Physiological Integrity

1313 questions

All types1,313 Multiple choice672 Multiple select289 Numeric68 Ordering284

Following the change-of-shift report, a practical nurse reviews the electronic health record of an older adult client hospitalized for a heart failure exacerbation. The client's morning serum potassium result is $2.8\text{ mEq/L}$ ( $2.8\text{ mmol/L}$ ). The active medication administration record includes scheduled oral furosemide, oral potassium chloride, and a new one-time order for intravenous (IV) push bumetanide. Which of the following actions should the practical nurse take? Select all that apply.

Select all that apply

Withhold the scheduled oral furosemide dose until the healthcare provider is consulted.

Promptly communicate the morning serum potassium results to the supervising registered nurse.

Auscultate the client's apical heart rate for one full minute to assess for irregular rhythms.

Administer the prescribed intravenous push dose of bumetanide to rapidly reduce fluid overload.

Confirm the client's identity by checking the bed and room number before administering the potassium chloride.

Give the oral furosemide as scheduled because the client is concurrently receiving a potassium supplement.

Show answer & explanation

Answer: Withhold the scheduled oral furosemide dose until the healthcare provider is consulted.; Promptly communicate the morning serum potassium results to the supervising registered nurse.; Auscultate the client's apical heart rate for one full minute to assess for irregular rhythms.

Answer

The correct actions are to withhold the scheduled oral furosemide, communicate the critical potassium level to the registered nurse, and auscultate the apical heart rate for irregularities.

A serum potassium level of 2.8 mEq/L indicates severe hypokalemia. The practical nurse must prioritize client safety by withholding the potassium-wasting diuretic (furosemide), reporting the critical lab value to the registered nurse for prompt intervention, and monitoring the client for hypokalemia-induced cardiac complications by checking the apical pulse for irregularities.

Step-by-Step Solution

Analyze the client's laboratory data.

The serum potassium level is 2.8 mEq/L, which indicates severe hypokalemia (normal reference range is typically 3.5-5.0 mEq/L).

Identifying abnormal laboratory values is essential before safely administering any medication.

Evaluate the prescribed medications in relation to the laboratory findings.

Furosemide is a potassium-wasting loop diuretic. Giving it would further deplete potassium levels.

Preventing medication-induced complications requires withholding contraindicated drugs when critical lab values are present.

Determine the practical nurse's scope of practice regarding the new IV orders.

The practical nurse identifies that administering IV push medications, such as bumetanide, is outside their scope of practice.

Ensuring safe delegation and assignment limits legal liability and protects the client from harm.

Formulate a safe plan of care based on the findings and scope of practice.

The nurse plans to hold the furosemide, report the critical potassium level to the registered nurse, and monitor the client's cardiac status by auscultating the apical pulse.

These actions align with the practical nurse's responsibilities for data collection, medication safety, and clinical escalation.

Key Concept

Medication safety, critical laboratory monitoring, and practical nursing scope of practice.

Question 182Question →

A practical nurse (PN) is preparing to apply knee-high anti-embolism stockings to a client who is prescribed prolonged bed rest. In what order should the PN perform the following actions? Arrange the steps in the correct sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

First, place the client in a supine position. Second, turn the stocking inside out to the heel. Third, apply the stocking over the toes and heel. Fourth, slide it up the calf. Finally, smooth out any wrinkles.

The correct sequence for applying anti-embolism stockings prioritizes promoting venous return and protecting skin integrity. The client must first be supine to allow blood to drain from the lower extremities. Preparing the stocking by turning it to the heel allows for smooth application over the foot, followed by pulling it up the calf. Finally, smoothing wrinkles prevents pressure injuries.

Step-by-Step Solution

Evaluate the client's position and timing before application.

The client is placed in a supine position for 15 to 30 minutes.

This prevents trapping dependent venous blood in the lower legs.

Prepare the stocking for application.

The stocking is inverted inside out down to the heel pocket.

This technique allows for controlled, precise placement over the foot without excessive pulling or friction.

Apply the stocking to the foot.

The stocking covers the toes and the heel pocket is correctly aligned.

Proper alignment of the heel pocket is crucial for comfort and correct compression distribution.

Apply the stocking to the lower leg.

The remainder of the stocking is slid up the calf.

This applies the graduated compression needed to promote venous return.

Inspect the applied stocking.

All wrinkles and creases are smoothed out.

Wrinkles act as a tourniquet, impeding venous return and potentially causing skin breakdown.

Key Concept

Application of Anti-Embolism Stockings

Question 183Question →

During a postoperative check, a practical nurse observes a 28-year-old client recovering from an open reduction and internal fixation of a femur fracture. Six hours after surgery, the client has developed new-onset restlessness and pale, cool skin. Vital signs show a heart rate of 118 bpm, a blood pressure of 102/68 mmHg, and a respiratory rate of 22 breaths/min. The client complains of moderate leg discomfort. Which priority action should the nurse implement?

Report the sudden change in clinical status to the supervising registered nurse.

Provide the scheduled PRN pain medication to address the leg discomfort.

Record the current data in the chart and plan to evaluate again at the next hourly check.

Raise the head of the client's bed to a high-Fowler's position to improve comfort.

Show answer & explanation

Answer: Report the sudden change in clinical status to the supervising registered nurse.

Answer

The correct priority action is to report the sudden change in clinical status to the supervising registered nurse.

The correct answer acknowledges that the client is displaying classic early signs of hypovolemic shock, including tachycardia, borderline hypotension, restlessness, and pale, cool skin. In the practical nursing scope of practice, recognizing acute physiological decompensation requires immediate escalation to the registered nurse or provider for advanced assessment and collaborative intervention.

Step-by-Step Solution

Analyze the clinical data.

The client has new-onset restlessness, pale/cool skin, tachycardia (118 bpm), and borderline hypotension (102/68 mmHg) following major bone surgery.

Recognizing clustered assessment cues is the first step in clinical judgment.

