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Question 561Question →

Following a right knee arthroplasty, a 74-year-old client is admitted to the orthopedic unit. The client's baseline mental status was alert and oriented. During a routine check, the practical nurse finds the client newly confused and persistently attempting to get out of bed. The client's heart rate is 118 beats/min, respiratory rate is 24 breaths/min, and blood pressure is 106/58 mm Hg. The closed-suction drain has accumulated 260 mL of bright red fluid within the last hour. Which action should the nurse prioritize?

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Answer: Alert the registered nurse immediately regarding the change in condition and increased drainage

Answer

The priority action is to alert the registered nurse immediately regarding the change in condition and increased drainage.
The client is displaying early signs of hypovolemic shock due to significant postoperative hemorrhage, evidenced by 260 mL of bright red drainage in a single hour. Tachycardia, tachypnea, and sudden confusion (due to decreased cerebral perfusion) are compensatory mechanisms indicating compromised circulation. The absolute priority for the practical nurse is escalating this unstable condition to the registered nurse for immediate medical intervention.

Step-by-Step Solution

1
Analyze the client's assessment data.
Identifies 260 mL of bright red drainage in one hour, accompanied by tachycardia, tachypnea, and new-onset confusion.
To determine the physiological significance of the physical findings and vital signs.
2
Correlate the clinical picture with potential postoperative complications.
Recognizes a pattern indicating acute blood loss and early compensatory hypovolemic shock.
To differentiate between expected postoperative recovery and a life-threatening emergency.
3
Determine the priority nursing intervention based on scope of practice.
Selects immediate escalation to the registered nurse for collaborative emergency management.
Hemodynamic instability requires immediate medical and RN intervention outside the independent scope of a practical nurse.

Key Concept

Hypovolemic Shock Recognition and Prioritization
Question 562Question →

A practical nurse (PN) is prioritizing care for a group of clients on a postoperative medical-surgical unit. Which actions by the PN demonstrate safe clinical judgment and appropriate risk reduction strategies? Select all that apply.

Select all that apply

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Answer: Notifying the registered nurse immediately about a morning serum potassium level of 2.8 mEq/L (2.8 mmol/L) for a client receiving continuous gastric suction.; Verifying a client's identity by having them state their full name and date of birth before administering a scheduled oral anticoagulant.; Assessing a client's peripheral pulses, skin temperature, and capillary refill distal to a newly placed femoral arterial line.

Answer

The correct risk reduction actions are notifying the registered nurse of the critically low potassium level, verifying the client's identity with two identifiers before medication administration, and assessing the neurovascular status distal to the newly placed arterial line.
Safe clinical judgment and risk reduction require the practical nurse to proactively monitor for complications, adhere to safety protocols, and operate strictly within their designated scope of practice. Reporting a critically low potassium level prevents life-threatening cardiac arrhythmias. Verifying two distinct client identifiers before giving a high-risk medication prevents severe medication administration errors. Assessing the neurovascular status distal to an arterial line ensures early detection of compromised tissue perfusion and ischemia.

Step-by-Step Solution

1
Analyze the scope of practice and priority safety protocols for a practical nurse.
Identify that the PN must recognize life-threatening physiological trends, escalate abnormal diagnostic findings, and perform fundamental safety checks.
Risk reduction requires proactive monitoring, strict adherence to protocols, and operating within established clinical boundaries.
2
Evaluate the correct actions for physiological integrity.
Escalating a potassium level of 2.8 mEq/L, verifying two client identifiers, and performing neurovascular checks distal to an arterial line are all necessary, safe, and within scope.
These specific actions directly prevent cardiac emergencies, medication errors, and ischemic tissue damage.
3
Evaluate the incorrect actions against standard safety and escalation protocols.
Dismissing tachycardia and hypotension as pain, delaying the reporting of a critically low hemoglobin (6.4 g/dL), and administering IV push opioids are unsafe actions.
These actions demonstrate a failure to recognize early shock, a failure to appropriately escalate critical labs, and operating outside the practical nurse's legal scope of practice.

Key Concept

Clinical Judgment and Risk Mitigation in Practical Nursing
Question 563Question →

A practical nurse (PN) is assisting a healthcare provider with a bedside thoracentesis for a client diagnosed with a large pleural effusion. In what order should the PN perform the following actions to minimize the risk of complications and ensure client safety? Arrange the actions from first to last.

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Answer

The correct sequence of actions requires the practical nurse to first verify informed consent, position the client safely to expand the ribs, monitor respiratory status during aspiration, apply an occlusive dressing immediately upon needle withdrawal, and finally ensure a follow-up chest X-ray is completed.
Risk reduction during invasive bedside procedures follows a chronological progression to protect the client. It begins with pre-procedural safety checks (verifying consent), moves to optimal anatomical preparation (upright leaning position) to prevent injury, involves continuous intra-procedural vigilance (oxygen saturation monitoring) for acute complications, utilizes immediate post-procedural site care (occlusive dressing) to prevent air entry, and concludes with post-procedural diagnostic verification (chest X-ray) to definitively rule out a collapsed lung.

