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Question 581Question →

A practical nurse (PN) is caring for a client who is receiving continuous enteral tube feedings. The client suddenly begins coughing vigorously, becomes cyanotic, and exhibits intercostal retractions. In what order should the PN perform the following actions? Arrange the actions from first to last.

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Answer

The correct sequence is: Stop the feeding, elevate the head of the bed, obtain vital signs, notify the RN, and then document the event.
In any acute emergency, the practical nurse must follow the Airway, Breathing, Circulation (ABC) framework. When a client receiving an enteral feeding shows signs of respiratory distress (coughing, cyanosis), aspiration is suspected. The absolute first action is to stop the feeding (Airway protection). Next, positioning the client upright assists with Breathing. Once these immediate life-saving interventions are done, the nurse assesses the client (vital signs) to gather data. This data is then reported to the RN for further intervention. Documentation is always the final step after the client's immediate needs are met.

Step-by-Step Solution

1
Stop the continuous enteral tube feeding.
The flow of formula is halted.
This is a potential aspiration event. The Airway must be protected first by removing the source of the aspiration.
2
Elevate the head of the bed to a high-Fowler's position.
The client is sitting upright.
This position facilitates optimal lung expansion, eases work of breathing, and uses gravity to keep stomach contents away from the airway.
3
Obtain current vital signs and oxygen saturation.
Baseline physiological data during the acute event is collected.
Once the immediate airway and breathing interventions are applied, the PN must gather data to determine the severity of the client's respiratory distress.
4
Notify the supervising registered nurse (RN).
The RN is made aware of the emergency.
The PN must report the acute change and the obtained vital signs so the RN can assess the client and coordinate further medical interventions.
5
Document the sudden change in condition and actions taken.
The event is recorded in the medical record.
Accurate documentation is legally and clinically necessary but is always the lowest priority during an active bedside emergency.

Key Concept

Airway, Breathing, Circulation (ABC) Prioritization in Acute Emergencies
Question 582Question →

A practical nurse is caring for an older adult client recovering from a total hip arthroplasty. The client is prescribed scheduled oral oxycodone for pain management. Upon entering the room to administer the morning dose, the nurse finds the client newly confused, lethargic, and exhibiting a respiratory rate of 9 breaths per minute. Which of the following is the priority action for the practical nurse to take?

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Answer: Withhold the dose of oxycodone and immediately report the clinical findings to the registered nurse.

Answer

The practical nurse should withhold the dose of oxycodone and immediately report the clinical findings to the registered nurse.
The client is demonstrating signs of opioid toxicity, specifically central nervous system depression (lethargy, new confusion) and respiratory depression (a respiratory rate less than 12 breaths per minute). The safest and most appropriate action within the practical nurse scope of practice is to withhold the central nervous system depressant and immediately notify the registered nurse, who can conduct a comprehensive assessment and collaborate with the healthcare provider for emergency interventions.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client is exhibiting lethargy, new-onset confusion, and a respiratory rate of 9 breaths per minute.
These are classic signs of opioid-induced respiratory depression and central nervous system depression.
2
Apply the ABCs (Airway, Breathing, Circulation) of prioritization.
The compromised breathing (bradypnea) is identified as a life-threatening priority.
Administering another dose of an opioid would further depress the respiratory drive and endanger the client's life.
3
Determine the appropriate action within the practical nurse scope of practice.
The nurse must withhold the medication and escalate the critical findings to the registered nurse.
The RN must perform a comprehensive assessment, and interventions such as administering intravenous push reversal agents are outside the scope of practice for a practical nurse.

Key Concept

Opioid toxicity monitoring and practical nurse scope of practice regarding critical client deterioration
Question 583Question →

A practical nurse is initiating a 24-hour urine collection for a client to evaluate kidney function. In what order should the nurse perform the following actions to ensure an accurate diagnostic test result?

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Answer

The correct sequence is to first have the client empty their bladder and discard the urine, record that exact time as the start, collect all subsequent voids on ice, ask for one final void at the 24-hour mark, and finally add that void to the container to send to the lab.
A 24-hour urine collection must reflect exactly 24 hours of kidney function. By discarding the first void, the nurse ensures the bladder is empty at the exact start time. Documenting the time establishes the 24-hour clock. Keeping subsequent voids on ice prevents specimen degradation. The final void at exactly 24 hours ensures the bladder is emptied at the end of the collection period, completing the exact timeframe before the specimen is sent to the laboratory.