Determine the underlying physiological complication.

These findings collectively indicate early hypovolemic shock, likely due to postoperative internal hemorrhage.

Connecting vital sign trends with physical symptoms helps identify life-threatening conditions.

Apply the practical nursing scope of practice and ABC prioritization principles.

The priority is to escalate acute circulatory compromise (Circulation) rather than addressing comfort or implementing routine postoperative tasks.

Airway, breathing, and circulation issues always take precedence over pain management or routine documentation.

Key Concept

Early recognition of hypovolemic shock and acute physiological decompensation

Question 184Question →

A practical nurse is providing care for a client who is on strict bed rest for a deep vein thrombosis. The client abruptly becomes restless and confused, exhibiting a respiratory rate of 24 breaths per minute and a heart rate of 98 beats per minute (baseline 72 beats per minute). The client also reports a vague sense of impending doom. Which action should the practical nurse take first?

Administer the prescribed PRN antianxiety medication for the sudden agitation.

Examine the affected extremity for any new changes in swelling or redness.

Elevate the head of the client's bed and notify the registered nurse.

Document the vital sign changes and continue to monitor the client closely.

Show answer & explanation

Answer: Elevate the head of the client's bed and notify the registered nurse.

Answer

Elevate the head of the client's bed and notify the registered nurse.

The client is exhibiting classic signs of a pulmonary embolism, a life-threatening complication of a deep vein thrombosis. The immediate priority is to support the client's breathing by elevating the head of the bed (high-Fowler's position) to maximize lung expansion. Because this is a medical emergency requiring advanced interventions, the practical nurse must simultaneously notify the registered nurse to activate a rapid medical response.

Step-by-Step Solution

Analyze the clinical presentation and client history.

The client has a known deep vein thrombosis and has suddenly developed restlessness, confusion, tachypnea (24 breaths/min), tachycardia (98 beats/min), and a sense of impending doom.

Identifying these classic signs is crucial for recognizing a potential pulmonary embolism, a severe complication of a deep vein thrombosis.

Determine the priority framework.

Apply the Airway, Breathing, and Circulation (ABC) prioritization framework.

A pulmonary embolism primarily compromises breathing and circulation, representing a life-threatening medical emergency.

Select the most appropriate initial nursing intervention.

Elevating the head of the bed supports the client's respiratory effort, and notifying the registered nurse initiates the rapid medical response required.

The practical nurse must take immediate actions within their scope of practice to protect the airway and escalate care for acute instability.

Key Concept

Recognition of Pulmonary Embolism and ABC Prioritization

Question 185Question →

A client diagnosed with active tuberculosis is receiving a daily pharmacological regimen that includes oral isoniazid, rifampin, pyrazinamide, and ethambutol. Prior to administering the scheduled morning doses, the practical nurse (PN) reviews the client's current data. The client states, "My urine has been a bright orange-red color for the last two days." The morning laboratory results show an aspartate aminotransferase (AST) of 152 U/L and an alanine aminotransferase (ALT) of 168 U/L. Based on these clinical findings, which action is most appropriate for the practical nurse to take?

Reassure the client that the orange-red urine is an expected effect of rifampin and administer the scheduled medications.

Withhold the scheduled tuberculosis medications and promptly report the laboratory results to the registered nurse (RN).

Administer the isoniazid and ethambutol, but withhold the rifampin due to the abnormal urine appearance.

Instruct the client to increase oral fluid intake to flush the kidneys, then proceed with administering the medication regimen.

Show answer & explanation

Answer: Withhold the scheduled tuberculosis medications and promptly report the laboratory results to the registered nurse (RN).

Answer

The most appropriate action is to withhold the scheduled tuberculosis medications and promptly report the laboratory results to the registered nurse (RN).

Isoniazid, rifampin, and pyrazinamide are highly hepatotoxic medications. The significant elevation of liver enzymes (AST and ALT > 3 times the upper limit of normal) indicates drug-induced liver injury. The practical nurse must recognize this critical laboratory finding, safely withhold the medications, and immediately escalate the information to the RN or healthcare provider. While the orange-red urine is a known, harmless side effect of rifampin, the elevated transaminases require immediate clinical intervention.

Step-by-Step Solution

Analyze the client's subjective report of orange-red urine.

Recognize this as a normal, expected, and harmless side effect.

Rifampin commonly causes discoloration of bodily fluids, including urine, sweat, and tears.

Evaluate the morning laboratory results (AST 152 U/L, ALT 168 U/L).

Identify that the liver enzymes are significantly elevated above normal ranges.

Isoniazid, rifampin, and pyrazinamide all carry a high risk of drug-induced hepatotoxicity.

Determine the safest clinical intervention based on the practical nursing scope of practice.

Withhold the scheduled hepatotoxic medications and notify the supervising RN.

Administering the medications in the presence of active liver injury can lead to severe or fatal hepatic failure, requiring immediate escalation.

Key Concept

Monitoring for severe adverse effects of antitubercular medications and applying the practical nursing scope of practice for critical laboratory values.

Question 186Question →

A client is resting in bed on the first postoperative day following a right total knee arthroplasty. The licensed practical nurse is adjusting the client's bed to promote rest and prevent joint complications. Which positioning technique is most appropriate for the affected extremity?

Supporting the lower leg with a pillow placed lengthwise under the calf and ankle.

Placing a soft, rolled towel directly underneath the operative knee to reduce joint tension.

Maintaining both legs in an abducted stance using an abduction wedge cushion.

Elevating the knee gatch on the bed frame to keep the joint in a flexed and relaxed state.

Show answer & explanation

Answer: Supporting the lower leg with a pillow placed lengthwise under the calf and ankle.

Answer

The most appropriate positioning technique is supporting the lower leg with a pillow placed lengthwise under the calf and ankle.

The correct positioning for a client following a total knee replacement is to keep the knee straight and fully extended. Supporting the distal leg (calf and ankle) achieves elevation to reduce postoperative swelling without bending the surgical joint.