Step-by-Step Solution

1
Verify the informed consent.
The client is legally and ethically cleared for the procedure.
Risk reduction begins with confirming that the client is aware of the procedural risks and has agreed to proceed.
2
Position the client upright and leaning forward over a table.
The ribs are separated and the pleural space is safely accessible.
This anatomical positioning pushes the diaphragm down and opens the intercostal spaces, heavily reducing the risk of a lung puncture by the needle.
3
Monitor vital signs and oxygen saturation during the aspiration.
Early signs of respiratory distress are immediately identified.
Removing fluid from the pleural space can cause fluid shifts or accidental lung injury; continuous monitoring ensures rapid intervention if status deteriorates.
4
Apply a sterile occlusive dressing upon needle removal.
The pleural space is sealed from the outside environment.
An airtight seal prevents air from being sucked into the negative-pressure pleural space, which would cause a collapsed lung.
5
Prepare for a post-procedure chest X-ray.
Internal structures are radiologically visualized.
An X-ray is the gold standard for confirming that no iatrogenic pneumothorax occurred during the procedure.

Key Concept

Nursing responsibilities and complication prevention during a thoracentesis
Question 564Question →

A client with a history of congestive heart failure is prescribed daily oral furosemide. During morning rounds, the practical nurse gathers data before administering the medication. The electronic health record displays a morning serum potassium level of 2.8 mEq/L2.8 \text{ mEq/L}. The client's current vital signs are: blood pressure 94/56 mmHg94/56 \text{ mmHg}, heart rate 114 bpm114 \text{ bpm}, and respiratory rate 18 breaths/min18 \text{ breaths/min}. What is the priority action by the nurse?

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Answer: Withhold the furosemide and immediately report the clinical findings to the supervising registered nurse.

Answer

The most appropriate action is to withhold the scheduled furosemide and report the critical potassium level and vital signs to the registered nurse.
Furosemide is a potent loop diuretic that causes the kidneys to excrete excess fluid along with essential electrolytes, particularly potassium. A serum potassium level of 2.8 mEq/L indicates significant hypokalemia (normal range is 3.5 to 5.0 mEq/L). Furthermore, the client's rapid heart rate (114 bpm) and low blood pressure (94/56 mmHg) are early clinical indicators of hypovolemia (fluid volume deficit). Administering the medication under these conditions could induce severe shock or fatal cardiac dysrhythmias. Therefore, the priority and safest action for a practical nurse is to withhold the dose and immediately notify the registered nurse or healthcare provider.

Step-by-Step Solution

1
Evaluate the laboratory data.
The client's serum potassium is 2.8 mEq/L2.8 \text{ mEq/L}.
Normal serum potassium is 3.53.5 to 5.0 mEq/L5.0 \text{ mEq/L}. A level of 2.8 mEq/L2.8 \text{ mEq/L} indicates severe hypokalemia.
2
Evaluate the client's vital signs.
The blood pressure is 94/56 mmHg94/56 \text{ mmHg} and the heart rate is 114 bpm114 \text{ bpm}.
Tachycardia and relative hypotension are early compensatory signs of fluid volume deficit (hypovolemia).
3
Analyze the pharmacological effects of the prescribed medication.
Furosemide is a potassium-wasting loop diuretic.
Administering furosemide will further deplete both the body's fluid volume and serum potassium levels.
4
Determine the safest clinical action within the practical nurse's scope of practice.
The nurse must withhold the medication and escalate the findings.
A practical nurse must advocate for client safety by holding contraindicated medications and communicating critical data to the directing registered nurse or provider.

Key Concept

Adverse effects of loop diuretics, recognition of hypokalemia and hypovolemia, and practical nurse scope of practice regarding medication safety.
Question 565Question →

A practical nurse is caring for a client with a history of heart failure who is scheduled to receive a routine morning dose of oral furosemide. The client's morning basic metabolic panel reveals a serum potassium level of 2.7 mEq/L (mmol/L). During data collection, the client reports feeling generalized muscle weakness, and the practical nurse notes an irregular apical pulse of 106 beats per minute. What is the most appropriate action for the practical nurse to take?

Show answer & explanation

Answer: Withhold the morning dose of furosemide and immediately alert the supervising registered nurse.

Answer

The correct action is to withhold the morning dose of furosemide and immediately notify the registered nurse.
The client's serum potassium level of 2.7 mEq/L is critically low (normal range is typically 3.5 to 5.0 mEq/L). Furosemide is a loop diuretic that causes potassium excretion. Administering this medication would further lower the potassium level, increasing the risk of life-threatening cardiac dysrhythmias, which are already suggested by the client's irregular heart rate and muscle weakness. The practical nurse must safely withhold the drug and escalate this critical finding to the registered nurse or healthcare provider to reduce risk potential.