Step-by-Step Solution

1
Instruct the client to empty their bladder and discard the initial urine.
The bladder is completely empty, ensuring no previously formed urine is included.
The 24-hour collection period must begin with an empty bladder to maintain an accurate measurement of urine output and concentration over the exact time frame.
2
Document the exact time of the discarded void.
A clear, precise 24-hour clock is initiated.
Recording the start time prevents timing errors and ensures the diagnostic test is not artificially shortened or extended.
3
Collect all subsequent urine in a container kept on ice.
All urine produced during the 24 hours is preserved.
Chilling the container prevents bacterial growth and degradation of the biochemical substances being measured by the laboratory.
4
Have the client void one last time exactly 24 hours after the start time.
The final amount of urine produced in the period is obtained.
This captures the final fraction of urine for the exact 24-hour window, ensuring the collection is fully complete.
5
Add the final void to the main container and send to the laboratory.
The collection is finalized and ready for processing.
Immediate transport prevents further degradation of the sample once the collection timeframe ends.

Key Concept

Accurate Specimen Collection and Diagnostic Preparation
Estimated Time:1m 30s
Question 584Question →

A practical nurse is preparing to administer cephalexin oral suspension to a pediatric client who weighs 39.6 lb. The healthcare provider's prescription is for 15 mg/kg/dose to be administered every 12 hours. The pharmacy dispenses a cephalexin suspension concentration of 125 mg/5 mL. How many mL should the practical nurse administer per dose? (Record your answer to the nearest tenth. Do not include units in your answer.)

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Answer: 10.8

Answer

10.8
To determine the correct volume, first convert the weight to kilograms (39.6 ÷ 2.2 = 18 kg). Next, find the required dose in milligrams (18 kg × 15 mg/kg = 270 mg). Finally, use the formula (Desired / Have) × Volume to find the correct volume to administer ((270 mg / 125 mg) × 5 mL = 10.8 mL).

Step-by-Step Solution

1
Convert the client's weight from pounds to kilograms.
39.6 lb ÷ 2.2 lb/kg = 18 kg
The medication dosage is prescribed based on the client's weight in kilograms.
2
Calculate the desired dose in milligrams.
18 kg × 15 mg/kg = 270 mg/dose
This determines the exact amount of medication the client needs for one single administration.
3
Calculate the volume of medication to administer.
(270 mg / 125 mg) × 5 mL = 2.16 × 5 mL = 10.8 mL
Using the dose calculation formula determines the correct liquid amount to draw up.

Key Concept

Weight-based medication dosage calculation and liquid volume conversion
Question 585Question →

A practical nurse (PN) is caring for a client who has a nasogastric (NG) tube connected to low continuous suction. The client's morning comprehensive metabolic panel reveals a serum potassium level of 2.8 mEq/L. The client's current vital signs are: blood pressure 98/58 mm Hg, heart rate 114 beats/min, and respiratory rate 18 breaths/min. The client is scheduled to receive an oral dose of digoxin in 30 minutes. Which action is the priority for the PN?

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Answer: Withhold the scheduled digoxin and immediately report the potassium level and vital signs to the registered nurse.

Answer

The priority action is to withhold the scheduled digoxin and immediately report the critical laboratory findings and vital signs to the registered nurse.
The correct answer identifies that a serum potassium level of 2.8 mEq/L is critically low (hypokalemia). Because hypokalemia significantly increases the risk of digoxin toxicity, administering the medication could provoke life-threatening cardiac dysrhythmias. The client's borderline hypotension and tachycardia further indicate physiological compromise. The safest and most appropriate action for the practical nurse is to withhold the dose and immediately notify the registered nurse for further intervention.

Step-by-Step Solution

1
Analyze the laboratory values.
The serum potassium level is 2.8 mEq/L, which indicates severe hypokalemia (normal is 3.5 to 5.0 mEq/L).
Nasogastric suction removes potassium-rich gastric fluids, leading to depletion.
2
Evaluate the clinical risks associated with the medications.
The client is scheduled to receive digoxin. Hypokalemia drastically increases the risk of digoxin toxicity.
Digoxin toxicity can precipitate life-threatening cardiac dysrhythmias, especially when potassium is low.
3
Assess the vital signs.
The blood pressure (98/58 mm Hg) and heart rate (114 beats/min) are abnormal.
These borderline vital signs indicate early cardiovascular compromise, hypovolemia, or developing dysrhythmia.
4
Determine the safest nursing action within the PN scope of practice.
The PN must withhold the digoxin and immediately escalate the situation.
Administering the medication could cause harm, and the client requires immediate RN and provider intervention for electrolyte replacement and stabilization.

Key Concept

Reduction of Risk Potential: Recognizing critical laboratory values (hypokalemia) and preventing medication complications (digoxin toxicity).
Question 586Question →

While conducting a scheduled assessment on an older adult client two days after an intestinal resection, the practical nurse observes that the client has become suddenly restless and disoriented. The client's vital signs are a heart rate of 118 beats per minute, a blood pressure of 96/58 mm Hg, and a respiratory rate of 26 breaths per minute. Which interventions should the practical nurse implement? Select all that apply.