Step-by-Step Solution

Identify the surgical procedure performed.

The client had a total knee arthroplasty (TKA).

Postoperative positioning requirements vary significantly based on the specific joint replaced and the mechanics of the new prosthesis.

Determine the primary risk factors associated with this specific surgery.

A major risk following a TKA is the development of a flexion contracture, which is an inability to fully straighten the knee.

Preventing contractures is essential for the client to regain full mobility and a normal, steady gait.

Select the positioning method that prevents complications while promoting comfort.

The extremity must be kept extended (straight) while resting in bed.

Elevating the distal portion of the leg supports venous return to decrease edema while allowing gravity to naturally extend and straighten the knee joint.

Key Concept

Basic Care and Comfort: Postoperative Proper Body Alignment

Question 187Question →

An $80$ -year-old client is $48$ hours post-operative following an exploratory laparotomy. The client, previously alert and cooperative, suddenly becomes profoundly restless, is disoriented to place, and repeatedly attempts to remove the intravenous catheter. Which of the following actions should the practical nurse take? Select all that apply.

Select all that apply

Measure the client's current oxygen saturation and assess the respiratory rate.

Obtain a complete set of vital signs to evaluate for potential hemodynamic instability.

Notify the registered nurse immediately regarding the acute change in the client's mental status.

Reassure the client's family that sudden confusion is a normal response to hospitalization in older adults.

Administer the prescribed PRN dose of opioid analgesic to calm the client's severe agitation.

Document the new heart rate of

104

bpm as an expected anxiety response and reassess during the next shift.

Show answer & explanation

Answer: Measure the client's current oxygen saturation and assess the respiratory rate.; Obtain a complete set of vital signs to evaluate for potential hemodynamic instability.; Notify the registered nurse immediately regarding the acute change in the client's mental status.

Answer

The practical nurse should measure the client's oxygen saturation and respiratory rate, obtain a complete set of vital signs, and notify the registered nurse immediately.

Sudden restlessness and confusion in an older adult client are critical clinical cues that often indicate hypoxia, inadequate cerebral perfusion, or developing shock. The practical nurse must immediately prioritize Airway, Breathing, and Circulation (ABC) by gathering objective data (oxygen saturation and full vital signs) and escalating the acute mental status change to the registered nurse for urgent medical evaluation.

Step-by-Step Solution

Analyze the clinical scenario to identify the primary problem.

An older adult client is exhibiting a sudden, acute change in mental status (restlessness and disorientation)

48

hours after major abdominal surgery.

Recognizing the timeline and the abrupt nature of the behavioral change is essential for determining if the issue is psychological or physiological.

Apply the principles of airway, breathing, and circulation (ABC) prioritization to the client's presentation.

The nurse identifies that sudden restlessness and confusion in an older adult are frequently the very first indicators of hypoxia (breathing) or inadequate cerebral perfusion due to shock (circulation).

Physiological needs outrank psychological symptoms. The root cause of the agitation must be investigated before attempting to simply sedate or calm the client.

Select the interventions that align with the practical nurse's scope of practice for an unstable client.

The correct actions involve immediate objective data collection (oxygen saturation, respiratory rate, and full vital signs) followed by urgent escalation to the registered nurse.

The practical nurse plays a critical role in early recognition and data gathering to facilitate prompt medical intervention for physiological decompensation.

Key Concept

In older adults, acute changes in mental status (such as sudden restlessness, agitation, or delirium) are frequently the earliest indicators of physiological decompensation, particularly hypoxia, infection, or hemodynamic instability. The nurse must prioritize ABC assessments over sedation.

Question 188Question →

A client is $24$ hours postoperative following a total abdominal hysterectomy. Which actions should the practical nurse take to minimize the risk of potential complications for this client? Select all that apply.

Select all that apply

Instruct the client to firmly hold a pillow against the abdomen when performing prescribed coughing exercises.

Ensure that prescribed sequential compression devices are securely applied and functioning whenever the client is resting in bed.

Examine the surgical incision site and vaginal pad for an increasing amount of bright red drainage.

Administer a prescribed dose of intravenous (IV) push fentanyl for a sudden spike in abdominal pain.

Provide oral acetaminophen and dim the lights for a client exhibiting a new-onset heart rate of

118\text{ beats/min}

and blood pressure of

88/54\text{ mmHg}

Acknowledge a laboratory alert for a serum potassium level of

2.7\text{ mEq/L}

(

2.7\text{ mmol/L}

) and wait for the registered nurse's scheduled rounds to discuss it.

Show answer & explanation

Answer: Instruct the client to firmly hold a pillow against the abdomen when performing prescribed coughing exercises.; Ensure that prescribed sequential compression devices are securely applied and functioning whenever the client is resting in bed.; Examine the surgical incision site and vaginal pad for an increasing amount of bright red drainage.

Answer

The correct actions are to instruct the client to splint the abdomen when coughing, ensure sequential compression devices are applied while in bed, and examine the surgical site and vaginal pad for bright red drainage.

To reduce the risk of postoperative complications following a total abdominal hysterectomy, the practical nurse should implement evidence-based prophylactic measures and closely monitor for adverse events. Splinting the abdomen with a pillow during coughing reduces tension on the surgical incision, preventing dehiscence and minimizing pain. Applying sequential compression devices promotes venous return and reduces the risk of deep vein thrombosis. Additionally, examining the incision site and vaginal pad for bright red drainage is essential to identify early signs of postoperative hemorrhage.

Step-by-Step Solution

Identify the client's postoperative risks and the practical nurse's scope of practice.

The client is at risk for hemorrhage, deep vein thrombosis, and respiratory complications. The nurse must implement prophylactic measures and escalate critical findings.

Understanding the clinical context is essential for selecting safe and effective risk reduction strategies.

Evaluate the options for appropriate prophylactic and monitoring interventions.