Step-by-Step Solution

1
Analyze the laboratory results against normal reference ranges.
The serum potassium level of 2.7 mEq/L is critically low (normal is 3.5 to 5.0 mEq/L).
Identifying abnormal laboratory values is essential to determine the client's current physiological stability.
2
Evaluate the clinical findings in the context of the laboratory results.
The client's muscle weakness and irregular tachycardia are classic clinical manifestations of severe hypokalemia.
Correlating lab data with physical symptoms confirms the client is experiencing adverse physiological effects.
3
Determine the pharmacological impact of the scheduled medication.
Furosemide is a loop diuretic that promotes the excretion of potassium in the urine.
Administering this medication would further deplete the client's already critical potassium levels.
4
Select the safest nursing intervention based on the practical nurse's scope of practice.
The practical nurse must withhold the contraindicated medication and escalate the critical findings to the registered nurse or provider.
Preventing harm by holding the drug and ensuring a higher level of care is initiated fulfills the requirement to reduce risk potential.

Key Concept

Recognizing critical laboratory values and mitigating risks associated with pharmacological therapies
Question 566Question →

A practical nurse is assigned to care for a client who is prescribed oral levofloxacin, subcutaneous regular insulin, and an intravenous (IV) push dose of ondansetron. The client's morning laboratory results reveal a serum potassium level of 2.9 mEq/L2.9\text{ mEq/L}. Which of the following actions are appropriate for the practical nurse to take? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Request that the registered nurse administer the intravenous push ondansetron.; Report the morning serum potassium result to the registered nurse or healthcare provider immediately.; Verify the client's identity using two distinct identifiers prior to any medication administration.

Answer

The appropriate actions are to request the registered nurse to administer the IV push medication, report the critical potassium level immediately, and verify the client's identity using two identifiers prior to any administration.
The correct actions prioritize client safety and adhere to the practical nurse scope of practice. Requesting the registered nurse to administer the IV push medication is correct because IV push administration requires advanced clinical judgment outside the practical nurse's scope. Reporting the serum potassium level of 2.9 mEq/L2.9\text{ mEq/L} is correct because this is a critical value (normal is 3.5 to 5.0 mEq/L3.5\text{ to }5.0\text{ mEq/L}) requiring prompt intervention, and administering the scheduled insulin would worsen this hypokalemia. Verifying the client's identity using two distinct identifiers prior to administration is a fundamental standard of medication safety.

Step-by-Step Solution

1
Analyze the practical nurse scope of practice regarding the prescribed medication routes.
The practical nurse can administer oral and subcutaneous medications, but intravenous (IV) push medications require a registered nurse.
To ensure care is delegated and provided within legal and safety boundaries.
2
Evaluate the provided morning laboratory results.
The serum potassium level is 2.9 mEq/L2.9\text{ mEq/L}, which indicates significant hypokalemia (normal range: 3.5 to 5.0 mEq/L3.5\text{ to }5.0\text{ mEq/L}).
To identify any contraindications or need for immediate medical intervention before giving scheduled medications.
3
Assess the relationship between the prescribed medications and the abnormal laboratory value.
Regular insulin causes potassium to shift into cells, which would dangerously exacerbate the client's hypokalemia. The medication must be withheld and the lab value reported.
To prevent iatrogenic harm from medication administration.
4
Apply standard medication administration safety principles.
Two distinct client identifiers must always be verified before, not after, administering any medication.
To adhere to the standard rights of medication administration and prevent errors.

Key Concept

Delegation, Scope of Practice, and Medication Safety
Question 567Question →

An older adult client with a history of congestive heart failure and chronic bronchitis is receiving inpatient care. The practical nurse observes that the client, who was alert and oriented two hours prior, has suddenly become highly agitated, is attempting to climb over the bed rails, and is unable to answer simple questions. Which of the following actions should the practical nurse prioritize?

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Answer: Apply a pulse oximeter to evaluate the client's current oxygen saturation level.

Answer

The practical nurse should prioritize applying a pulse oximeter to evaluate the client's current oxygen saturation level.
The correct action is to apply a pulse oximeter. In clinical practice, sudden onset of restlessness, agitation, or confusion—especially in a client with cardiopulmonary comorbidities—is one of the earliest signs of hypoxia. Using the ABC (Airway, Breathing, Circulation) framework, the nurse must prioritize assessing respiratory status before implementing any other interventions.

Step-by-Step Solution

1
Identify the acute change in the client's condition.
The client has transitioned from alert and oriented to highly agitated and confused within a short timeframe.
Recognizing a sudden change in mental status is the first step in identifying a physiological decompensation.
2
Apply the ABC (Airway, Breathing, Circulation) priority framework to the client's symptoms and history.
The client has a history of congestive heart failure and chronic bronchitis, putting them at high risk for respiratory compromise.
In clients with cardiopulmonary disease, sudden restlessness and confusion are classic early indicators of hypoxia.
3
Select the intervention that addresses the highest priority physiological need.
Assessing oxygenation via pulse oximetry provides immediate data on the 'Breathing' component of the ABCs.
Before treating symptoms with medications or restraints, the underlying life-threatening cause must be investigated.