Select all that apply

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Answer: Alert the charge registered nurse immediately about the acute changes in mental status and hemodynamics; Examine the surgical incision site and any drainage systems for evidence of hemorrhage; Verify that the client's airway is clear and initiate supplemental oxygen therapy per facility protocol

Answer

The correct interventions are to alert the charge registered nurse, examine the surgical site for bleeding, and verify airway patency while preparing to administer oxygen.
The client is exhibiting classic early signs of hypovolemic shock, likely due to postoperative hemorrhage. These signs include unexplained restlessness, tachycardia, tachypnea, and borderline hypotension. The practical nurse must prioritize airway and oxygenation, assess for the source of bleeding at the surgical site, and immediately escalate the situation to the registered nurse for advanced medical orders.

Step-by-Step Solution

1
Analyze the client's new-onset symptoms: restlessness, disorientation, tachycardia, tachypnea, and borderline hypotension.
Identify these as classic compensatory signs of early hypovolemic shock, likely due to internal bleeding following the recent intestinal surgery.
Recognizing early shock is critical because delaying intervention until blood pressure profoundly drops can lead to irreversible organ damage.
2
Determine the appropriate priority nursing interventions within the practical nurse scope of practice.
Select actions that support airway and breathing (oxygen), assess the source of the problem (checking the surgical site), and escalate the critical situation (notifying the registered nurse).
The practical nurse must immediately address life-threatening physiological adaptations before attending to routine tasks or assuming findings are benign.

Key Concept

Early Recognition and Prioritization of Hypovolemic Shock
Estimated Time:1m 30s
Question 587Question →

A practical nurse (PN) is caring for a client who underwent a right total hip arthroplasty (posterior approach) 24 hours ago. Which of the following nursing actions should the PN implement to reduce the risk of postoperative complications? (Select all that apply.)

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Answer: Maintain the client's right leg in an abducted position using a designated wedge pillow.; Notify the registered nurse (RN) regarding a morning hemoglobin level of 7.9 g/dL.; Encourage the client to use the incentive spirometer 10 times every hour while awake.

Answer

The correct actions are maintaining the leg in an abducted position, notifying the RN of the critical hemoglobin level, and encouraging incentive spirometry.
Maintaining abduction prevents hip dislocation. Notifying the RN of a low hemoglobin level ensures timely intervention for potential hemorrhage. Incentive spirometry prevents respiratory complications like atelectasis.

Step-by-Step Solution

1
Evaluate each action for its safety and effectiveness in preventing postoperative complications.
Identified that abduction, lung expansion, and reporting critical labs are safe and necessary actions.
Postoperative care requires interventions that directly address risks such as dislocation, atelectasis, and hemorrhage.
2
Analyze the remaining actions for safety hazards or contraindications.
Identified that acute hip flexion, ignoring shock indicators, and bypassing proper medication verification are unsafe.
These actions increase the client's risk for dislocation, delayed treatment of shock, and medication administration errors.

Key Concept

Postoperative Risk Reduction and Patient Safety
Question 588Question →

A practical nurse (PN) is providing care for a group of clients on a medical-surgical unit. Which of the following actions by the PN demonstrate safe pharmacological practice and appropriate adherence to the PN scope of practice? Select all that apply.

Select all that apply

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Answer: Withholds a scheduled dose of oral potassium chloride and notifies the registered nurse (RN) after noting a morning serum potassium level of 5.9 mEq/L.; Administers scheduled oral levothyroxine to a client on an empty stomach, 30 to 60 minutes before the breakfast tray arrives.; Reinforces dietary teaching for a client prescribed oral warfarin by reviewing a list of foods high in vitamin K provided by the RN.

Answer

The correct actions include withholding the potassium dose due to an elevated lab value and notifying the RN, administering levothyroxine on an empty stomach, and reinforcing established dietary teaching for warfarin.
Safe pharmacological practice within the PN scope involves verifying pertinent laboratory values before administration to prevent toxicity, ensuring the correct timing of medications like levothyroxine for maximum efficacy, and actively reinforcing educational plans previously established by the RN.

Step-by-Step Solution

1
Evaluate each action against medication safety protocols and the practical nurse (PN) scope of practice.
Identified which actions reflect safe practices and which represent scope or safety violations.
Safe pharmacological therapy requires adherence to both correct administration techniques and legal scope limitations.
2
Identify correct medication administration practices.
Withholding potassium when levels are high (5.9 mEq/L) and giving levothyroxine on an empty stomach are correct pharmacological interventions.
These actions prevent dangerous drug toxicity and ensure optimal medication absorption.
3
Analyze delegation and teaching responsibilities.
Reinforcing an RN-developed teaching plan is within the PN scope. However, initiating and titrating IV insulin is beyond the PN scope.
PNs support the primary RN teaching plan but do not independently manage high-risk, titratable continuous IV infusions.
4
Assess client identification and adverse reaction monitoring protocols.
Asking a family member for patient ID is unsafe; confusion after opioid administration must be reported as a potential adverse effect, not normal aging.
Strict adherence to two independent patient identifiers is mandatory, and acute changes in mentation always indicate a need for further assessment for drug toxicity.