Splinting the abdomen, using sequential compression devices, and checking for bright red drainage are correct actions.

These interventions directly prevent respiratory complications and DVT, and allow for early detection of hemorrhage.

Evaluate the remaining options for inappropriate or unsafe actions.

Administering IV push fentanyl, treating shock symptoms with acetaminophen, and delaying the report of a critical potassium level are incorrect actions.

IV push medications exceed the practical nurse's scope. Shock indicators and critical hypokalemia require immediate escalation to prevent severe morbidity or mortality.

Key Concept

Postoperative Risk Reduction and Scope of Practice

Question 189Question →

The practical nurse is analyzing morning data for several assigned clients on a medical-surgical unit. Which client-specific finding represents an immediate risk to physiological safety and must be reported to the registered nurse?

A client taking oral spironolactone whose morning serum potassium level is reported as

5.9

mEq/L (

5.9

mmol/L).

A client recovering from an appendectomy

24

hours ago who exhibits a temperature of

99.4^\circ

F (

37.4^\circ

C) and a heart rate of

84

beats/min.

A client with chronic obstructive pulmonary disease whose morning arterial blood gas reveals a partial pressure of carbon dioxide (

PaCO_2

) of

48

mm Hg.

A client who requests to take their scheduled oral levothyroxine simultaneously with their morning breakfast tray.

Show answer & explanation

Answer: A client taking oral spironolactone whose morning serum potassium level is reported as $5.9$ mEq/L ( $5.9$ mmol/L).

Answer

The client taking spironolactone with a potassium level of 5.9 mEq/L requires immediate escalation.

Spironolactone is a potassium-sparing diuretic. A serum potassium level of

5.9

mEq/L (

5.9

mmol/L) indicates significant hyperkalemia (normal range

3.5

5.0

mEq/L). If the nurse administers the scheduled dose, the client is at severe risk for life-threatening cardiac dysrhythmias. This critical laboratory value must be escalated to the registered nurse immediately so the medication can be safely held and the healthcare provider notified.

Step-by-Step Solution

Analyze the laboratory finding for the client taking spironolactone.

The potassium level is

5.9

mEq/L, which is significantly above the normal range of

3.5

5.0

mEq/L.

Identifying critical laboratory values is the first step in clinical risk reduction.

Determine the pharmacological effect of the prescribed medication.

Spironolactone is a potassium-sparing diuretic that causes the body to excrete sodium and retain potassium.

Understanding medication mechanisms helps predict and prevent severe adverse effects.

Evaluate the risk potential of the abnormal finding.

Hyperkalemia places the client at immediate risk for life-threatening cardiac dysrhythmias if further potassium is retained.

Prioritization requires identifying the most acute and immediate threat to a client's life.

Determine the appropriate nursing action.

The practical nurse must immediately report this critical finding to the registered nurse.

Immediate escalation ensures the medication is held and medical interventions to lower the potassium level can be initiated.

Key Concept

Recognizing Critical Laboratory Values and Medication Adverse Effects

Question 190Question →

A practical nurse is caring for a client who underwent a diagnostic cardiac catheterization via the right femoral artery 3 hours ago. Upon assessment, the client reports new-onset, severe right lower back pain. The nurse observes that the client is mildly restless, with a heart rate of 114 beats/min and a blood pressure of 96/58 mm Hg. Which action should the practical nurse take first?

Notify the registered nurse immediately while keeping the client in a flat, supine position.

Administer the prescribed as-needed oral analgesic to relieve the client's back discomfort.

Elevate the head of the bed to a high-Fowler's position to help decrease the client's restlessness.

Reassure the client that lower back pain is an expected finding from lying flat on the procedural table.

Show answer & explanation

Answer: Notify the registered nurse immediately while keeping the client in a flat, supine position.

Answer

The priority action is to immediately notify the registered nurse while maintaining the client in a flat, supine position.

The client is exhibiting classic signs of a retroperitoneal hemorrhage, a severe complication of femoral cardiac catheterization where blood leaks into the retroperitoneal space. Symptoms include severe back or flank pain, restlessness, tachycardia, and hypotension. To reduce risk potential, the practical nurse must prioritize circulation by keeping the client flat to minimize stress on the femoral puncture site and immediately notify the registered nurse for rapid medical intervention.

Step-by-Step Solution

Analyze the client's symptoms and vital signs.

The client has severe lower back pain, restlessness, tachycardia (114 beats/min), and mild hypotension (96/58 mm Hg).

Identifying abnormal clinical indicators is the first step in recognizing postoperative complications.

Correlate the findings with the recent femoral artery procedure.

The combination of back/flank pain and early signs of shock strongly indicates a retroperitoneal hemorrhage, a critical complication of a femoral puncture.

Connecting data points allows the nurse to prioritize physiological needs based on the risk of rapid deterioration.

Determine the safest immediate nursing action within the practical nurse scope of practice.

The nurse must keep the client flat to prevent disruption of the femoral clot and immediately report the critical findings to the registered nurse.

Life-threatening complications require immediate escalation to the registered nurse or provider for advanced interventions (e.g., fluid resuscitation, surgical evaluation).

Key Concept

Recognizing and Escalating Post-Procedural Hemorrhage

Question 191Question →

A $75$ -year-old resident at a rehabilitative care center is recovering from viral pneumonia. During evening rounds, the resident exhibits sudden, acute agitation, fails to recognize family members, and demonstrates a respiratory rate of $32$ breaths per minute. The current blood pressure is $100/62$ mmHg, a significant decrease from the morning baseline reading of $145/88$ mmHg, while the heart rate is $108$ bpm. Which of the following responses by the practical nurse demonstrate correct clinical prioritization? (Select all that apply.)

Select all that apply

Escalate the deteriorating hemodynamic status and altered mentation to the supervising registered nurse immediately.

Elevate the head of the bed, assess pulse oximetry, and prepare to administer supplemental oxygen.