Key Concept

Prioritization of Airway and Breathing (ABCs) in Acute Decompensation
Question 568Question →

An older adult resident in a long-term care facility is prescribed daily oral digoxin and hydrochlorothiazide. During the morning assessment, the resident reports a sudden onset of poor appetite, nausea, and severe fatigue. The electronic health record indicates a morning serum potassium level of 3.0 mEq/L3.0\text{ mEq/L}. Which action is most appropriate for the practical nurse to take?

Show answer & explanation

Answer: Withhold the scheduled digoxin dose and promptly report the findings to the supervising registered nurse.

Answer

Withhold the scheduled digoxin dose and promptly report the findings to the supervising registered nurse.
The correct action is to withhold the medication and escalate the findings. The resident is exhibiting signs of digoxin toxicity (nausea, anorexia, fatigue), which is closely linked to the abnormally low potassium level of 3.0 mEq/L3.0\text{ mEq/L}. Hydrochlorothiazide is a potassium-wasting diuretic that frequently causes hypokalemia. The practical nurse's priority is client safety, which requires holding the dangerous medication and notifying the registered nurse for further assessment.

Step-by-Step Solution

1
Analyze the resident's clinical symptoms.
The resident has a sudden onset of poor appetite, nausea, and severe fatigue.
These are classic early signs of digoxin toxicity, which must be closely monitored in older adults.
2
Evaluate the laboratory values provided in the context of the prescribed medications.
The serum potassium level is 3.0 mEq/L3.0\text{ mEq/L}.
A normal potassium level is 3.5 to 5.0 mEq/L3.5\text{ to }5.0\text{ mEq/L}. A level of 3.0 mEq/L3.0\text{ mEq/L} indicates hypokalemia (likely caused by the hydrochlorothiazide), which significantly increases the heart's sensitivity to digoxin and the risk of toxicity.
3
Determine the appropriate nursing action based on the practical nurse scope of practice.
The nurse must withhold the digoxin and notify the registered nurse.
Administering the medication could cause severe harm. The practical nurse must recognize the abnormal findings, ensure client safety by holding the drug, and escalate the situation to the registered nurse or provider for medical evaluation.

Key Concept

Digoxin Toxicity and Hypokalemia Management
Question 569Question →

A practical nurse (PN) is monitoring a client who had a laparoscopic appendectomy 4 hours ago. The client is resting in bed and states, 'I feel very tired and a little lightheaded.' The PN collects the following vital signs: blood pressure 90/56 mm Hg, heart rate 118 beats/minute, respiratory rate 22 breaths/minute, and oxygen saturation 96% on room air. The client's baseline preoperative blood pressure was 128/78 mm Hg. Which action should the PN take first?

Show answer & explanation

Answer: Notify the registered nurse (RN) immediately regarding the vital sign changes and the client's symptoms.

Answer

The most appropriate action is to immediately notify the registered nurse (RN) regarding the vital sign changes and the client's symptoms.
The client is demonstrating early indicators of hypovolemic shock or internal hemorrhage, evidenced by tachycardia, hypotension, and lightheadedness following an abdominal surgery. The primary responsibility of the practical nurse in this scenario is to reduce the risk of further complications by immediately recognizing these critical changes and escalating the situation to the registered nurse (RN) or healthcare provider for advanced assessment and medical intervention.

Step-by-Step Solution

1
Analyze the client's vital signs compared to their baseline.
The client has a new onset of tachycardia (118 beats/minute) and hypotension (90/56 mm Hg) compared to their preoperative baseline.
Identifying significant deviations from baseline vital signs is crucial for detecting postoperative complications.
2
Correlate the objective data with the client's subjective symptoms.
The client's reports of fatigue and lightheadedness align with decreased cardiac output and inadequate tissue perfusion.
Combining subjective and objective data helps form a complete clinical picture of early hypovolemic shock.
3
Determine the appropriate nursing intervention based on the practical nurse's scope of practice.
The priority action is to immediately report the findings to the RN or healthcare provider.
Practical nurses must recognize signs of instability and promptly escalate care to ensure patient safety and reduce the risk of further deterioration.

Key Concept

Recognizing and Escalating Early Signs of Postoperative Shock
Question 570Question →

A client with a history of angina is prescribed a daily nitroglycerin transdermal patch. Place the following steps for administering this transdermal medication in the correct chronological order.

