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A practical nurse (PN) is prioritizing care and performing interventions for several clients on a medical-surgical unit. Which of the following actions by the PN demonstrate safe practice and appropriately reduce the risk of client harm? (Select all that apply.)

Select all that apply

Verifying a client's name and date of birth against the medication administration record and scanning the identification wristband before administration.

Respectfully declining an assignment to formulate the initial nursing care plan for a newly transferred client.

Placing a laboratory report with a serum potassium level of

2.9

mEq/L (

2.9

mmol/L) in the chart to be reviewed during the provider's afternoon rounds.

Documenting a fresh postoperative client's blood pressure of

92/60

mm Hg and heart rate of

112

beats per minute while continuing routine care.

Administering a scheduled oral analgesic after confirming the client's identity by checking the room number and the name written on the door.

Delegating the task of evaluating a client's pain relief after oral analgesic administration to the unlicensed assistive personnel (UAP).

Show answer & explanation

Answer: Verifying a client's name and date of birth against the medication administration record and scanning the identification wristband before administration.; Respectfully declining an assignment to formulate the initial nursing care plan for a newly transferred client.

Answer

The correct actions are verifying identity using two identifiers before medication administration and declining the assignment to create an initial care plan.

Safe practical nursing practice involves strict adherence to medication safety protocols, such as using two unique identifiers, and working within the legal scope of practice, which prohibits the PN from formulating initial care plans.

Step-by-Step Solution

Analyze the scope of practice for the practical nurse (PN).

The PN's scope includes reinforcing teaching, administering most medications, and collecting data, but excludes initial assessments and initial care planning.

Understanding the PN scope of practice is essential for identifying safe assignments and proper delegation.

Evaluate the clinical data and vital signs presented in the options.

A potassium level of

2.9

mEq/L is critically low, and a postoperative blood pressure of

92/60

mm Hg with a heart rate of

112

bpm indicates potential shock.

Recognizing life-threatening abnormalities allows the PN to appropriately escalate care to the RN.

Review medication administration safety principles.

Safe medication administration requires two acceptable identifiers (name, date of birth, medical record number) and prohibits the use of room numbers.

Strict adherence to the rights of medication administration prevents errors and reduces risk potential.

Key Concept

The practical nurse must recognize critical clinical changes (such as abnormal lab values and early signs of shock), strictly adhere to medication safety rights, and operate within the defined scope of practice to minimize risks to client safety.

Question 542Question →

While assigned to a medical-surgical unit, a practical nurse prepares to administer medications to multiple clients. Which actions represent safe pharmacological practices within the practical nursing scope of practice? Select all that apply.

Select all that apply

Scanning the client's identification band and the medication barcode prior to administering oral digoxin.

Measuring the liquid dose of an anticonvulsant using a standard household teaspoon provided by the client.

Administering scheduled metoprolol to a client with a resting heart rate of 54 beats per minute without consulting the registered nurse.

Checking the medical record for documented penicillin allergies before administering a newly prescribed dose of amoxicillin.

Delegating the administration of a routine oral docusate sodium dose to the unlicensed assistive personnel (UAP).

Documenting the administration of a prescribed opioid analgesic immediately after the client swallows the tablet.

Show answer & explanation

Answer: Scanning the client's identification band and the medication barcode prior to administering oral digoxin.; Checking the medical record for documented penicillin allergies before administering a newly prescribed dose of amoxicillin.; Documenting the administration of a prescribed opioid analgesic immediately after the client swallows the tablet.

Answer

The correct actions include scanning the identification band and medication barcode, checking the medical record for allergies before administering amoxicillin, and documenting the medication administration immediately after the client swallows the tablet.

Safe pharmacological practice requires strict adherence to the rights of medication administration and the practical nursing scope of practice. This includes verifying the client's identity using approved identifiers like a barcode scanner, checking for allergies prior to giving new medications to prevent anaphylaxis, and documenting the administration immediately after the client takes the medication to maintain accurate records and prevent duplicate dosing.

Step-by-Step Solution

Evaluate each medication administration action against the standard rights of medication administration.

Scanning barcodes, verifying allergies, and performing immediate documentation align with the rights of medication administration.

These actions prevent common errors such as giving the wrong drug, causing severe allergic reactions, or double-dosing a client.

Identify actions that fall outside the practical nursing scope of practice or violate established safety protocols.

Delegating medication administration to a UAP, ignoring bradycardia before giving a beta-blocker, and using uncalibrated household spoons are identified as unsafe and incorrect practices.

UAPs cannot legally administer medications, beta-blockers require careful parameter checks to prevent cardiovascular collapse, and household spoons lead to inaccurate dosing.

Key Concept

Safe Medication Administration and Scope of Practice

Question 543Question →

A practical nurse is caring for an older adult client admitted with a suspected upper gastrointestinal bleed. During data collection, the nurse notes that the client appears increasingly restless and newly confused. The client's vital signs are: blood pressure 104/72 mm Hg, heart rate 112 beats/minute, and respiratory rate 22 breaths/minute. Which of the following actions should the nurse take? Select all that apply.

Select all that apply

Notify the registered nurse (RN) immediately about the changes in mental status and vital signs.

Apply a pulse oximeter to continuously monitor the client's oxygen saturation levels.

Verify the patency of the client's established peripheral intravenous (IV) access.

Administer the prescribed oral analgesic to manage the client's reported abdominal discomfort.

Reassure the family that sudden confusion is an expected reaction to being in a new hospital environment.

Document the heart rate and blood pressure as acceptable baseline findings for an older adult.

Show answer & explanation

Answer: Notify the registered nurse (RN) immediately about the changes in mental status and vital signs.; Apply a pulse oximeter to continuously monitor the client's oxygen saturation levels.; Verify the patency of the client's established peripheral intravenous (IV) access.