Key Concept

Safe medication administration and adherence to the Practical Nurse (PN) scope of practice, which includes monitoring for adverse effects, checking relevant lab values prior to administration, and reinforcing established client education.
Question 589Question →

While preparing morning treatments on a telemetry unit, a licensed practical nurse checks the latest laboratory values for a client who takes warfarin sodium daily for atrial fibrillation. The laboratory report indicates an International Normalized Ratio (INR) of 5.5. What is the appropriate nursing action concerning the morning dose of this anticoagulant?

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Answer: Hold the scheduled dose and urgently report the elevated value to the primary registered nurse.

Answer

Hold the scheduled dose and urgently report the elevated value to the primary registered nurse.
The therapeutic INR range for a client on warfarin therapy is typically 2.0 to 3.0. An INR of 5.5 is critically high and indicates a significant risk for spontaneous bleeding. The LPN's scope of practice requires recognizing this critical laboratory value, withholding the medication that would exacerbate the condition, and immediately reporting the finding to the supervising registered nurse or healthcare provider for further medical orders.

Step-by-Step Solution

1
Identify the client's current medication and the corresponding laboratory result.
The client is taking warfarin, an anticoagulant, and has an INR of 5.5.
Evaluating relevant laboratory values prior to medication administration is essential for client safety.
2
Compare the client's INR to the expected therapeutic range for warfarin.
The normal therapeutic INR range for a client with atrial fibrillation is 2.0 to 3.0. An INR of 5.5 is critically high.
Recognizing a supratherapeutic level determines whether the medication is safe to administer.
3
Determine the appropriate nursing intervention based on the critical laboratory finding and the LPN scope of practice.
The nurse must hold the medication to prevent hemorrhage and immediately escalate the finding to the supervising registered nurse.
Administering the drug would increase the bleeding risk, and altering dosages independently is outside the LPN scope of practice.

Key Concept

Recognizing critical laboratory values related to pharmacological therapies and adhering to pre-administration withholding criteria within the LPN scope of practice.
Question 590Question →

A practical nurse reviews the morning electronic health record for a client with end-stage renal disease who is awaiting their scheduled afternoon hemodialysis treatment. The client's serum potassium level is reported at 6.8 mEq/L (6.8 mmol/L). The client is currently resting quietly in bed and denies any physical distress. Which action should the practical nurse take first?

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Answer: Report the laboratory results to the registered nurse immediately for prompt medical evaluation.

Answer

The correct action is to immediately report the critical laboratory results to the registered nurse so that prompt medical evaluation and emergency treatment can be initiated.
The correct answer addresses the immediate physiological threat. A potassium level of 6.8 mEq/L is critically high and severely alters myocardial cell depolarization. This places the client at imminent risk for ventricular fibrillation or cardiac arrest. The practical nurse must immediately notify the registered nurse so that emergency interventions can be initiated.

Step-by-Step Solution

1
Evaluate the reported laboratory value against normal reference ranges.
The client's serum potassium is 6.8 mEq/L. The normal reference range is 3.5 to 5.0 mEq/L.
Identifying abnormal laboratory values is the first step in recognizing potential physiological risks.
2
Analyze the clinical implications of the abnormal finding in the context of the client's condition.
Severe hyperkalemia (greater than 6.5 mEq/L) can cause fatal cardiac dysrhythmias, regardless of the client's lack of physical symptoms.
Understanding the severity of the complication guides prioritization.
3
Determine the appropriate scope of practice and escalation protocol.
The practical nurse must immediately notify the registered nurse or healthcare provider to initiate emergency treatment protocols.
Critical lab values that pose an immediate threat to life require rapid escalation outside the independent scope of the practical nurse.

Key Concept

Identifying and Escalating Critical Laboratory Values (Hyperkalemia)
Question 591Question →

A practical nurse is preparing to administer 10 units of regular insulin and 15 units of NPH insulin subcutaneously to a client with type 2 diabetes mellitus. Arrange the steps for preparing this medication in the correct chronological sequence.

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Answer

The correct sequence for mixing insulins is: 1) Roll the NPH vial, 2) Inject air into NPH, 3) Inject air into regular, 4) Withdraw regular insulin, 5) Withdraw NPH insulin.
When mixing intermediate-acting (NPH, cloudy) and short-acting (regular, clear) insulins, the standard sequence 'clear before cloudy' prevents the contamination of the short-acting insulin with the longer-acting insulin. The nurse must first gently roll the NPH vial to resuspend the particles. Next, air must be injected into both vials to equalize pressure, starting with the NPH vial to ensure the needle does not inadvertently carry NPH insulin into the regular insulin vial. Finally, the regular insulin is drawn up, followed by the NPH insulin.