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Answer

The correct sequence requires the nurse to first protect themselves by putting on gloves, then remove the old patch, clean both sites, prepare the new patch without touching the adhesive, and finally apply it securely to a new site.
Applying a transdermal patch requires sequential steps to ensure client safety and protect the nurse. The nurse must first put on gloves to avoid absorbing the medication. Next, the old patch is removed and disposed of to prevent an overdose. The skin at both the old and new sites is washed to remove residual medication and ensure proper adhesion. The backing of the new patch is then peeled off carefully, avoiding the adhesive. Finally, the patch is applied to a clean, hairless site and pressed firmly to secure it.

Step-by-Step Solution

1
Perform hand hygiene and put on clean gloves.
The nurse's hands are protected from the medication.
Nitroglycerin is readily absorbed through the skin; gloves prevent the nurse from experiencing adverse effects like headaches or hypotension.
2
Remove the existing transdermal patch and fold it with the adhesive sides together.
The continuous delivery of the previous dose is stopped.
Leaving the old patch on while applying a new one causes medication overdose and severe hypotension.
3
Cleanse the previous application site and the newly selected site with mild soap and water.
Residual medication is removed and the new site is prepared.
This prevents continued absorption from the old site and removes oils or debris from the new site to ensure the patch sticks properly.
4
Peel the protective backing from the new patch without touching the medication surface.
The adhesive is exposed while keeping the dose intact.
Touching the adhesive can rub off some of the medication, leading to an inaccurate dose.
5
Apply the patch to a clean, hairless area of the upper body and press firmly.
The patch is secured for the prescribed duration.
Firm pressure ensures an adequate seal against the skin for steady absorption, while a hairless site prevents the patch from loosening.

Key Concept

Safe Administration of Transdermal Medications
Question 571Question →

A 45-year-old client is 6 hours post-operative following an abdominal hysterectomy. The client reports incisional pain rated as 7 on a 0 to 10 scale and appears increasingly restless. The practical nurse (PN) obtains the following vital signs: heart rate 116 beats/minute, blood pressure 100/60 mm Hg, respiratory rate 20 breaths/minute, and oxygen saturation 96% on room air. Which action should the PN take first?

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Answer: Check the surgical incision site and underneath the client for signs of hemorrhage.

Answer

The priority action is to check the surgical incision site and underneath the client for signs of hemorrhage.
The correct answer correctly prioritizes data collection for a potential life-threatening complication. Tachycardia, restlessness, and borderline low blood pressure are early compensatory signs of hypovolemic shock due to hemorrhage. Following the ABCs (Airway, Breathing, Circulation), the nurse must first check for bleeding (circulation) before taking other actions.

Step-by-Step Solution

1
Analyze the client's vital signs and clinical presentation.
The client presents with tachycardia (116 bpm), borderline hypotension (100/60 mm Hg), and unexpected restlessness 6 hours after major surgery.
Identifying abnormal data points is the essential first step in clinical judgment.
2
Correlate the assessment findings with potential post-operative complications.
The combination of tachycardia, borderline low blood pressure, and restlessness strongly suggests early hypovolemic shock (likely due to internal or external bleeding) rather than just pain or anxiety.
Recognizing physiological adaptation to blood loss allows the nurse to anticipate life-threatening conditions.
3
Determine the priority nursing intervention based on the ABCs (Airway, Breathing, Circulation).
The priority is to assess circulation by checking for active bleeding at the surgical site and pooling under the client.
Data collection regarding the most immediate life-threatening condition (circulation/shock) takes precedence over symptom management like pain relief.

Key Concept

Early recognition of hypovolemic shock and prioritization of circulatory assessment in post-operative clients.
Question 572Question →

A practical nurse is preparing a client who is scheduled for an abdominal paracentesis to treat severe ascites. In what order should the nurse perform the following preparatory actions? Arrange the steps from first to last.

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Answer

The correct sequence of actions is to first verify informed consent, then have the client empty their bladder, followed by obtaining baseline measurements, and finally positioning the client upright.
The standard of care for assisting with a paracentesis dictates a specific logical flow to ensure client safety. Administrative and legal checks (consent) must occur first. Next, the client must empty their bladder while they are still ambulatory or easily movable to eliminate the primary procedural risk (bladder puncture). Once the bladder is empty, true baseline measurements of weight, girth, and vital signs can be taken immediately prior to the intervention. Finally, the client is placed in the optimal anatomical position (upright) for the provider to begin the sterile procedure.

Step-by-Step Solution

1
Verify that the informed consent document has been signed.
Legal and facility requirements for the invasive procedure are met.
Consent is the absolute first prerequisite before any invasive procedure preparations begin.
2
Instruct the client to empty their bladder completely.
The bladder size is reduced, moving it down into the pelvic cavity.
This greatly reduces the risk of accidental bladder perforation during needle insertion, which is a major safety priority.
3
Measure baseline vital signs and abdominal girth.
Accurate pre-procedure data is recorded.
Because fluid removal can cause fluid shifts leading to hypotension or hypovolemic shock, having an immediate pre-procedure baseline is essential for comparison.
4
Assist the client into a sitting position on the edge of the bed.
The client is in the correct position for the healthcare provider to begin.
Gravity pulls the fluid down to the lower abdomen, minimizing the risk of puncturing the bowel or other internal organs.