Answer

The practical nurse should immediately notify the RN of the changes, apply a pulse oximeter to monitor oxygenation, and verify IV patency for potential emergency fluid administration.

In a client with a gastrointestinal bleed, new-onset restlessness, confusion, and tachycardia are early indicators of hypovolemic shock and decreased cerebral perfusion. The practical nurse must prioritize circulatory and respiratory support by verifying IV patency and monitoring oxygenation, while immediately escalating these critical findings to the RN for further collaborative intervention.

Step-by-Step Solution

Analyze the client's clinical presentation and vital signs.

The combination of restlessness, new confusion, tachycardia (112 bpm), and borderline blood pressure (104/72 mm Hg) in a client with a GI bleed indicates early hypovolemic shock.

Identifying acute physiological deterioration is the first step in clinical judgment.

Prioritize interventions based on the ABCs (Airway, Breathing, Circulation).

Monitoring oxygen saturation and ensuring IV access for fluid resuscitation address the immediate respiratory and circulatory risks.

Airway, breathing, and circulation take precedence over routine comfort measures or documentation.

Determine the appropriate scope of practice and escalation protocol.

The RN is notified immediately because the client is becoming hemodynamically unstable and requires a higher level of assessment.

Practical nurses must report significant physiological changes to the supervising RN promptly.

Key Concept

Recognition and early intervention for hypovolemic shock

Question 544Question →

A 30-year-old client is admitted to the medical-surgical unit with acute pancreatitis. The client is receiving continuous intravenous normal saline at 100 mL/hr. During a routine check, the client appears restless and anxious. Current vital signs are: pulse 124 beats per minute, blood pressure 88/54 mm Hg, and respirations 24 breaths per minute. Total urine output over the previous 4 hours is 55 mL.

What is the most appropriate initial action for the practical nurse to take?

Provide the as-needed intramuscular analgesic, attributing the elevated heart rate and restlessness to abdominal discomfort.

Position the client flat in bed with their lower extremities elevated and immediately report the findings to the supervising nurse.

Reduce the rate of the continuous intravenous fluid infusion because the client is exhibiting signs of decreased renal clearance.

Record the assessment findings in the chart, recognizing that mild hypotension and tachycardia are expected physiological responses to pancreatitis.

Show answer & explanation

Answer: Position the client flat in bed with their lower extremities elevated and immediately report the findings to the supervising nurse.

Answer

Position the client flat in bed with their lower extremities elevated and immediately report the findings to the supervising nurse.

The client is demonstrating classic signs of hypovolemic shock (restlessness, tachycardia, hypotension, and oliguria) secondary to fluid shifting (third-spacing) caused by acute pancreatitis. Placing the client flat with elevated legs (passive leg raise) promotes venous return to vital organs. Immediately escalating the situation to the supervising nurse ensures the client receives prompt medical interventions, such as aggressive fluid resuscitation.

Step-by-Step Solution

Analyze the clinical data provided in the scenario.

The client has tachycardia (124 bpm), hypotension (88/54 mm Hg), tachypnea (24/min), oliguria (55 mL over 4 hours, which is less than the minimum 30 mL/hr), and restlessness.

Identifying abnormal findings is the first step in clinical judgment.

Correlate the findings with the underlying pathophysiology of acute pancreatitis.

These vital signs represent hypovolemic shock, a serious complication of pancreatitis caused by significant fluid shifting (third-spacing) into the peritoneal cavity.

Understanding the disease process helps distinguish expected symptoms from life-threatening emergencies.

Determine the priority nursing action within the practical nurse's scope of practice.

The priority is to support circulation (ABCs) by elevating the legs to increase venous return and immediately escalating the situation to the registered nurse or provider for advanced interventions.

Circulatory collapse takes precedence over pain management or routine documentation, and rapid escalation is required for critical instability.

Key Concept

Early Recognition and Prioritization of Hypovolemic Shock

Question 545Question →

A practical nurse is assigned to care for an adult client who has dysphagia following a recent stroke. The client receives continuous enteral nutrition via an established gastrostomy tube. The client's morning vital signs include a blood pressure of 118/76 mm Hg, heart rate of 78 beats/minute, and respiratory rate of 16 breaths/minute. The client has no known drug allergies. The practical nurse is preparing to administer a scheduled dose of a liquid multivitamin via the gastrostomy tube. Which of the following actions should the practical nurse take to ensure safe medication administration?

Flush the gastrostomy tube with 15 to 30 milliliters of water before and after administering the medication.

Verify the client's identity by checking the room number on the door and asking the client to nod.

Estimate the milliliter equivalent of a prescribed tablespoon dosage without using a calibrated measuring device.

Agree to administer a concurrent intravenous push analgesic for the client as delegated by the registered nurse.

Show answer & explanation

Answer: Flush the gastrostomy tube with 15 to 30 milliliters of water before and after administering the medication.

Answer

The correct action is to flush the gastrostomy tube with 15 to 30 milliliters of water before and after administering the medication.

Administering medications via an enteral route, such as a gastrostomy tube, requires the nurse to maintain tube patency and ensure complete drug delivery. Flushing the tube with 15 to 30 milliliters of water before administration confirms the tube is clear and functioning. Flushing again with 15 to 30 milliliters of water after administration clears the tube of any residual medication, preventing blockages and ensuring the client receives the entire prescribed dose.

Step-by-Step Solution

Analyze the clinical scenario and the prescribed route of medication administration.

The medication is to be administered via a gastrostomy tube to a clinically stable client.

Identifying the administration route is essential to determine the specific procedural safety checks required.

Evaluate the principles of safe enteral medication administration.