Stay at the bedside to provide a safe environment and monitor for further respiratory compromise.

Attribute the new-onset disorientation to sundowning syndrome and document the behavioral changes in the shift note.

Delay vital sign reporting, as the systolic blood pressure remains above

90

mmHg and does not strictly indicate severe hypotension.

Prioritize administering a prescribed PRN oral analgesic to calm the resident before performing a full airway and breathing assessment.

Show answer & explanation

Answer: Escalate the deteriorating hemodynamic status and altered mentation to the supervising registered nurse immediately.; Elevate the head of the bed, assess pulse oximetry, and prepare to administer supplemental oxygen.; Stay at the bedside to provide a safe environment and monitor for further respiratory compromise.

Answer

The correct actions are to immediately escalate the condition to the registered nurse, elevate the head of the bed while preparing oxygen, and remain at the bedside to ensure safety.

The client is exhibiting clinical manifestations of acute hypoxia and early shock, characterized by tachypnea, tachycardia, relative hypotension, and acute confusion. The priority actions involve stabilizing the airway and breathing by elevating the head of the bed and assessing oxygenation, ensuring client safety by remaining at the bedside, and immediately escalating the critical change in condition to the registered nurse for urgent medical intervention.

Step-by-Step Solution

Analyze the vital signs and clinical presentation.

Identified that tachypnea (

32

breaths/min), a significant relative BP drop, tachycardia, and sudden agitation strongly indicate acute hypoxia or early sepsis.

Recognizing subtle but critical physiological deterioration is the first step in clinical judgment.

Apply ABC (Airway, Breathing, Circulation) prioritization principles.

Determined that interventions supporting airway and breathing (positioning, oxygenation) take immediate precedence over comfort measures.

Airway and breathing are the most critical systems for immediate survival.

Determine the appropriate scope of practice and safety measures.

Decided to remain with the unstable client to prevent injury and immediately notify the registered nurse for further medical orders.

Practical nurses must escalate acute, life-threatening changes while maintaining immediate client safety.

Key Concept

Recognition and Prioritization of Acute Hypoxia and Hemodynamic Instability

Question 192Question →

An older adult client is admitted to the medical-surgical unit with dehydration and orthostatic hypotension. The client's blood pressure is $98/60\text{ mm Hg}$ and heart rate is $112\text{ beats/minute}$ . The healthcare provider prescribes a continuous intravenous (IV) infusion of $0.9\%$ sodium chloride $1,000\text{ mL}$ to infuse over $8\text{ hours}$ . The available IV administration set has a drop factor of $15\text{ drops/mL}$ .

How many drops per minute (gtt/min) will the practical nurse regulate the IV flow rate to deliver? Record your answer to the nearest whole number. Do not include units in answer.

Show answer & explanation

Answer: 31

Answer

To safely regulate the IV gravity infusion, the practical nurse must determine the drops per minute. This is achieved by multiplying the total fluid volume (

1,000\text{ mL}

) by the tubing drop factor (

15\text{ gtt/mL}

) to find the total number of drops. That sum (

15,000\text{ drops}

) is then divided by the total infusion time in minutes (

480\text{ minutes}

). The resulting mathematical value is

31.25

, which must be rounded to the nearest whole number, giving a final rate of

31\text{ gtt/min}

Step-by-Step Solution

Convert the prescribed infusion time from hours to minutes.

8\text{ hours} \times 60\text{ minutes/hour} = 480\text{ minutes}

The gravity IV drip rate formula requires the total time to be expressed in minutes.

Set up the IV drip rate formula.

\text{Drip Rate} = \frac{\text{Total Volume (mL)} \times \text{Drop Factor (gtt/mL)}}{\text{Total Time (minutes)}}

This is the mathematical standard for determining gravity infusion flow rates.

Substitute the given values into the formula and calculate the unrounded rate.

\frac{1,000 \times 15}{480} = \frac{15,000}{480} = 31.25\text{ gtt/min}

Performing the multiplication and division operations yields the exact mathematical delivery rate.

Round the result to the nearest whole number.

31.25

rounds down to

31

Because standard IV tubing cannot deliver a fraction of a drop, the calculated rate must be rounded to the nearest whole drop.

Key Concept

Calculating IV flow rates for gravity infusions requires converting the total prescribed time into minutes and applying the administration set's drop factor to determine the required drops per minute.

Question 193Question →

An adult client is admitted to the telemetry unit immediately following a diagnostic cardiac catheterization using the right femoral artery approach. Which basic care and comfort measures should the practical nurse (PN) implement? Select all that apply.

Select all that apply

Restrict the backrest elevation to a maximum of 30 degrees.

Instruct the client to keep the affected lower extremity perfectly straight.

Provide a fracture bedpan to assist with elimination needs without excessive movement.

Position a folded blanket beneath the right knee to ease lower back strain.

Reposition the client into a side-lying posture every two hours to protect the sacral skin.

Show answer & explanation

Answer: Restrict the backrest elevation to a maximum of 30 degrees.; Instruct the client to keep the affected lower extremity perfectly straight.; Provide a fracture bedpan to assist with elimination needs without excessive movement.

Answer

The correct interventions are restricting the backrest elevation, instructing the client to keep the affected leg straight, and using a fracture bedpan.

The correct basic care interventions prioritize minimizing mechanical stress on the femoral artery puncture site to prevent life-threatening hemorrhage. Restricting the backrest elevation to a maximum of 30 degrees, maintaining strict leg straightness, and utilizing a low-profile fracture bedpan all successfully address the client's basic comfort and elimination needs without causing dangerous hip flexion.

Step-by-Step Solution

Identify the client's procedure and specific anatomical access site.

The client underwent a cardiac catheterization via the right femoral artery.

Different access sites (e.g., radial vs. femoral) require entirely different postoperative mobility and comfort restrictions.

Determine the primary physiological risk associated with the femoral approach.

The greatest immediate risk is arterial hemorrhage or hematoma formation at the groin puncture site.