Key Concept

Preparation for a paracentesis requires specific risk reduction measures, most notably having the client empty their bladder to prevent accidental puncture, and establishing vital sign baselines to monitor for subsequent hypovolemia.
Estimated Time:1m 0s
Question 573Question →

A practical nurse is evaluating a client who underwent a percutaneous coronary intervention via the right femoral approach two hours ago. The client reports a new sensation of right flank fullness. The client's heart rate is 114 beats per minute and blood pressure is 92/58 mm Hg. The femoral insertion site dressing is completely dry. Which action should the nurse take first?

Show answer & explanation

Answer: Escalate the clinical findings to the supervising registered nurse without delay.

Answer

The nurse must escalate the clinical findings to the supervising registered nurse without delay.
The correct action is to immediately report the findings. Flank pain, tachycardia, and hypotension following a femoral arterial procedure are classic signs of retroperitoneal hemorrhage. Because the bleeding is internal, the external dressing remains dry. This is a life-threatening emergency that requires immediate medical intervention, making escalation the priority action for a practical nurse.

Step-by-Step Solution

1
Analyze the client's symptoms and vital signs.
The client has right flank fullness, tachycardia (114 beats per minute), and hypotension (92/58 mm Hg).
Identifying abnormal clinical data is the first step in recognizing potential complications.
2
Correlate the findings with the recent procedure (right femoral approach percutaneous coronary intervention).
The combination of flank pain and signs of hypovolemic shock after a femoral procedure strongly suggests retroperitoneal bleeding, even if the external dressing is dry.
Understanding procedural risks allows the nurse to interpret the meaning of the assessment data.
3
Determine the appropriate nursing action within the practical nurse scope of practice.
The practical nurse must immediately report these critical findings to the registered nurse or healthcare provider.
Life-threatening complications require immediate escalation for medical intervention.

Key Concept

Recognizing and escalating signs of retroperitoneal hemorrhage following femoral artery access.
Question 574Question →

A client hospitalized on a medical-surgical unit reports difficulty swallowing and asks the practical nurse to crush their scheduled morning medications. The client's medication administration record includes enteric-coated aspirin, extended-release potassium chloride, and a scored acetaminophen tablet. Which action should the practical nurse take?

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Answer: Crush the scored acetaminophen tablet, withhold the aspirin and potassium chloride, and notify the registered nurse.

Answer

The practical nurse should crush only the scored acetaminophen tablet, withhold the enteric-coated aspirin and extended-release potassium chloride, and notify the registered nurse.
The correct action demonstrates safe pharmacological practice and adherence to the practical nurse's scope. Scored standard tablets like acetaminophen can be crushed. However, crushing enteric-coated aspirin destroys the coating designed to protect the stomach lining, and crushing extended-release potassium chloride causes immediate release of the entire dose, which can lead to life-threatening arrhythmias. The nurse must withhold the uncrushable medications and notify the registered nurse so alternative prescriptions can be obtained.

Step-by-Step Solution

1
Evaluate the pharmacokinetic properties of the prescribed medications.
Identify that acetaminophen is scored and safe to crush, while enteric-coated aspirin and extended-release potassium chloride cannot be crushed.
Crushing enteric-coated pills causes severe gastric irritation, and crushing extended-release pills causes immediate release of the entire dose (dose dumping), which can lead to life-threatening arrhythmias.
2
Determine the appropriate action within the practical nursing scope of practice.
Decide to administer the safe medication (acetaminophen), withhold the unsafe ones, and escalate the issue.
Practical nurses must advocate for client safety and report the need for alternative medication routes or forms to the registered nurse or healthcare provider.

Key Concept

Safe medication administration and the practical nurse's scope of practice regarding uncrushable medications.
Question 575Question →

A client recovering on an orthopedic rehabilitation unit is prescribed a scheduled dose of oral carvedilol. The practical nurse assesses the client and notes a heart rate of 52 beats per minute and a blood pressure of 94/58 mm Hg. The client states, "I feel very lightheaded today." Which action should the practical nurse take?

Show answer & explanation

Answer: Withhold the carvedilol and promptly report the client's vital signs and symptoms to the registered nurse.

Answer

The practical nurse should withhold the medication and notify the registered nurse.
Carvedilol is a beta-blocker that decreases cardiac output, heart rate, and blood pressure. The client is already experiencing bradycardia, hypotension, and symptomatic lightheadedness, which indicates decreased cerebral perfusion. Administering the medication would exacerbate these issues. The practical nurse must safely withhold the dose and communicate the findings to the supervising registered nurse for further clinical decisions.