Best practice guidelines dictate flushing the enteral tube with 15 to 30 mL of water before and after giving medications.

Flushing prevents tube occlusion, verifies patency, and ensures the entire medication dose reaches the stomach.

Review the distractors for violations of safe nursing practice.

Using a room number for identification, estimating liquid dosages, and accepting intravenous push assignments all violate practical nurse scope of practice and safety standards.

Recognizing and avoiding unsafe practices reinforces the boundaries of the practical nurse role and protects client safety.

Key Concept

Safe Medication Administration via Enteral Tubes

Question 546Question →

A practical nurse (PN) is caring for an alert and conscious client with type 1 diabetes mellitus who suddenly reports feeling shaky, dizzy, and diaphoretic. The PN performs a capillary blood glucose test, which reads 48 mg/dL (2.7 mmol/L). In which 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 order is to administer a simple carbohydrate, wait 15 minutes to recheck the glucose, repeat the simple carbohydrate if still low, provide a complex snack once stable, and finally document the event.

The 'Rule of 15' is the standard evidence-based protocol for managing hypoglycemia in a conscious client. The nurse first provides 15 grams of a fast-acting simple carbohydrate to rapidly raise the blood sugar. Waiting 15 minutes allows the sugar to absorb before rechecking the blood glucose. If it remains below 70 mg/dL, the 15-gram carbohydrate dose is repeated. Once the blood glucose is above 70 mg/dL, a complex carbohydrate and protein snack is given to sustain the blood sugar levels. Finally, the nurse documents the entire event.

Step-by-Step Solution

Administer 15 grams of a fast-acting simple carbohydrate.

The client receives an immediate source of glucose to rapidly treat the acute hypoglycemia.

Because the client is conscious and can swallow, a fast-acting oral carbohydrate (like 4 ounces of juice) is the fastest and safest way to increase blood sugar and prevent progression to unconsciousness or seizures.

Recheck the capillary blood glucose level after 15 minutes.

The PN evaluates the client's response to the initial intervention.

It takes approximately 15 minutes for the simple carbohydrate to enter the bloodstream and effectively raise the blood glucose level.

Repeat the simple carbohydrate dose if the blood glucose is still below 70 mg/dL (3.9 mmol/L).

The client receives additional glucose if the first dose was insufficient.

If the blood glucose remains below the safe threshold of 70 mg/dL, the hypoglycemia has not resolved, and another immediate rapid intervention is necessary.

Provide a snack containing a complex carbohydrate and a protein.

The client's blood glucose is stabilized over a longer period.

Simple carbohydrates are metabolized quickly. Providing a complex carbohydrate and protein ensures a steady, prolonged release of glucose to prevent a recurrent drop in blood sugar.

Document the hypoglycemic episode, interventions, and the client's response.

The medical record is updated with accurate clinical data.

Accurate documentation is legally and clinically required, but it is the lowest priority and must be done only after the client is safe and stable.

Key Concept

Management of Acute Hypoglycemia (Rule of 15)

Question 547Question →

During a morning assessment, a practical nurse evaluates a client who is 12 hours postoperative following a right total hip arthroplasty. The client appears mildly restless and reports a pain level of 4 on a 0 to 10 scale at the operative site. The current vital signs are a blood pressure of 104/64 mm Hg (baseline 134/78 mm Hg), a heart rate of 104 bpm, and a respiratory rate of 20/min. The morning hemoglobin level is reported as 6.9 g/dL (69 g/L). Which of the following is the most appropriate initial action for the nurse?

Immediately report the client's status and morning blood work to the supervising registered nurse.

Administer the prescribed as-needed analgesic to address the reported surgical pain.

Reassure the client and continue with the routine four-hour postoperative vital sign checks.

File the laboratory value in the chart and verify that an afternoon blood draw is ordered.

Show answer & explanation

Answer: Immediately report the client's status and morning blood work to the supervising registered nurse.

Answer

The correct action is to immediately report the client's status and morning blood work to the supervising registered nurse.

The client is displaying a classic presentation of early hypovolemic shock due to postoperative hemorrhage. The combination of a significant drop in blood pressure from baseline, tachycardia, new-onset restlessness, and a critically low hemoglobin level (6.9 g/dL) indicates severely compromised circulation. Because managing complex, unstable clients and initiating blood transfusions fall outside the practical nurse's scope of independent practice, the most appropriate and immediate action is to report these critical findings to the supervising registered nurse for rapid medical intervention.

Step-by-Step Solution

Analyze the client's vital signs compared to baseline.

The blood pressure has dropped significantly (from 134/78 to 104/64 mm Hg) and the heart rate is elevated (104 bpm).

Identifying trends is essential for detecting early postoperative complications such as bleeding.

Evaluate the laboratory results and clinical presentation.

The hemoglobin is critically low at 6.9 g/dL, and the client is exhibiting new-onset restlessness.

Low hemoglobin combined with tachycardia, hypotension, and restlessness strongly indicates active bleeding or hypovolemic shock.

Determine the priority intervention based on ABCs and scope of practice.

The most critical need is addressing the circulatory compromise, which requires RN or provider intervention.

Airway, breathing, and circulation take precedence over routine monitoring or pain management, necessitating immediate escalation.

Key Concept

Recognizing early signs of postoperative hemorrhage and hypovolemia

Question 548Question →

A client with a history of stable angina is prescribed a daily nitroglycerin transdermal patch. After gathering the necessary supplies, entering the client's room, and verifying the client using two identifiers, the practical nurse proceeds with the medication administration. Arrange the following actions in the correct sequential order from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: Don clean gloves, remove the old patch, clean the old site, label the new patch, and apply the new patch.