Step-by-Step Solution

1
Identify the types of insulins being mixed.
NPH is an intermediate-acting (cloudy) insulin, and regular is a short-acting (clear) insulin.
Understanding the medication characteristics dictates the 'clear before cloudy' safety rule.
2
Sequence the air injections.
Air is injected into the NPH vial first, followed by the regular insulin vial.
This equalizes pressure in both vials while ensuring the needle does not touch the cloudy insulin before entering the clear insulin vial.
3
Sequence the insulin withdrawal.
Regular insulin is withdrawn first, followed by the NPH insulin.
Drawing the clear insulin first prevents accidental contamination of the regular insulin vial with the longer-acting NPH insulin.

Key Concept

Safe Medication Administration: Mixing Insulins
Estimated Time:1m 30s
Question 592Question →

A 79-year-old client is admitted to the medical unit for treatment of a severe urinary tract infection. Upon entering the room, the practical nurse (PN) finds the client highly agitated, disoriented to place, and pulling at their intravenous tubing. Current vital signs reveal a temperature of 101.4°F (38.5°C), heart rate of 115 beats/min, respiratory rate of 26 breaths/min, and blood pressure of 92/54 mmHg (admission blood pressure was 130/76 mmHg). Which action should the PN take first?

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Answer: Immediately report the clinical findings to the supervising registered nurse (RN) for further evaluation.

Answer

The practical nurse should immediately report the changes in vital signs and mental status to the registered nurse.
The correct action identifies that the client is exhibiting classic signs of systemic inflammatory response and potential septic shock (hypotension, tachycardia, tachypnea, and fever) combined with altered mental status. In the practical nursing role, recognizing this physiological instability requires immediate escalation to the RN or provider for rapid medical intervention.

Step-by-Step Solution

1
Analyze the client's current clinical presentation against their baseline.
The client exhibits new-onset agitation, disorientation, tachycardia (115 beats/min), tachypnea (26 breaths/min), and a substantial drop in blood pressure (92/54 mmHg).
Identifying abnormal findings and vital sign trends is the first step in recognizing physiological deterioration.
2
Correlate the assessment data with the client's primary diagnosis.
The combination of a known infection with fever, hypotension, and altered mentation points strongly toward sepsis or early septic shock.
Understanding the pathophysiology of the condition allows the nurse to anticipate severe complications.
3
Determine the priority nursing action based on the PN scope of practice.
The PN must immediately escalate these critical findings to the RN or provider.
Acute hemodynamic instability requires rapid medical intervention (such as fluid resuscitation) and RN-level assessment to stabilize the client's circulation.

Key Concept

Recognition of Sepsis and Septic Shock
Question 593Question →

A practical nurse (PN) is reviewing the morning laboratory results for a 7272-year-old client who is scheduled for a computed tomography (CT) scan with intravenous (IV) contrast later this morning. The client was admitted yesterday with community-acquired pneumonia. Which laboratory finding indicates the highest risk for a potential procedure-related complication and should be reported to the registered nurse (RN) immediately?

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Answer: Serum creatinine level of 2.4 mg/dL2.4\text{ mg/dL}

Answer

Serum creatinine level of 2.4 mg/dL2.4\text{ mg/dL}
IV contrast media is nephrotoxic. A serum creatinine level of 2.4 mg/dL2.4\text{ mg/dL} is abnormally high (normal is approximately 0.6−1.2 mg/dL0.6-1.2\text{ mg/dL}) and indicates impaired renal function. Administering contrast dye to this client significantly increases the risk of contrast-induced nephropathy (acute kidney injury). The PN must report this to the RN immediately so the provider can modify the diagnostic plan.

Step-by-Step Solution

1
Analyze the scheduled procedure and its associated risks.
The client is scheduled for a CT scan with IV contrast. IV contrast dye is nephrotoxic and can cause contrast-induced nephropathy.
Identifying the specific risks of a procedure is essential for anticipating complications and ensuring client safety.
2
Evaluate the laboratory results to determine if any values indicate a high risk for the procedure.
The serum creatinine level of 2.4 mg/dL2.4\text{ mg/dL} is significantly elevated above the normal range (typically 0.6−1.2 mg/dL0.6-1.2\text{ mg/dL}), indicating impaired renal function.
Administering nephrotoxic contrast dye to a client with preexisting renal impairment poses a severe risk of acute kidney injury.
3
Determine the appropriate nursing action based on the LPN scope of practice.
The PN must immediately report the elevated creatinine to the RN or healthcare provider.
The provider must be notified to potentially cancel the scan, order intravenous hydration, or utilize an imaging modality without contrast to protect the client's kidneys.