Step-by-Step Solution

1
Analyze the client's vital signs and reported symptoms.
The heart rate is 52 bpm (bradycardia), blood pressure is 94/58 mm Hg (hypotension), and the client is lightheaded.
To determine if the scheduled medication is safe to administer based on current physiological parameters.
2
Identify the pharmacological action of carvedilol.
Carvedilol is a beta-blocker that decreases heart rate and blood pressure.
To predict how the drug will affect the client's current compromised cardiovascular status.
3
Determine the appropriate nursing intervention within the practical nurse scope of practice.
The medication must be held, and the abnormal findings must be reported to the RN or provider.
Administering the drug would worsen the condition, and modifying the dose is outside the PN scope of practice.

Key Concept

Safe administration of beta-blockers and practical nurse scope of practice regarding holding medications.
Question 576Question →

A 78-year-old client is receiving treatment for bacterial pneumonia. During afternoon rounds, the practical nurse (PN) observes that the client, who was previously alert, has suddenly become highly restless, confused, and is actively trying to remove their intravenous (IV) catheter. The client's respiratory rate has increased to 26 breaths/min. Which action should the PN take first?

Show answer & explanation

Answer: Measure the client's current oxygen saturation level.

Answer

The correct action is to measure the client's current oxygen saturation level, as sudden confusion and restlessness strongly indicate acute hypoxia.
The correct action is to measure the client's oxygen saturation because sudden restlessness, confusion, and an increased respiratory rate in a client with pneumonia are classic, early indicators of hypoxia. In the nursing process and ABC prioritization, assessing the client's breathing and oxygenation status is paramount before implementing symptom-management interventions.

Step-by-Step Solution

1
Identify the sudden change in mental status (restlessness and confusion) and increased respiratory rate.
Recognition that the client's condition has acutely decompensated.
Sudden neurological changes often have a physiological, rather than psychological, origin.
2
Correlate the client's diagnosis (bacterial pneumonia) with the new symptoms.
Hypoxia is identified as the most probable cause of the sudden agitation.
Pneumonia impairs gas exchange, leading to decreased oxygen levels in the blood and brain.
3
Prioritize interventions based on the ABCs (Airway, Breathing, Circulation).
Gathering data on the client's oxygenation status is prioritized over managing the behavioral symptoms.
Addressing a potential breathing and oxygenation deficit is critical to preventing severe physiological injury.

Key Concept

Prioritization of ABCs in Acute Hypoxia
Question 577Question →

A practical nurse (PN) is preparing to administer scheduled oral medications to a client. Upon entering the room, the PN notices the client's identification wristband has been removed and is resting on the bedside table. The client is alert and states, "They took it off to start my new IV line." Which action should the PN take first?

Show answer & explanation

Answer: Obtain a new identification band, attach it to the client, and verify two client identifiers before administration.

Answer

The PN must obtain a new identification band, attach it to the client, and verify two client identifiers before administering any medications.
Safe medication administration requires the nurse to verify the client's identity using two distinct identifiers (such as name and date of birth) against an identification band that is physically attached to the client. Administering medications without an attached band, or scanning a detached band, violates the fundamental 'right client' principle of medication safety.

Step-by-Step Solution

1
Recognize that a detached identification band invalidates the client identification process.
The current identification method is deemed unsafe for medication administration.
A detached band on a table could easily belong to a previous occupant or another client.
2
Follow facility protocol to obtain a new identification band.
A new band is printed and brought to the client's room.
The client must have an attached band for barcode scanning and verification.
3
Attach the new band to the client and verify two distinct identifiers (e.g., name and date of birth) before administering the medication.
The medication is safely administered to the correct client.
This process strictly adheres to the 'right client' principle of medication administration.

Key Concept

Medication Administration Rights: Client Identification
Question 578Question →

A practical nurse (PN) is organizing care for a group of clients on a medical-surgical unit. Which of the following nursing actions demonstrate the correct application of risk reduction principles? (Select all that apply)

Select all that apply

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Answer: Escalating a post-liver biopsy client's blood pressure of 94/58 mmHg and heart rate of 112 beats/min to the registered nurse (RN); Verifying nasogastric tube placement by checking the pH of aspirated gastric contents prior to initiating a scheduled enteral feeding; Instructing a client who is recovering from an open abdominal surgery to splint the incision with a pillow while coughing

Answer

The correct actions include escalating borderline vital signs that suggest shock, verifying nasogastric tube placement via pH testing, and instructing a postoperative client to splint their incision.
To reduce the risk of potential complications, the practical nurse must recognize early signs of clinical deterioration and implement evidence-based preventative measures. A borderline low blood pressure with tachycardia after an invasive biopsy suggests early hypovolemic shock and requires immediate escalation. Verifying gastric pH prevents the severe complication of pulmonary aspiration during tube feeding. Splinting an abdominal incision supports the wound and reduces the risk of dehiscence during coughing. These actions directly prioritize client safety.