The femoral artery is a major vessel under high pressure; any disruption of the clotting process can lead to rapid blood loss.

Evaluate each comfort and care measure against the need to protect the access site.

Measures that keep the hip flat and straight (low backrest, straight leg, flat bedpan) are safe. Measures that flex the hip (knee pillows, side-lying) are unsafe.

Hip flexion places mechanical stress directly on the femoral artery, potentially dislodging the newly formed clot.

Key Concept

Post-procedure positioning and mobility restrictions for femoral access

Question 194Question →

A practical nurse (PN) is preparing to administer an intramuscular injection of prescribed iron dextran to an adult client using the Z-track method. In what order should the PN perform the following steps to ensure safe administration? Arrange the actions in the correct chronological sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first change the drawing-up needle, then retract the skin and subcutaneous tissue, insert the needle at a 90-degree angle, inject the medication while pausing for 10 seconds, and finally withdraw the needle while simultaneously releasing the skin.

The Z-track method requires strict adherence to a specific sequence to prevent tissue damage. First, a new needle must be attached to ensure the outside is free of irritating medication. Next, the skin is retracted to displace the tissue layers. The needle is then inserted at 90 degrees. After injecting slowly, a 10-second pause is necessary for medication dispersion. Finally, withdrawing the needle and releasing the skin simultaneously seals the track, trapping the medication in the muscle.

Step-by-Step Solution

Change the drawing-up needle to a new, sterile administration needle.

Ensures the exterior of the needle shaft is free of medication.

Iron dextran can cause permanent tissue staining and severe irritation if deposited in the subcutaneous layers during insertion.

Retract the skin and subcutaneous tissue 1 to 1.5 inches laterally.

Moves the superficial tissues out of alignment with the underlying muscle.

This is the core principle of the Z-track method, preparing the 'zigzag' path that will lock the medication in the muscle.

Insert the needle at a 90-degree angle.

Penetrates through the displaced tissue directly into the muscle belly.

A 90-degree angle is required for intramuscular injections to ensure the medication reaches deep muscle tissue.

Inject the medication slowly and maintain the needle's position for 10 seconds.

Deposits the medication and allows it to begin diffusing into the surrounding muscle fibers.

Slow injection minimizes discomfort, and the 10-second pause prevents the medication from immediately welling up the injection track.

Withdraw the needle and release the retracted skin simultaneously.

The tissue layers slide back into their original positions, breaking the needle track alignment.

This seals the track, effectively trapping the irritating medication deep within the muscle and preventing seepage to the surface.

Key Concept

The Z-track method for intramuscular injections is used to prevent highly irritating or staining medications from leaking back into the subcutaneous tissue by displacing tissue layers before injection.

Estimated Time:1m 30s

Question 195Question →

A practical nurse is providing morning care and assisting a 72-year-old client with repositioning on the first postoperative day following a lumbar laminectomy. Which of the following actions should the nurse implement?

Utilize a draw sheet with the assistance of a second staff member to roll the client's body as a single unit.

Raise the head of the bed to a semi-Fowler's position before initiating the turn to improve respiratory effort.

Ask the client to reach across and pull on the opposite side rail to actively assist in turning their upper body.

Document any sudden onset of acute confusion observed during the care routine as a normal, age-related change.

Show answer & explanation

Answer: Utilize a draw sheet with the assistance of a second staff member to roll the client's body as a single unit.

Answer

The correct action is to utilize a draw sheet with the assistance of a second staff member to roll the client's body as a single unit.

The correct action involves logrolling the client. Following a lumbar laminectomy, the client's spine must be maintained in strict, straight alignment to prevent injury to the surgical site. Using a draw sheet and at least two staff members allows the client's shoulders and hips to turn simultaneously as a single unit without twisting.

Step-by-Step Solution

Identify the surgical procedure and its specific mobility precautions.

The client had a lumbar laminectomy, a spinal surgery which requires strict maintenance of spinal alignment to prevent surgical site injury.

Understanding the anatomical risks directly dictates safe physical repositioning techniques.

Evaluate the proposed positioning techniques for safety.

Logrolling (moving the body simultaneously as one continuous unit) is the only method that prevents spinal twisting or flexing.

Raising the head of the bed or having the client pull their upper body compromises spinal alignment.

Evaluate the assessment distractor regarding age and confusion.

Recognize that acute confusion is an abnormal finding (delirium) that requires clinical intervention, not an expected part of the aging process.

To ensure that basic care routines do not overshadow critical physiological assessments.

Key Concept

Logrolling Technique and Postoperative Spinal Alignment

Question 196Question →

While performing morning rounds, a practical nurse evaluates a 71-year-old client admitted for severe melena secondary to peptic ulcer disease. The client, who was previously alert, is now acutely restless and disoriented. The client's heart rate is 124 bpm, blood pressure is 92/58 mm Hg (baseline 128/74 mm Hg), and respiratory rate is 24 breaths/min. Which action should the practical nurse take FIRST?

Position the client supine with the legs elevated and immediately notify the registered nurse

Initiate delirium precautions by reorienting the client and minimizing environmental stimuli

Ask the client to rate their abdominal pain and prepare a prescribed analgesic

Record the current vital signs in the chart and plan to reassess the blood pressure in 30 minutes

Show answer & explanation

Answer: Position the client supine with the legs elevated and immediately notify the registered nurse

Answer

The practical nurse should position the client supine with the legs elevated and immediately notify the registered nurse.

The client's presentation of melena, tachycardia, hypotension, and sudden restlessness is a classic triad for acute hypovolemic shock resulting from blood loss. The priority is to maintain circulation and perfusion to vital organs, specifically the brain and heart. Placing the client in a supine position with the legs elevated (modified Trendelenburg) uses gravity to increase venous return from the lower extremities. Because this is a medical emergency requiring rapid interventions beyond the practical nursing scope (such as IV fluid resuscitation or blood transfusions), immediately notifying the registered nurse is critical.