Safe transdermal patch administration requires a strict sequence to ensure client safety and protect the nurse. The nurse must first don gloves to prevent absorbing the medication. Next, the old patch must be removed and safely discarded, and the old site must be thoroughly cleaned to prevent an overdose from residual medication. The new patch is then labeled with the date, time, and initials prior to application to avoid causing discomfort by writing directly on the client's skin. Finally, the patch is firmly applied to a new, hairless site to ensure consistent absorption and prevent tissue irritation.

Step-by-Step Solution

Put on a pair of clean gloves.

The nurse's hands are protected from the medication.

Nitroglycerin can be absorbed through the nurse's skin, causing adverse effects such as a severe headache or hypotension.

Remove the previously applied patch and fold the adhesive sides together.

The continuous delivery of the previous dose is halted.

Failing to remove the old patch before applying a new one can lead to a dangerous medication overdose.

Wash the old application site with soap and water, then dry the skin completely.

The skin is clear of residual medication.

Residual nitroglycerin left on the skin continues to be absorbed; cleaning the site ensures accurate dosing of the new patch.

Write the current date, time, and nurse's initials on the outer backing of the new patch.

The new patch is properly identified for future shifts.

Writing on the patch before applying it prevents the nurse from pressing a pen into the client's skin.

Press the newly labeled patch firmly onto a different, hairless area of the upper chest or arm.

The new dose is securely administered.

Site rotation prevents skin breakdown and irritation, while applying to a hairless area ensures optimal skin contact and absorption.

Key Concept

Safe Administration of Transdermal Medications

Question 549Question →

While performing afternoon rounds, a practical nurse evaluates an older adult client who underwent an abdominal bowel resection two days ago. The client's current vital signs reveal a heart rate of 114 beats per minute and a blood pressure of 96/64 mm Hg. The client, who was previously fully oriented, is now restless, repeatedly asking where they are, and picking at the bed linens. Which action should the practical nurse take first?

Measure the client's oxygen saturation level and immediately notify the registered nurse.

Reorient the client to the hospital room and ensure the bed alarm is activated.

Administer the prescribed as-needed analgesic to help calm the client.

Document the current vital signs and reassess the client at the next scheduled interval.

Show answer & explanation

Answer: Measure the client's oxygen saturation level and immediately notify the registered nurse.

Answer

Measure the client's oxygen saturation level and immediately notify the registered nurse.

The correct action prioritizes the collection of critical respiratory data and immediate escalation. A sudden change in mental status accompanied by tachycardia and borderline hypotension strongly suggests hypoxia or early shock. The practical nurse must prioritize Airway, Breathing, and Circulation (ABC) assessments and promptly notify the registered nurse for collaborative management.

Step-by-Step Solution

Analyze the clinical cues presented by the client.

The client has tachycardia, borderline hypotension, and a sudden change in mental status including restlessness and confusion.

Identifying abnormal findings is the first step in clinical reasoning.

Correlate the clinical cues with potential complications.

These findings are classic early signs of hypoxia or hypovolemic shock, which are life-threatening conditions.

Understanding the physiological meaning of the symptoms determines the urgency of the situation.

Determine the priority action within the practical nurse scope of practice.

The priority is to gather targeted respiratory data and escalate the findings to the registered nurse for immediate medical intervention.

Airway, Breathing, and Circulation (ABC) issues take precedence over routine care or symptom management.

Key Concept

Early Recognition of Hypoxia and Shock

Question 550Question →

A practical nurse (PN) is caring for a 16-year-old client who is 4 hours postoperative following a tonsillectomy. The client is awake but quietly and repeatedly swallowing. The client's heart rate has increased from 78 bpm to 110 bpm over the last hour, while blood pressure has decreased slightly from 118/74 mm Hg to 108/66 mm Hg. Which of the following is the most appropriate action for the PN to take?

Notify the registered nurse immediately regarding the assessment findings.

Document the frequent swallowing and vital signs as expected postoperative findings.

Offer the client sips of clear, cool liquids to soothe the throat.

Increase the intravenous fluid rate to compensate for the slight drop in blood pressure.

Show answer & explanation

Answer: Notify the registered nurse immediately regarding the assessment findings.

Answer

Notify the registered nurse immediately regarding the assessment findings.

The correct action is to notify the registered nurse immediately. In a post-tonsillectomy client, frequent swallowing is a hallmark sign of active bleeding trickling down the throat. When combined with an increasing heart rate and a slightly decreasing blood pressure, these findings strongly indicate early hypovolemic shock. Prompt escalation is necessary to stabilize the client and prevent further deterioration.

Step-by-Step Solution

Analyze the client's postoperative presentation and behavioral cues.

The client is 4 hours post-tonsillectomy and is repeatedly swallowing.

Frequent swallowing is a classic indicator that blood is pooling in the posterior pharynx, suggesting active surgical site bleeding.

Evaluate the trend in the client's vital signs over the past hour.

The heart rate has increased significantly (tachycardia) and the blood pressure has started to drop.

These vital sign changes represent the body's compensatory mechanisms attempting to maintain cardiac output during early hypovolemic shock caused by hemorrhage.

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

The practical nurse must immediately escalate the situation to the registered nurse.

Active hemorrhage is a life-threatening complication requiring immediate comprehensive assessment, potential medical intervention, and possible return to the operating room.

Key Concept

Early recognition and escalation of postoperative hemorrhage and hypovolemic shock.

Question 551Question →

An older adult client is hospitalized with severe lower extremity cellulitis and is receiving intravenous antibiotic therapy. Over a 4-hour period, the client's urine output totals 55 mL. The client's resting heart rate has trended upward from 78 to 96 beats/min, and blood pressure has trended downward from 132/78 to 106/62 mm Hg. The client now appears unusually agitated and is unsure of their location. Which actions should the practical nurse take? Select all that apply.