Key Concept

Assessing laboratory values for procedure-related risks
Question 594Question →

A practical nurse is preparing to administer scheduled morning medications to a client diagnosed with heart failure. The medication administration record includes a prescription for oral digoxin. Upon reviewing the client's electronic health record, the nurse notes a morning serum potassium level of 2.9 mEq/L. Based on these findings, which of the following actions should the practical nurse take first?

Show answer & explanation

Answer: Withhold the dose of digoxin and promptly notify the registered nurse about the laboratory result.

Answer

The practical nurse should withhold the dose of digoxin and promptly notify the registered nurse about the critical laboratory result.
The normal serum potassium range is 3.5 to 5.0 mEq/L. A level of 2.9 mEq/L indicates severe hypokalemia. Because hypokalemia strongly predisposes a client to digoxin toxicity, the safest and most appropriate action for the practical nurse is to withhold the dose and escalate the critical finding to the registered nurse or healthcare provider for further evaluation.

Step-by-Step Solution

1
Evaluate the client's laboratory results against normal reference ranges.
The serum potassium level is 2.9 mEq/L, which is significantly below the normal range of 3.5 to 5.0 mEq/L (hypokalemia).
Identifying abnormal laboratory values is an essential pre-administration safety check.
2
Correlate the abnormal laboratory finding with the prescribed medication.
Hypokalemia is identified as a major risk factor that precipitates digoxin toxicity, even if the digoxin level itself is within a normal range.
Understanding drug-lab interactions is necessary to prevent severe adverse pharmacological events, such as life-threatening cardiac arrhythmias.
3
Determine the appropriate nursing intervention within the practical nurse scope of practice.
The safest and legally correct action is to withhold the contraindicated medication and immediately report the finding to the supervising RN or healthcare provider.
A practical nurse must advocate for client safety by not administering harmful medications and by escalating critical findings to higher-level providers for medical intervention.

Key Concept

Pharmacological Therapies: Digoxin Administration and Electrolyte Monitoring
Estimated Time:1m 0s
Question 595Question →

A healthcare provider prescribes amoxicillin oral suspension for a toddler weighing 14 kg14\text{ kg} to treat acute otitis media. The prescription is for 30 mg/kg/day30\text{ mg/kg/day} divided into two equal doses administered every 12 hours. The medication label indicates a concentration of 250 mg/5 mL250\text{ mg}/5\text{ mL}. How many mL will the practical nurse administer for one dose? Record your answer to the nearest tenth. Do not include units in your answer.

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Answer: 4.2

Answer

4.2
To find the correct volume for one dose, first calculate the total daily requirement: 14 kg×30 mg/kg/day=420 mg/day14\text{ kg} \times 30\text{ mg/kg/day} = 420\text{ mg/day}. Next, divide this by 22 for the every-12-hour dosing schedule: 420 mg/day÷2=210 mg/dose420\text{ mg/day} \div 2 = 210\text{ mg/dose}. Finally, determine the liquid volume using the supplied concentration: 210 mg250 mg×5 mL=4.2 mL\frac{210\text{ mg}}{250\text{ mg}} \times 5\text{ mL} = 4.2\text{ mL}.

Step-by-Step Solution

1
Determine the total daily dose of the medication.
420 mg/day420\text{ mg/day}
The prescription is weight-based at 30 mg/kg/day30\text{ mg/kg/day}. Multiplying the weight (14 kg14\text{ kg}) by the dose per kg (30 mg30\text{ mg}) gives the total daily requirement.
2
Calculate the amount of medication needed for a single dose.
210 mg/dose210\text{ mg/dose}
The daily dose is divided into two equal doses administered every 12 hours. Dividing the daily total (420 mg420\text{ mg}) by 22 gives the single dose amount.
3
Calculate the volume of liquid required for the single dose.
4.2 mL4.2\text{ mL}
Using the dosage formula Desired DoseAvailable Dose×Volume=210 mg250 mg×5 mL=4.2 mL\frac{\text{Desired Dose}}{\text{Available Dose}} \times \text{Volume} = \frac{210\text{ mg}}{250\text{ mg}} \times 5\text{ mL} = 4.2\text{ mL}.

Key Concept

Weight-based pediatric dosage calculation and liquid medication administration.
Question 596Question →

A practical nurse (PN) is assigned to care for a client who is receiving a continuous intravenous (IV) heparin infusion to treat a deep vein thrombosis (DVT). Which of the following actions should the PN take to reduce the risk of potential complications? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Institute bleeding precautions by providing a soft-bristle toothbrush and an electric razor.; Monitor the client's urine and stool output for the presence of occult or frank blood.; Evaluate the client promptly for any sudden onset of chest pain, tachycardia, and dyspnea.