Step-by-Step Solution

Analyze the client's clinical presentation and vital sign trends.

The client has a history of melena (gastrointestinal bleeding) and now presents with tachycardia (124 bpm), hypotension (92/58 mm Hg), and acute mental status changes.

Identifying the pattern of symptoms helps determine if the client is experiencing a life-threatening complication.

Correlate the findings with physiological processes.

The combination of these signs strongly indicates hypovolemic shock resulting from acute blood loss. The brain is not receiving adequate perfusion, causing the sudden restlessness and disorientation.

Understanding the pathophysiology guides the selection of the most appropriate immediate intervention.

Apply the ABC (Airway, Breathing, Circulation) priority framework to select the best action.

Circulation is severely compromised. The nurse must support blood pressure and cerebral perfusion by elevating the legs and escalate the situation to the RN.

In emergent situations, interventions that support ABCs and escalate care take precedence over routine assessments or comfort measures.

Key Concept

Recognition and initial bedside management of hypovolemic shock

Question 197Question →

A practical nurse (PN) is performing hourly rounds on a medical-surgical unit. Which of the following client assessment findings represent an increased risk for physiological instability and require immediate escalation to the registered nurse (RN)? Select all that apply.

Select all that apply

A client

14

hours post-thyroidectomy who reports new-onset numbness and tingling around the lips

A client receiving intravenous antibiotics whose blood pressure decreased from

132/84\text{ mm Hg}

96/62\text{ mm Hg}

over the past two hours

A client

18

hours post-total knee arthroplasty who has a morning hemoglobin level of

10.8\text{ g/dL}

(

108\text{ g/L}

)

A client with a casted lower extremity who reports deep, throbbing pain that is unrelieved by the prescribed opioid analgesic

A client with an indwelling urinary catheter that has drained

180\text{ mL}

of clear yellow urine over the last

4

hours

A client prescribed a daily oral beta-blocker who has a resting apical pulse of

68\text{ beats/min}

prior to administration

Show answer & explanation

Answer: A client $14$ hours post-thyroidectomy who reports new-onset numbness and tingling around the lips; A client receiving intravenous antibiotics whose blood pressure decreased from $132/84\text{ mm Hg}$ to $96/62\text{ mm Hg}$ over the past two hours; A client with a casted lower extremity who reports deep, throbbing pain that is unrelieved by the prescribed opioid analgesic

Answer

The correct findings that require immediate escalation are the client post-thyroidectomy with lip numbness, the client with a dropping blood pressure on antibiotics, and the client with cast pain unrelieved by opioids.

Escalation to the RN is required for findings that indicate impending physiological collapse or permanent tissue damage. Numbness around the lips after a thyroidectomy signals hypocalcemia, which can progress to tetany and airway obstruction. A sudden drop in blood pressure while receiving antibiotics indicates potential anaphylaxis or sepsis. Severe, unrelieved pain in a casted extremity is a classic sign of compartment syndrome, which can lead to limb loss if not addressed immediately.

Step-by-Step Solution

Analyze each client's assessment finding to differentiate between expected post-procedure outcomes and early signs of critical complications.

Identified that lip numbness, significant blood pressure drops, and unrelieved cast pain represent abnormal, high-risk conditions.

The PN must accurately recognize clinical deterioration to ensure timely intervention and reduce risk potential.

Evaluate the remaining findings against normal physiological parameters and expected post-operative baselines.

Determined that a hemoglobin of

10.8\text{ g/dL}

post-arthroplasty,

45\text{ mL/hr}

urine output, and a heart rate of

68\text{ beats/min}

are acceptable and stable findings.

Recognizing normal and expected findings prevents unnecessary delays in routine care and inappropriate escalation.

Key Concept

Identifying early indicators of physiological instability and escalating critical findings within the PN scope of practice to reduce client risk.

Question 198Question →

A practical nurse (PN) is providing care for a client who is two days postoperative following a bowel resection. The client has a prescription for oral metoprolol to manage a history of hypertension. During the morning assessment, the PN notes a blood pressure of 96/64 mm Hg, a heart rate of 118 beats/min, and moderate serosanguineous drainage on the abdominal dressing. The client states, "I feel very weak and dizzy today." Which action should the PN take regarding the scheduled metoprolol dose?

Retain the dose and urgently report the client's vital signs and symptoms to the registered nurse.

Administer the dose as prescribed to help decrease the client's elevated heart rate.

Reposition the client flat in bed and recheck the vital signs in one hour before giving the drug.

Start an intravenous fluid bolus to stabilize the blood pressure prior to administering the drug.

Show answer & explanation

Answer: Retain the dose and urgently report the client's vital signs and symptoms to the registered nurse.

Answer

The practical nurse should withhold the metoprolol and immediately report the findings to the registered nurse.

The client is exhibiting early signs of hypovolemic shock (tachycardia, borderline hypotension, dizziness, weakness) likely related to postoperative fluid loss or bleeding. The tachycardia is a critical compensatory mechanism attempting to maintain cardiac output. Metoprolol, a beta-adrenergic blocker, works by decreasing both heart rate and blood pressure. Administering this medication would block the client's compensatory response, potentially leading to immediate cardiovascular collapse. The practical nurse must recognize this dangerous clinical trend, withhold the drug, and immediately notify the RN for further medical evaluation.

Step-by-Step Solution

Analyze the client's vital signs and physical assessment findings.

The blood pressure is borderline low, the heart rate is significantly elevated, and the client reports weakness and dizziness alongside abdominal drainage.

Identifying abnormal data is the first essential step in clinical decision-making.

Correlate the assessment findings with the client's physiological state.

These findings collectively indicate early compensatory signs of fluid volume deficit or potential hemorrhage (hypovolemic shock).

Understanding the underlying cause of vital sign changes determines the safety of nursing interventions.

Evaluate the effects of the prescribed medication on the current physiological state.