Select all that apply

Report the changing clinical parameters to the supervising registered nurse immediately.

Evaluate the client's lung sounds, respiratory rate, and pulse oximetry readings.

Anticipate assisting the registered nurse with a rapid intravenous fluid bolus or stat laboratory draws.

Attribute the altered mental status to expected age-related changes and minimize room stimulation.

Maintain the current frequency of data collection because the vital signs have not reached critical threshold levels.

Prioritize giving the client's scheduled oral analgesic to ensure comfort before conducting further assessments.

Show answer & explanation

Answer: Report the changing clinical parameters to the supervising registered nurse immediately.; Evaluate the client's lung sounds, respiratory rate, and pulse oximetry readings.; Anticipate assisting the registered nurse with a rapid intravenous fluid bolus or stat laboratory draws.

Answer

The correct actions are to report the changing clinical parameters to the supervising registered nurse immediately, evaluate the client's respiratory status, and anticipate assisting with rapid fluid resuscitation or laboratory draws.

The client is exhibiting early signs of decreased tissue perfusion and potential systemic inflammatory response syndrome (SIRS) or sepsis, evidenced by oliguria, tachycardia, a downward trend in blood pressure, and altered mental status. Immediate escalation to the RN, evaluating respiratory function (ABCs), and preparing for rapid therapeutic interventions (like fluids and cultures) are critical, life-saving actions within the practical nurse's scope of practice.

Step-by-Step Solution

Analyze the clinical cues presented in the scenario.

The client has oliguria (55 mL over 4 hours is roughly 14 mL/hr, which is well below the minimum 30 mL/hr), a rising heart rate, falling blood pressure, and new-onset agitation.

Recognizing abnormal assessment data is the first step in clinical judgment.

Synthesize the cues to identify the underlying physiological problem.

The combination of these subtle but progressive signs indicates early systemic hypoperfusion, likely related to sepsis from the severe cellulitis.

Understanding the pathophysiology of infection leading to shock helps determine the urgency of the situation.

Determine the appropriate practical nurse interventions.

The priority is to maintain ABCs (assessing respiratory status), immediately escalate the findings to the RN for rapid medical management, and prepare to assist with emergency interventions.

The PN scope of practice requires prompt reporting of unstable physiological changes and assisting the healthcare team in stabilizing the client.

Key Concept

Early recognition of shock and physiological deterioration

Estimated Time:1m 30s

Question 552Question →

A practical nurse is caring for an adult client experiencing an acute asthma exacerbation. The client appears restless, and auscultation of the lungs reveals bilateral expiratory wheezing. The client's current vital signs are blood pressure 134/86 mmHg, heart rate 114 beats per minute, respiratory rate 26 breaths per minute, and oxygen saturation 92% on room air. The healthcare provider has prescribed an immediate albuterol nebulizer treatment and an oral dose of prednisone. Which action should the nurse take first?

Withhold the albuterol nebulizer and notify the provider, as the client is already experiencing tachycardia.

Delegate the administration of the oral prednisone to an unlicensed assistive personnel (UAP) while preparing the nebulizer.

Administer the albuterol nebulizer treatment before providing the oral prednisone.

Administer the oral prednisone immediately without checking the client's identification band to save time.

Show answer & explanation

Answer: Administer the albuterol nebulizer treatment before providing the oral prednisone.

Answer

Administer the albuterol nebulizer treatment before providing the oral prednisone.

The correct action is to administer the albuterol nebulizer treatment first. Albuterol is a short-acting beta-2 agonist (SABA) that causes rapid bronchodilation, addressing the client's immediate airway and breathing needs. Prednisone is a corticosteroid that reduces airway inflammation, but its onset of action takes several hours. In an acute respiratory scenario, the nurse must prioritize the fastest-acting rescue medication to stabilize the client's airway before administering slower-acting oral medications.

Step-by-Step Solution

Assess the client's clinical presentation and vital signs.

The client is in acute respiratory distress with wheezing, hypoxia (SpO2 92%), and tachycardia (HR 114 bpm).

Baseline assessment data dictates the urgency and prioritization of pharmacological interventions.

Analyze the prescribed medications based on their onset of action and mechanisms.

Albuterol is a rapid-acting bronchodilator. Prednisone is a slower-acting systemic corticosteroid.

Understanding pharmacokinetics ensures the fastest-acting rescue medication is given first.

Prioritize administration based on the airway, breathing, and circulation (ABC) framework.

The albuterol nebulizer is administered first to immediately open the airways, followed by the oral prednisone to manage underlying inflammation.

Airway patency and breathing are the highest physiological priorities in an asthma exacerbation.

Key Concept

During an acute respiratory exacerbation, rapid-acting bronchodilators (like albuterol) must be prioritized over slower-acting anti-inflammatory medications (like oral corticosteroids) to immediately secure the airway and improve breathing.

Question 553Question →

An adult client is receiving postpartum care on the maternal-newborn unit following an uncomplicated vaginal birth. During the ongoing evaluation, the practical nurse reviews the client's current clinical data. Which assessment findings indicate a developing complication and require immediate escalation to the registered nurse? Select all that apply.

Select all that apply

Heart rate of

118

beats/min with a blood pressure of

88/54

mm Hg

Saturation of one perineal pad within a

15

-minute timeframe

Client report of new, severe perineal pressure that is unrelieved by analgesia

Dark red vaginal discharge with a small clot expelled when first standing up

White blood cell count of

15,000/\text{mm}^3

(

15.0 \times 10^9/\text{L}

) on the morning laboratory report

Oral temperature of

100.1^\circ\text{F}

(

37.8^\circ\text{C}

) accompanied by mild diaphoresis

Show answer & explanation

Answer: Heart rate of $118$ beats/min with a blood pressure of $88/54$ mm Hg; Saturation of one perineal pad within a $15$ -minute timeframe; Client report of new, severe perineal pressure that is unrelieved by analgesia

Answer

The findings requiring immediate escalation are the elevated heart rate with hypotension, the rapidly saturated perineal pad, and the severe, unrelieved perineal pressure.