Answer

The practical nurse should institute bleeding precautions, monitor output for the presence of blood, and evaluate the client promptly for sudden chest pain, tachycardia, and dyspnea.
To reduce risk potential, the PN must prioritize interventions that address the most significant threats to the client: bleeding (due to heparin) and pulmonary embolism (due to the DVT). Implementing bleeding precautions (electric razor, soft toothbrush) and monitoring excreta for occult blood directly mitigate and detect hemorrhage. Assessing for sudden chest pain and shortness of breath ensures rapid detection of a pulmonary embolism, which is a medical emergency.

Step-by-Step Solution

1
Identify the primary clinical risks associated with the client's diagnosis and prescribed treatment.
The client is at high risk for hemorrhage due to the continuous heparin infusion and at risk for a pulmonary embolism (PE) due to the presence of a deep vein thrombosis.
Recognizing specific risk factors guides the nurse in selecting appropriate targeted assessments and preventive interventions.
2
Evaluate each nursing action against the identified risks and the established LPN/LVN scope of practice.
Providing an electric razor, monitoring stool/urine for blood, and assessing for signs of a PE are appropriate risk reduction strategies within the PN scope.
These actions directly mitigate the risk of bleeding and ensure early detection of life-threatening complications.
3
Identify and eliminate actions that are unsafe, outside the scope of practice, or represent clinical misinterpretations.
Administering IV push medications, withholding therapy for a normal platelet count, and dismissing early signs of shock are incorrect and unsafe actions.
Adhering to scope of practice and accurately interpreting objective clinical data are essential components of safe client care.

Key Concept

Reduction of Risk Potential: Anticoagulant Therapy Monitoring and Complication Recognition
Question 597Question →

During morning rounds on a medical-surgical unit, a client with heart failure is due for a scheduled oral dose of spironolactone. The electronic health record indicates the client's morning serum potassium level is 6.1 mEq/L6.1\text{ mEq/L}. What is the most appropriate action for the practical nurse to take?

Show answer & explanation

Answer: Withhold the spironolactone and promptly report the laboratory finding to the registered nurse.

Answer

The practical nurse should withhold the spironolactone and immediately report the elevated potassium level to the registered nurse.
Spironolactone is a potassium-sparing diuretic. A normal serum potassium level ranges from 3.53.5 to 5.0 mEq/L5.0\text{ mEq/L}. A level of 6.1 mEq/L6.1\text{ mEq/L} indicates severe hyperkalemia, which can lead to life-threatening cardiac dysrhythmias. Therefore, the safest and most appropriate action within the PN scope of practice is to withhold the medication and notify the RN immediately.

Step-by-Step Solution

1
Analyze the client's laboratory data against normal reference ranges.
The serum potassium level is 6.1 mEq/L6.1\text{ mEq/L}, which is significantly above the normal range of 3.53.5 to 5.0 mEq/L5.0\text{ mEq/L}.
Identifying normal versus abnormal laboratory values is a critical safety step before medication administration.
2
Correlate the laboratory finding with the prescribed medication's mechanism of action.
Spironolactone is recognized as a potassium-sparing diuretic.
Understanding pharmacodynamics reveals that administering this drug will further elevate the already critical potassium level.
3
Determine the appropriate clinical action within the practical nursing scope of practice.
The medication must be withheld and the critical finding escalated to the supervising registered nurse.
The PN must ensure client safety by preventing the administration of a contraindicated drug and communicating critical data promptly.

Key Concept

Medication Safety: Recognizing contraindications and escalating critical laboratory values
Estimated Time:1m 0s
Question 598Question →

A practical nurse (PN) is assigned to care for an 84-year-old client who has experienced severe vomiting and diarrhea for the last 72 hours. The client's baseline blood pressure is typically 138/78 mm Hg. During the current observation, the PN notes the client is increasingly restless and disoriented. The vital signs are: blood pressure 104/62 mm Hg, heart rate 108 beats per minute, and respiratory rate 20 breaths per minute. Which of the following actions should the PN take? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Notify the registered nurse (RN) immediately about the changes in mental status and vital signs.; Ensure the patency of the client's peripheral intravenous (IV) catheter.; Administer supplemental oxygen as prescribed.

Answer

The correct actions are to notify the registered nurse (RN) immediately about the changes, ensure the patency of the peripheral IV catheter, and administer supplemental oxygen as prescribed.
The correct actions prioritize recognizing and responding to the early signs of hypovolemic shock resulting from severe dehydration. Notifying the RN ensures appropriate escalation and medical intervention, ensuring IV patency prepares the client for necessary rapid fluid resuscitation, and administering oxygen addresses potential tissue hypoxia that is causing the client's new-onset restlessness.

