Physiological Integrity

While conducting mid-morning rounds, a practical nurse observes that a conscious, alert client with type 1 diabetes mellitus is trembling, pale, and profusely diaphoretic. The client's point-of-care capillary blood glucose reading is 52 mg/dL (2.9 mmol/L). Place the following nursing actions in the correct chronological sequence to safely manage this situation.

Four hours following an uncomplicated laparoscopic appendectomy, a client is transferred to the surgical step-down unit. The client reports feeling unusually anxious, very thirsty, and experiencing moderate abdominal aching. The practical nurse performs an initial assessment and observes that the client's skin is slightly cool and pale. The client's current vital signs reveal a blood pressure of 102/66 mm Hg, a heart rate of 110 beats/min, and a respiratory rate of 22 breaths/min. The preoperative baseline vital signs were blood pressure 130/76 mm Hg, heart rate 74 beats/min, and respiratory rate 16 breaths/min. Based on these findings, which intervention is the priority?

A practical nurse (PN) is reviewing the electronic health record of an adult client admitted with an exacerbation of heart failure. The client is scheduled to receive a dose of oral furosemide. The morning laboratory results indicate a serum potassium level of $3.1\text{ mEq/L}$. The client's most recent vital signs include a blood pressure of $96/58\text{ mm Hg}$ and a heart rate of $114\text{ beats/min}$. Which of the following is the most appropriate action for the PN to take?

A practical nurse (PN) is monitoring a client admitted with acute pancreatitis who is receiving continuous intravenous (IV) fluids. Which of the following findings or situations require the PN to immediately escalate care to the registered nurse (RN)? Select all that apply.

Two hours following a percutaneous liver biopsy, a client calls the nursing station to report sudden, sharp pain in the right shoulder. Current vital signs reveal a heart rate of 106 beats/minute and a blood pressure of 102/62 mm Hg, compared to a pre-procedure baseline of 78 beats/minute and 126/74 mm Hg. Which action should the practical nurse take first?

A charge nurse in an acute care facility is observing a newly licensed practical nurse (PN) provide care to a group of assigned clients. Which of the following actions by the PN require immediate intervention by the charge nurse? Select all that apply.

A client residing in a long-term care facility requires scheduled medications via a percutaneous endoscopic gastrostomy (PEG) tube. The primary health care provider prescribes liquid levetiracetam $750 \text{ mg}$ every $12 \text{ hours}$ for seizure management. The supplied medication concentration is $100 \text{ mg/mL}$. According to the facility's enteral medication protocol, the practical nurse must flush the tube with $30 \text{ mL}$ of purified water immediately before and $30 \text{ mL}$ immediately after administering the medication. Calculate the total fluid volume in milliliters the nurse will administer for a single medication sequence, including the flushes. Record answer to the nearest tenth. Do not include units in answer.

A healthcare provider prescribes cefazolin $350$ mg intramuscularly (IM) every $8$ hours for a client with a respiratory infection. The medication is supplied in a vial containing $500$ mg of cefazolin powder. The reconstitution instructions on the label state: 'Add $2.0$ mL of sterile water for injection to provide a total reconstituted volume of $2.2$ mL.' How many milliliters (mL) should the practical nurse (PN) withdraw to administer one dose? Record your answer to the nearest tenth. Do not include units in your answer.

A practical nurse and an assistive personnel (AP) are preparing to move a postoperative client who has limited mobility up in bed using a draw sheet. In what order should the nurse perform the following actions? Arrange the steps in the correct sequence.

A practical nurse (PN) is participating in the care of a client who is 24 hours postoperative following an exploratory laparotomy and small bowel resection. Which of the following actions by the PN demonstrate appropriate application of risk reduction principles? Select all that apply.

An adult client who recently underwent orthopedic surgery is receiving care on a medical-surgical unit. The client reports a pain level of 8 on a 0-to-10 scale and requests their prescribed as-needed (PRN) oral oxycodone. During the pre-administration assessment, the practical nurse (PN) notes that the client is extremely drowsy and has a respiratory rate of 9 breaths per minute. Which of the following actions should the PN take?

A practical nurse is assisting a client with right-sided weakness and a history of dysphagia to eat their prescribed pureed meal. During the meal, the client begins to cough continuously and their voice sounds noticeably wet and gurgly. Which of the following is the priority action for the nurse to take?

A practical nurse (PN) is preparing to administer scheduled morning doses of oral digoxin and furosemide to a client diagnosed with heart failure. Which actions must the PN take to ensure safe medication administration? Select all that apply.

A practical nurse (PN) is caring for a client who had an uncomplicated vaginal delivery 4 hours ago. The client reports feeling dizzy. The PN observes that the client's perineal pad, which was changed 30 minutes ago, is now completely saturated with dark red blood. Current vital signs are blood pressure 96/58 mm Hg and heart rate 115 beats/min. Which of the following actions should the PN take first?

A practical nurse (PN) is assigned to a team of clients on a step-down unit. Which medication administration action demonstrates appropriate clinical judgment and adherence to the PN scope of practice?

A practical nurse (PN) is assessing a client who is 6 hours postoperative following a total abdominal hysterectomy. The PN is evaluating the client's current clinical status. Which of the following findings indicates a potential life-threatening complication that requires the most urgent escalation to the registered nurse (RN)?

A practical nurse (PN) is collecting data on a client who is 4 hours post-operative following a total thyroidectomy. The client exhibits new-onset restlessness, a heart rate of 114 beats/min, and reports a tingling sensation around the lips. Which of the following actions should the PN take? Select all that apply.

A client is recovering in the orthopedic unit after undergoing a right total hip arthroplasty via a posterior approach. The client requires a fracture bedpan for elimination. Which technique should the practical nurse use to place the bedpan safely?

A practical nurse (PN) is assisting a client who is 2 days postoperative following an abdominal surgery. The client coughs forcefully and reports a sudden "popping" sensation. The PN observes that the surgical wound has completely separated and loops of bowel are protruding. In what order should the PN perform the following actions? Arrange the actions from first priority to last.

A practical nurse is preparing to administer a morning dose of 10 units of regular insulin and 20 units of NPH insulin subcutaneously to a client with type 2 diabetes mellitus. Arrange the following steps for preparing and mixing these insulins in the correct chronological order.