A heart rate of

118

beats/min with a blood pressure of

88/54

mm Hg are classic signs of impending hypovolemic shock. Saturation of a perineal pad in

15

minutes or less indicates active postpartum hemorrhage. Severe, unrelieved perineal pressure is a hallmark sign of a developing vaginal or vulvar hematoma. All of these findings indicate potentially life-threatening complications that require immediate escalation to the registered nurse for rapid intervention.

Step-by-Step Solution

Analyze the clinical scenario for the primary risk factors.

The client is in the immediate postpartum period following a vaginal delivery, making hemorrhage and hematoma formation the primary life-threatening risks.

Identifying the highest risk potential guides the prioritization of clinical data.

Evaluate each finding to differentiate between normal physiological adaptations and potential complications.

Tachycardia with hypotension, rapid pad saturation, and severe pressure are abnormal findings indicating shock, active bleeding, or hematoma.

Recognizing deviations from expected postpartum recovery is essential for safe practice.

Identify the expected, benign findings that do not require escalation.

Mild temperature elevation, leukocytosis, and the expulsion of pooled lochia upon standing are normal physiological responses to childbirth.

Accurate clinical judgment prevents unnecessary escalation and focuses care on true emergencies.

Key Concept

Postpartum Complications and Risk Reduction

Estimated Time:1m 30s

Question 554Question →

A practical nurse in a long-term care facility is reviewing a new medication order for a resident diagnosed with a lower respiratory tract infection. The provider's prescription reads: 'Azithromycin $500\text{ mg}$ PO on day 1, followed by $250\text{ mg}$ PO daily on days 2 through 5.' The pharmacy dispenses an azithromycin oral suspension with a concentration of $200\text{ mg}/5\text{ mL}$ . How many total milliliters (mL) of this medication will the nurse administer over the entire 5-day treatment course? (Record answer to the nearest tenth. Do not include units in answer.)

Show answer & explanation

Answer: 37.5

Answer

37.5

The prescription requires a total of

1,500\text{ mg}

of azithromycin over 5 days (

500\text{ mg}

on day 1, plus

1,000\text{ mg}

over days 2 through 5). Using the supplied concentration of

200\text{ mg}/5\text{ mL}

, the required volume is calculated by dividing

1,500

200

, which equals

7.5

. Multiplying

7.5

5

yields exactly

37.5\text{ mL}

Step-by-Step Solution

Calculate the total milligrams required for the full 5-day prescription.

Day 1 =

500\text{ mg}

. Days 2-5 (4 days) =

1,000\text{ mg}

. Total =

1,500\text{ mg}

To determine the complete volume needed, the total medication dosage over all days must first be established.

Set up the dimensional analysis or standard dosage formula to convert total milligrams to milliliters.

(\frac{1,500\text{ mg}}{200\text{ mg}}) \times 5\text{ mL}

This aligns the prescribed dose with the available concentration (

200\text{ mg}

per

5\text{ mL}

) supplied by the pharmacy.

Solve the equation and round to the nearest tenth as instructed.

7.5 \times 5 = 37.5\text{ mL}

Ensures the correct final liquid volume is calculated without rounding errors.

Key Concept

Multi-step Dosage Calculation and Course Accumulation

Question 555Question →

A 79-year-old client on a medical-surgical unit is undergoing treatment for a complicated urinary tract infection with intravenous antibiotics. During the night, the client, whose baseline mental status is alert and oriented, becomes highly agitated, attempts to climb out of bed, and pulls at the intravenous line. The practical nurse obtains the following vital signs: temperature 97.2°F (36.2°C), heart rate 118 beats/minute, blood pressure 94/52 mm Hg, and respiratory rate 24 breaths/minute. Which action should the practical nurse take first?

Remain with the client and immediately report the vital signs and behavior changes to the registered nurse.

Apply a protective wrap to the intravenous site to ensure the antibiotic infusion is not interrupted.

Document the behavior in the medical record as expected nighttime disorientation common in older adults.

Continue routine monitoring and plan to check vital signs again in four hours since the client is afebrile.

Show answer & explanation

Answer: Remain with the client and immediately report the vital signs and behavior changes to the registered nurse.

Answer

The priority action is to remain with the client and immediately report the vital signs and behavior changes to the registered nurse.

The correct answer addresses the immediate need for escalation when a client shows signs of acute physiological deterioration. The combination of sudden agitation, tachycardia, tachypnea, and hypotension in a client with a severe infection points directly to early septic shock. The practical nurse correctly identifies the emergency and immediately reports to the registered nurse while keeping the client safe.

Step-by-Step Solution

Analyze the client's new onset of symptoms.

The client has suddenly developed agitation and confusion, deviating from their alert baseline.

Sudden changes in mental status often indicate an acute physiological problem, such as poor cerebral perfusion, not a psychological one.

Evaluate the current vital signs in the context of the client's diagnosis.

Heart rate (118 bpm) is elevated, respiratory rate (24 breaths/min) is elevated, and blood pressure (94/52 mm Hg) is low.

These vital signs suggest circulatory compromise and inadequate tissue perfusion, which are early signs of septic shock associated with the urinary tract infection.

Determine the priority nursing action within the practical nurse scope of practice.

The practical nurse must immediately notify the registered nurse to escalate care while ensuring client safety.

Acute physiological deterioration requires immediate assessment and medical intervention beyond the practical nurse's independent scope.