Metoprolol is a beta-adrenergic blocker that decreases heart rate and blood pressure; administering it would blunt the compensatory tachycardia that is currently keeping the client stable.

Administering a contraindicated medication during instability could precipitate severe cardiovascular collapse.

Determine the appropriate nursing action within the PN scope of practice.

The safest and most appropriate action is to hold the medication and escalate the critical findings to the RN.

Practical nurses must recognize clinical deterioration, withhold medications that could worsen the condition, and promptly report to the supervising RN.

Key Concept

Recognizing compensatory mechanisms of shock and identifying pharmacological contraindications within the practical nursing scope of practice.

Estimated Time:1m 30s

Question 199Question →

While providing care on a medical-surgical unit, a practical nurse manages medication administration and reinforces teaching for several assigned clients. Which of the following clinical actions demonstrate safe pharmacological practice? Select all that apply.

Select all that apply

Withholding a scheduled dose of levothyroxine and notifying the registered nurse for a client with a resting heart rate of 118 beats/minute.

Administering a live-attenuated influenza vaccine to a client who is actively receiving immunosuppressive chemotherapy.

Reinforcing the instruction to rinse the mouth with water and spit after using an inhaled fluticasone corticosteroid.

Delivering a prescribed dose of intravenous push morphine to a client reporting sudden, severe surgical site pain.

Bypassing the electronic barcode medication scan to expedite the delivery of an urgent, first-dose antibiotic.

Reminding a client prescribed sublingual nitroglycerin to keep the tablets stored in their original, dark glass container.

Show answer & explanation

Answer: Withholding a scheduled dose of levothyroxine and notifying the registered nurse for a client with a resting heart rate of 118 beats/minute.; Reinforcing the instruction to rinse the mouth with water and spit after using an inhaled fluticasone corticosteroid.; Reminding a client prescribed sublingual nitroglycerin to keep the tablets stored in their original, dark glass container.

Answer

The correct actions include withholding levothyroxine for significant tachycardia, reinforcing the need to rinse the mouth after inhaled corticosteroids, and instructing clients to keep nitroglycerin in its original dark container.

Safe pharmacological practice requires the practical nurse to understand medication actions, side effects, and strict adherence to scope of practice. Levothyroxine increases the metabolic rate; a resting heart rate of 118 beats/minute indicates potential toxicity, requiring the nurse to withhold the dose and notify the registered nurse. Inhaled corticosteroids like fluticasone can cause oral candidiasis, so reinforcing the need to rinse the mouth helps prevent local infection. Nitroglycerin tablets degrade rapidly when exposed to light or moisture, making it essential to reinforce storing them in their original light-resistant container.

Step-by-Step Solution

Evaluate each clinical action against established medication safety protocols and the practical nurse scope of practice.

Actions involving withholding medication for adverse clinical signs, reinforcing proper medication storage, and teaching side-effect prevention are identified as safe and within the designated scope.

The practical nurse must consistently recognize clinical red flags, provide accurate client education reinforcement, and operate strictly within legal and professional boundaries.

Identify actions that violate fundamental safety standards or exceed the practical nursing scope of practice.

Administering IV push opioids, giving live vaccines to immunosuppressed clients, and bypassing safety barcode scans are identified as unsafe or out of scope.

These specific actions compromise patient safety by increasing the risk of adverse reactions, severe infections, and medication administration errors.

Key Concept

Safe Medication Administration and Scope of Practice

Question 200Question →

A pediatric client weighing $33 \text{ lb}$ is diagnosed with acute otitis media. The primary healthcare provider prescribes amoxicillin $80 \text{ mg/kg/day}$ by mouth, to be administered in two equally divided doses. The pharmacy dispenses a powder for oral suspension with the manufacturer instructions: 'Reconstitute with $68 \text{ mL}$ of purified water to yield a final volume of $100 \text{ mL}$ and a concentration of $400 \text{ mg}/5 \text{ mL}$ .' Based on this prescription, how many milliliters should the nurse administer for a single dose? (Record answer to the nearest tenth. Do not include units in answer.)

Show answer & explanation

Answer: 7.5

Answer

7.5

The correct dose is calculated by first converting the child's weight to kilograms (

33 \text{ lb} / 2.2 = 15 \text{ kg}

). Next, the total daily dose is found by multiplying the weight by the prescribed rate (

15 \text{ kg} \times 80 \text{ mg/kg/day} = 1200 \text{ mg/day}

). Since the medication is divided into two doses, the single dose requirement is

600 \text{ mg}

. Finally, using the supplied concentration of

400 \text{ mg}

per

5 \text{ mL}

, the required liquid volume is calculated as

600 \text{ mg} \times (5 \text{ mL} / 400 \text{ mg}) = 7.5 \text{ mL}

Step-by-Step Solution

Convert the client's weight from pounds to kilograms.

15 \text{ kg}

The prescribed dosage is weight-based in mg/kg, so the weight must first be converted by dividing pounds by 2.2 (

33 \div 2.2 = 15

Calculate the total daily medication dose.

1200 \text{ mg/day}

Multiply the client's weight in kilograms by the prescribed daily amount (

15 \text{ kg} \times 80 \text{ mg/kg/day} = 1200 \text{ mg/day}

Determine the required milligrams for a single dose.

600 \text{ mg/dose}

The total daily dose is prescribed to be given in two equally divided doses, so it must be divided by 2 (

1200 \text{ mg} \div 2 = 600 \text{ mg/dose}

Calculate the liquid volume to administer per dose.

7.5 \text{ mL}

Use the final concentration ratio (

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

) to find the volume:

600 \text{ mg} \times (5 \text{ mL} / 400 \text{ mg}) = 7.5 \text{ mL}

. The diluent volume (

68 \text{ mL}

) and total bottle volume (

100 \text{ mL}

) are distractor data points not used in calculating the individual dose.

Key Concept

Weight-based pediatric dosage calculation and filtering of extraneous reconstitution data.

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