize Airway, Breathing, and Circulation (ABCs). Restlessness, agitation, and acute confusion are early indicators of hypoxia. A client who recently underwent surgery on a long bone (such as a tibia) is at high risk for complications like a fat embolism or pulmonary embolism. The nurse's immediate priority is to assess the client's oxygenation status before initiating other actions.

Step-by-Step Solution

1
Analyze the clinical data provided in the scenario.
The client has a long bone fracture, new onset of severe restlessness, acute confusion, and an elevated respiratory rate.
Identifying the client's risk factors and acute symptom changes is necessary to determine the physiological urgency of the situation.
2
Apply the ABC (Airway, Breathing, Circulation) prioritization framework.
The symptoms point toward a potential compromise in oxygenation (Breathing/Circulation), possibly due to a respiratory complication like a fat embolism.
The ABC framework dictates that physiological needs, specifically airway and oxygenation, must be addressed before pain management or cognitive baseline checks.
3
Select the immediate nursing intervention that addresses the highest priority need.
Gathering objective data regarding the client's respiratory status is the most immediate priority.
Data about the client's oxygenation is required to confirm hypoxia and guide prompt emergency interventions or provider notification.

Key Concept

Recognizing early signs of hypoxia and prioritizing respiratory assessment (ABCs) in postoperative orthopedic clients.
PreviousPage 27 / 147Next
All practice questions — NCLEX-PN | Examkin