Key Concept

Recognizing early signs of shock and prioritizing acute physiological changes over secondary equipment issues or assumptions about aging.

Question 556Question →

An adult client with a history of type 2 diabetes mellitus and hypertension is assigned to a practical nurse. During the morning assessment, the client is awake and reports feeling slightly shaky. The vital signs are a blood pressure of 142/88 mm Hg, an apical heart rate of 54 beats/minute, and a capillary blood glucose level of 64 mg/dL (3.5 mmol/L). The medication administration record includes scheduled morning doses of oral glipizide, subcutaneous regular insulin, and oral atenolol. Which of the following actions should the practical nurse take? Select all that apply.

Select all that apply

Withhold the scheduled doses of oral glipizide and subcutaneous regular insulin.

Provide the client with 15 grams of a fast-acting oral carbohydrate.

Withhold the scheduled dose of oral atenolol and report the apical heart rate.

Administer the oral atenolol to manage the client's current blood pressure.

Give the subcutaneous regular insulin and hold the oral glipizide until after a meal.

Delegate the administration of fruit juice and the follow-up blood glucose check to an unlicensed assistive personnel (UAP).

Show answer & explanation

Answer: Withhold the scheduled doses of oral glipizide and subcutaneous regular insulin.; Provide the client with 15 grams of a fast-acting oral carbohydrate.; Withhold the scheduled dose of oral atenolol and report the apical heart rate.

Answer

The practical nurse should withhold the glipizide and regular insulin, provide a fast-acting carbohydrate to treat the hypoglycemia, and withhold the atenolol due to the client's bradycardia.

The client is experiencing both hypoglycemia (blood glucose 64 mg/dL with shakiness) and bradycardia (heart rate 54 beats/minute). Safe nursing practice requires holding all medications that would exacerbate these conditions. Glipizide and regular insulin must be withheld to prevent further drops in blood glucose, and a fast-acting carbohydrate must be given immediately. Atenolol must be withheld because it is a beta-blocker that will further lower the client's heart rate. The nurse must report these abnormal findings to the healthcare provider or registered nurse.

Step-by-Step Solution

Evaluate the capillary blood glucose level against the client's symptoms and scheduled medications.

The blood glucose is 64 mg/dL (hypoglycemia) with symptoms of shakiness.

Recognizing hypoglycemia dictates that medications lowering blood sugar (glipizide, regular insulin) must be withheld and immediate treatment initiated.

Select the appropriate intervention for an awake, hypoglycemic client.

Provide 15 grams of a fast-acting oral carbohydrate.

Oral carbohydrates are the first-line treatment for conscious clients experiencing hypoglycemia to rapidly restore safe blood glucose levels.

Evaluate the vital signs against the scheduled cardiac medication.

The apical heart rate is 54 beats/minute (bradycardia), which is a contraindication for atenolol.

Beta-blockers depress myocardial contractility and heart rate; administering atenolol to a bradycardic client is unsafe.

Key Concept

Safe medication administration requires the nurse to verify that current clinical data, such as vital signs and laboratory values, support the safe administration of scheduled medications.

Question 557Question →

A practical nurse (PN) is preparing to obtain an aerobic wound culture from a client's sacral pressure injury. In what order should the PN perform the following actions? (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 for obtaining a wound culture is to first remove the soiled dressing, perform hand hygiene and don new gloves, cleanse the wound with normal saline, swab the granulating tissue, and finally place the swab in the collection tube.

To obtain an accurate wound culture without cross-contamination, the PN must first remove the soiled dressing and change gloves. Next, the wound is cleansed with normal saline to remove surface exudate and skin flora. The PN then swabs viable granulating tissue, where the active infection resides, before securing the swab in the sterile tube.

Step-by-Step Solution

Remove the soiled dressing.

The wound bed is exposed.

Necessary to access the site for culture.

Perform hand hygiene and put on new gloves.

Hands are clean and protected.

Prevents introducing bacteria from the old dressing into the wound.

Cleanse the wound with sterile normal saline.

Surface exudate and flora are removed.

Ensures the culture isolates pathogens causing the infection, not surface contaminants.

Swab clean, granulating tissue.

A sample of the infecting organism is obtained.

Pathogens are most concentrated in viable, granulating tissue rather than in slough or purulent drainage.

Place the swab in the collection tube.

The specimen is secured for transport.

Preserves the sample and prevents environmental contamination.

Key Concept

Proper technique for obtaining a wound culture involves cleansing the wound first to avoid culturing surface flora and swabbing only viable tissue.

Question 558Question →

A client is receiving care on the surgical unit 6 hours after an abdominal hysterectomy. During data collection, the practical nurse notes that the client appears restless and pale. The client's vital signs are: blood pressure 88/52 mm Hg, heart rate 116 beats/min, and respiratory rate 24 breaths/min. A recent laboratory report shows a hemoglobin level of 8.1 g/dL (81 g/L). Which action should the practical nurse take first?

Continue monitoring the vital signs routinely because mild hypotension is expected following surgery.

File the laboratory report in the electronic health record and wait for the provider to review it during rounds.

Promptly notify the registered nurse about the assessment findings and remain with the client.

Administer a prescribed intravenous push sedative to address the client's increasing restlessness.

Show answer & explanation

Answer: Promptly notify the registered nurse about the assessment findings and remain with the client.

Answer

Promptly notify the registered nurse about the assessment findings and remain with the client.

The correct action demonstrates an understanding of the practical nurse's role in risk reduction. The client's presentation of tachycardia, hypotension, restlessness, pallor, and low hemoglobin strongly suggests postoperative hemorrhage and hypovolemic shock. Because this is an unstable, critical situation requiring advanced assessment, fluid resuscitation, and potential blood transfusions, the practical nurse must immediately notify the registered nurse to escalate care while ensuring client safety by staying at the bedside.