Step-by-Step Solution

1
Analyze the client's history and presenting clinical data.
The client has a history of severe fluid loss (vomiting and diarrhea). Current findings reveal new-onset confusion, tachycardia (108 bpm), and a relative drop in blood pressure from 138/78 to 104/62 mm Hg.
Comparing current data against the client's baseline is essential to accurately identify physiological deterioration.
2
Correlate the assessment findings to a potential physiological complication.
The combination of significant fluid loss, borderline abnormal vital signs, and acute mental status changes indicates the early compensatory stages of hypovolemic shock.
Connecting clinical manifestations to their underlying pathophysiological cause guides nursing prioritization and intervention.
3
Select the most appropriate interventions within the practical nurse (PN) scope of practice.
The PN must escalate the findings to the RN, secure IV access for anticipated fluid resuscitation, and administer oxygen to support tissue perfusion.
In emergent situations, the PN plays a critical role in data collection, basic physiological support of airway, breathing, and circulation (ABCs), and rapid communication.

Key Concept

Early Recognition and Prioritization of Hypovolemic Shock
Estimated Time:1m 30s
Question 599Question →

A client who underwent a total knee arthroplasty 12 hours ago suddenly becomes restless, continuously picking at the bedsheets, and asking for a family member who is not present. The surgical dressing is dry and intact. Current vital signs are: heart rate 114 bpm, blood pressure 104/62 mm Hg, and respiratory rate 24 breaths/min. Which action should the practical nurse prioritize?

Show answer & explanation

Answer: Obtain a pulse oximetry reading to check oxygen saturation.

Answer

Obtain a pulse oximetry reading to check oxygen saturation.
Sudden restlessness, agitation, and confusion in a postoperative client are primary indicators of underlying physiological compromise, most commonly hypoxia or early hemorrhagic shock. The borderline elevated heart rate and respiratory rate further support a compensatory physiological response. The priority action within the practical nursing scope is to immediately collect focused data on the client's respiratory and oxygenation status to identify or rule out hypoxia before implementing other measures.

Step-by-Step Solution

1
Analyze the client's new-onset symptoms.
The client is exhibiting sudden restlessness, confusion, borderline tachycardia (114 bpm), and tachypnea (24 breaths/min).
Identifying acute deviations from the baseline status is the crucial first step in clinical judgment.
2
Correlate symptoms with potential postoperative physiological complications.
Sudden restlessness and altered mental status in a postoperative client are primary early indicators of hypoxia or impaired perfusion.
Physiological adaptation issues must be investigated before assuming psychological or cognitive causes for confusion.
3
Determine the priority nursing intervention within the PN scope of practice.
Gathering specific data regarding the client's respiratory status directly addresses the most life-threatening potential cause.
Airway and Breathing (ABCs) always take priority in emergent or acute status changes.

Key Concept

Early Recognition of Hypoxia and Shock
Question 600Question →

A practical nurse (PN) is assigned to care for a client who is receiving multiple pharmacological therapies for a severe respiratory infection. Which of the following actions by the PN are appropriate? (Select all that apply.)

Select all that apply

Show answer & explanation

Answer: Verify the client's identity using two distinct identifiers prior to administering an oral antibiotic.; Monitor the client's peripheral intravenous (IV) site for redness or swelling during a piggyback antibiotic infusion.; Reinforce the registered nurse's teaching regarding the common adverse effects of the prescribed medications.

Answer

The appropriate actions are: verifying the client's identity using two distinct identifiers, monitoring the peripheral IV site during the infusion, and reinforcing teaching regarding medication adverse effects.
The correct actions align with the practical nurse's scope of practice and strict medication administration standards. Verifying two unique identifiers ensures the medication is given to the correct client. Monitoring an IV site during a piggyback infusion is a required safety check to detect infiltration or phlebitis early. Reinforcing teaching that was initially provided by the registered nurse or provider is a primary educational responsibility of the practical nurse.

Step-by-Step Solution

1
Analyze the clinical scenario and the role of the nurse.
The scenario involves a practical nurse caring for a client receiving pharmacological therapies for an acute infection.
Understanding the client's condition (acute infection) and the nurse's specific scope of practice (PN) is necessary to evaluate the appropriateness of each intervention.
2
Evaluate each option based on established medication safety principles.
Verifying two identifiers promotes safety. Leaving medications at the bedside violates the rights of medication administration.
Adhering to the rights of medication administration prevents errors and ensures client safety.
3
Evaluate each option against the legal scope of practice for a practical nurse.
Reinforcing teaching and monitoring an IV site are within the PN scope. Administering an IV push medication is generally outside the PN scope.
Delegated tasks must match the nurse's licensure, education, and competency level.
4
Evaluate options involving pharmacological contraindications.
Administering a live-attenuated vaccine is inappropriate for a client currently suffering from a severe acute illness.
Recognizing contraindications prevents serious adverse therapeutic reactions.

Key Concept

Safe Medication Administration and Practical Nurse Scope of Practice
Estimated Time:1m 30s
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