Step-by-Step Solution

1
Evaluate each nursing action against the principles of risk reduction and safe scope of practice.
Identify which actions proactively prevent complications or appropriately address potentially life-threatening changes.
Risk reduction requires the practical nurse to combine preventative care with the immediate recognition of instability.
2
Analyze the clinical data provided in the options.
A blood pressure of 94/58 mmHg with a heart rate of 112 beats/min indicates potential bleeding. A potassium level of 2.6 mEq/L is critically low. Chest tightness is a potential cardiopulmonary emergency.
Recognizing abnormal parameters is the critical first step before deciding on the appropriate risk-reduction action.
3
Select the actions that correctly mitigate risk.
Escalating the abnormal vital signs, checking gastric pH prior to feeding, and splinting the abdominal incision are correct risk-reduction actions.
These actions directly align with patient safety guidelines and prioritize the client's physiological stability.

Key Concept

Early recognition of complications and implementation of preventative nursing measures.
Estimated Time:1m 30s
Question 579Question →

A licensed practical nurse is tasked with giving a prescribed dose of iron dextran via intramuscular injection using the Z-track method. To ensure client safety and proper medication delivery, in what chronological order should the nurse perform the following procedural steps?

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: pull the skin laterally, insert the needle at a 90-degree angle, slowly depress the plunger to instill the medication, wait 10 seconds, and finally withdraw the needle while releasing the skin.
The Z-track method is specifically utilized for intramuscular administration of highly irritating or staining medications, such as iron dextran. The technique physically misaligns the tissue layers by pulling the skin and subcutaneous tissue to the side before insertion. The needle is inserted at a 90-degree angle, followed by slow instillation of the drug. Crucially, the nurse must wait 10 seconds before removing the needle to allow tissue accommodation. Finally, withdrawing the needle and releasing the skin simultaneously creates a broken, zigzag pathway that securely traps the medication deeply within the muscle, preventing tracking into the subcutaneous layer.

Step-by-Step Solution

1
Identify the first distinct step of the Z-track method prior to needle insertion.
Pull the skin and subcutaneous tissue laterally 1 to 1.5 inches from the injection site.
Displacing the tissue is the defining first physical manipulation of the Z-track technique, setting up the shifted pathway.
2
Determine the correct needle insertion technique once the skin is displaced.
Insert the needle at a 90-degree angle to penetrate the deep muscle layer.
The needle must be inserted perpendicularly while the non-dominant hand maintains the tissue displacement.
3
Identify the action for actual drug delivery.
Depress the plunger slowly to instill the medication.
Slow injection minimizes tissue trauma and promotes gradual absorption.
4
Determine the necessary pause before needle removal.
Maintain the needle in the muscle for 10 seconds.
This dwell time provides an opportunity for the medication to disperse locally rather than forcing its way back up the needle track.
5
Identify the final coordinated step to seal the track.
Withdraw the needle smoothly and immediately release the displaced skin.
Releasing the tissue shifts the superficial puncture site away from the muscle puncture site, locking the medication deep within the tissue.

Key Concept

Z-track method for intramuscular injections
Question 580Question →

A practical nurse is completing hourly rounds on a 42-year-old client who returned from a total abdominal hysterectomy six hours ago. The client appears restless and states, "I just cannot seem to settle down." Upon reviewing the electronic flowsheet, the nurse notes the client's heart rate has climbed from 84 to 112 beats/min, and blood pressure has trended down from 126/80 to 102/64 mm Hg over the past two hours. The abdominal surgical dressing is dry and intact. Which action should the practical nurse take first?

Show answer & explanation

Answer: Notify the supervising registered nurse immediately about the vital sign trends.

Answer

The most critical action is to immediately notify the supervising registered nurse about the client's changing vital signs and symptoms.
The correct action demonstrates an understanding of risk reduction by identifying early indicators of hypovolemic shock (tachycardia, decreasing blood pressure, and restlessness) and immediately escalating the situation. Because the surgical dressing is dry, the nurse must suspect internal hemorrhage, which requires urgent evaluation and intervention beyond the practical nursing scope of practice.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has unexplained restlessness, a steadily rising heart rate (84 to 112 beats/min), and a decreasing blood pressure (126/80 to 102/64 mm Hg).
Recognizing data trends is necessary to differentiate between normal postoperative recovery and emerging complications.
2
Correlate the findings with the surgical history.
Despite a dry and intact external dressing, the vital signs point to internal hemorrhage following major abdominal surgery.
Internal bleeding is a major, life-threatening risk following a total abdominal hysterectomy that requires prompt identification.
3
Determine the priority nursing action within the practical nurse's scope of practice.
The nurse must escalate the findings to the registered nurse (RN) or healthcare provider.
Suspected internal hemorrhage and hypovolemic shock are critical conditions that mandate immediate medical evaluation and advanced RN-level interventions (e.g., rapid IV fluids, blood products).

Key Concept

Early Recognition of Hypovolemic Shock and Internal Hemorrhage
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