Step-by-Step Solution

Analyze the client's vital signs and clinical presentation.

The client is experiencing hypotension (88/52 mm Hg), tachycardia (116 beats/min), tachypnea (24 breaths/min), pallor, and restlessness.

Identifying abnormal assessment findings is the fundamental first step in recognizing clinical deterioration.

Correlate the physical assessment findings with the recent laboratory data.

The low hemoglobin level (8.1 g/dL) combined with the abnormal vital signs indicates active bleeding and impending hypovolemic shock.

Connecting laboratory values with physical signs provides a comprehensive clinical picture of the postoperative complication.

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

The practical nurse must immediately escalate the situation to the registered nurse for advanced assessment and collaborative management.

Managing acute hypovolemic shock requires RN-level clinical judgment and interventions, such as fluid resuscitation and blood product administration.

Key Concept

Early recognition of hypovolemic shock and prompt escalation of critical findings

Question 559Question →

During a pediatric clinic visit, a practical nurse prepares to administer a scheduled measles, mumps, and rubella (MMR) vaccine to a 15-month-old child. The client's health record indicates a current prescription for high-dose systemic corticosteroids to manage an autoimmune disorder. What is the most appropriate action for the practical nurse to take?

Withhold the MMR vaccine and notify the healthcare provider about the client's corticosteroid therapy.

Administer the vaccine as scheduled to ensure the child remains compliant with standard immunization timelines.

Administer the vaccine without completing the electronic barcode scan as long as the parent verbally confirms the child's identity.

Accept a delegation to administer a prophylactic intravenous (IV) push antihistamine prior to giving the immunization.

Show answer & explanation

Answer: Withhold the MMR vaccine and notify the healthcare provider about the client's corticosteroid therapy.

Answer

The practical nurse should withhold the MMR vaccine and notify the healthcare provider, as live attenuated vaccines are contraindicated for clients receiving immunosuppressive therapies such as high-dose corticosteroids.

The measles, mumps, and rubella (MMR) vaccine is a live attenuated vaccine. Clients receiving high-dose systemic corticosteroids are immunocompromised and lack the necessary cellular immune response to safely process live viruses. Administering a live vaccine to this client could result in a severe or life-threatening infection. Therefore, the safest and most appropriate action is to withhold the dose and alert the provider.

Step-by-Step Solution

Review the client's current medication list and medical history prior to administering any vaccine.

The nurse identifies that the client is actively taking high-dose systemic corticosteroids.

Identifying current medications is essential to determine potential drug interactions or contraindications before proceeding with administration.

Analyze the pharmacological properties of the prescribed vaccine in relation to the client's immune status.

The nurse recognizes that the MMR vaccine contains live attenuated viruses, which are contraindicated for immunocompromised individuals.

High-dose corticosteroids suppress the immune system, significantly increasing the risk of a severe, disseminated infection from a live vaccine.

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

The nurse withholds the immunization and escalates the finding to the prescribing healthcare provider or registered nurse.

Practical nurses must advocate for client safety by holding unsafe medications and communicating critical contraindications to the healthcare team.

Key Concept

Contraindications for live attenuated vaccines in immunocompromised clients

Question 560Question →

While observing an 82-year-old client admitted 12 hours ago with severe diarrhea and vomiting, the practical nurse (PN) notes several clinical findings. Which of the following data points strongly suggest the client is developing hypovolemic shock and warrant immediate notification of the registered nurse (RN)? Select all that apply.

Select all that apply

New-onset restlessness and repeated attempts to remove the intravenous catheter

A resting heart rate that has steadily climbed from 86 to 124 beats per minute

A total urine output of 45 mL accumulated over the past three hours

Verbalization of dull, intermittent abdominal cramping

An oral temperature reading of 37.6°C (99.7°F)

Inability to recall the name of the admitting healthcare provider while fully oriented to person and place

Show answer & explanation

Answer: New-onset restlessness and repeated attempts to remove the intravenous catheter; A resting heart rate that has steadily climbed from 86 to 124 beats per minute; A total urine output of 45 mL accumulated over the past three hours

Answer

The findings that indicate acute physiological deterioration and early hypovolemic shock are the new-onset restlessness, the climbing heart rate, and the significantly low urine output.

In a client experiencing severe fluid loss, hypovolemia can rapidly progress to shock. The body compensates for the decreased blood volume by increasing the heart rate to maintain cardiac output. As blood flow to vital organs diminishes, the client exhibits signs of cerebral hypoxia (restlessness and agitation) and decreased renal perfusion (oliguria, defined as less than 30 mL/hr). Recognizing this cluster of systemic signs is essential for prompt intervention.

Step-by-Step Solution

Identify the client's primary risk factor based on the admission diagnosis.

The client has severe gastroenteritis, which places them at high risk for fluid volume deficit and hypovolemic shock.

Understanding the baseline risk directs the focus toward signs of perfusion and hydration status.

Analyze each assessment finding to differentiate between expected symptoms and signs of systemic deterioration.

Abdominal cramping, slight memory gaps, and a low-grade temperature are expected or stable findings. Restlessness, tachycardia, and oliguria represent acute systemic changes.

Systemic complications like shock present with compensatory mechanisms (such as tachycardia) and signs of decreased end-organ perfusion.

Prioritize the findings that indicate a threat to circulation and airway/breathing (ABCs).

The increasing heart rate, very low urine output, and acute neurological changes confirm compromised circulation.

Immediate escalation to the RN is required when airway, breathing, or circulation is compromised.

Key Concept

Recognition of early hypovolemic shock and inadequate tissue perfusion

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