Examkin

Physiological Integrity

1313 questions

All types1,313Multiple choice672Multiple select289Numeric68Ordering284
Question 321Question →

A client recovering from a radical neck dissection has a newly established tracheostomy. The client exhibits restlessness, and coarse rhonchi are heard upon auscultation. The practical nurse prepares to suction the artificial airway. Arrange the following steps of the procedure in the correct chronological order from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first hyperoxygenate the client, then advance the catheter without suction, apply intermittent suction only during withdrawal, flush the catheter with saline, and finally reassess the client's lung sounds.
Airway clearance via tracheostomy suctioning must follow strict chronological steps to ensure safety and prevent hypoxia. The client must first be pre-oxygenated to build a respiratory reserve. The catheter is then advanced without suction to protect the mucosal lining from trauma. Once resistance is met or the desired depth is reached, intermittent suction is applied only during withdrawal for a maximum of 10 to 15 seconds to remove secretions while limiting oxygen deprivation. Afterward, the catheter is flushed to maintain patency, and the client's respiratory status is reassessed to evaluate the procedure's success.

Step-by-Step Solution

1
Hyperoxygenate the client with 100% oxygen.
The client's oxygen reserves are maximized.
To prevent severe hypoxemia when oxygen is removed from the airway along with secretions.
2
Advance the sterile suction catheter into the airway without applying suction.
The catheter reaches the proper depth safely.
Applying negative pressure during insertion strips and traumatizes the tracheal mucosa, increasing the risk of bleeding.
3
Apply intermittent suction for no longer than 10 to 15 seconds during catheter withdrawal.
Secretions are cleared from the airway.
Intermittent suction clears the mucus, while the strict time limit minimizes oxygen deprivation and mucosal damage.
4
Flush the suction catheter and connecting tubing with sterile saline.
The catheter and tubing are cleared of thick secretions.
To maintain patency for subsequent passes or future use.
5
Auscultate bilateral lung sounds to evaluate the effectiveness of the intervention.
The client's respiratory status is documented.
To confirm whether the airway is clear or if the suctioning process needs to be repeated.

Key Concept

Airway Management: Tracheostomy Suctioning Sequence
Question 322Question →

A practical nurse is caring for a 6-year-old child who has just returned to the pediatric unit following a tonsillectomy. The child is currently sleeping but arouses easily to verbal stimuli. Which position is the safest and most appropriate for the nurse to place this client in?

Show answer & explanation

Answer: Partially prone or side-lying with the head turned to one side

Answer

The safest and most appropriate position is partially prone or side-lying with the head turned to one side.
Following a tonsillectomy, clients who are not fully awake should be placed in a side-lying or partially prone position. This alignment uses gravity to naturally drain blood and oral secretions out of the mouth rather than down the throat, thereby maintaining a clear airway and preventing aspiration.

Step-by-Step Solution

1
Identify the client's surgical procedure and current level of consciousness.
The client had a tonsillectomy and is currently drowsy and sleeping.
Postoperative tonsillectomy clients are at high risk for bleeding and aspiration of secretions, especially when not fully awake.
2
Determine the primary goal of positioning for this specific client.
The primary goal is to maintain a patent airway by allowing blood and oral secretions to drain out of the mouth.
Airway maintenance is always the highest priority in postoperative care (ABC prioritization).
3
Evaluate the positioning options against the primary goal.
A side-lying or partially prone position allows gravity to drain fluids from the mouth, whereas supine positions encourage fluids to pool in the back of the throat.
Gravity-assisted drainage minimizes the risk of choking and aspiration in a client who cannot independently clear their own airway.

Key Concept

Postoperative Airway Management and Positioning
Question 323Question →

A practical nurse (PN) is reviewing the morning laboratory results for an adult client who is scheduled to receive a dose of subcutaneous enoxaparin. The client's most recent platelet count is 45,000/mm345,000/\text{mm}^3 (normal reference range: 150,000 to 400,000/mm3150,000 \text{ to } 400,000/\text{mm}^3). Which of the following is the most appropriate action for the PN to take?

Show answer & explanation

Answer: Withhold the scheduled medication and immediately notify the supervising registered nurse (RN) or healthcare provider.

Answer

The most appropriate action is to withhold the scheduled dose of enoxaparin and promptly report the abnormal laboratory result to the registered nurse (RN) or healthcare provider.
The correct answer involves withholding the medication and notifying the supervising RN or healthcare provider. Enoxaparin is a low-molecular-weight heparin used as an anticoagulant. The client's platelet count is 45,000/mm345,000/\text{mm}^3, which indicates severe thrombocytopenia (normal is 150,000 to 400,000/mm3150,000 \text{ to } 400,000/\text{mm}^3). Administering an anticoagulant to a client with critically low platelets creates a severe risk for hemorrhage. A key responsibility within the practical nurse's scope of practice is to evaluate relevant laboratory data prior to medication administration, withhold medications when safety parameters are not met, and immediately report these critical findings.

Step-by-Step Solution

1
Identify the normal reference range for a platelet count.
The normal platelet count is 150,000 to 400,000/mm3150,000 \text{ to } 400,000/\text{mm}^3.
Comparing the client's laboratory results to the expected normal range is necessary to identify potential abnormalities before administering medications.
2
Evaluate the client's specific laboratory value.
The client's platelet count of 45,000/mm345,000/\text{mm}^3 is critically low, a condition known as thrombocytopenia.
Recognizing a critical laboratory value determines whether the scheduled pharmacological therapy is safe to administer or if it poses a risk to the client.
3
Determine the appropriate nursing intervention based on safety and the PN scope of practice.
The medication should be withheld and the abnormal finding escalated to the supervising RN.
Enoxaparin is an anticoagulant that can cause severe bleeding in a client with existing thrombocytopenia. It is within the PN's scope to withhold a contraindicated medication and report the critical finding.

Key Concept

Pre-administration safety checks and escalating critical laboratory values
Question 324Question →

A practical nurse (PN) is monitoring an older adult client who is 12 hours post-operative following a total abdominal hysterectomy. The client suddenly becomes restless, appears mildly confused, and reports feeling 'out of breath.' Vital signs are heart rate 105 beats/minute, blood pressure 106/62 mm Hg, and respiratory rate 24 breaths/minute. Which action should the PN take first?

Show answer & explanation

Answer: Elevate the head of the bed and measure the client's oxygen saturation.

Answer

Elevate the head of the bed and measure the client's oxygen saturation.
The client is exhibiting early signs of hypoxia (restlessness, confusion, tachypnea, tachycardia), which is a potential life-threatening complication such as a pulmonary embolism or acute respiratory distress. Prioritizing the ABCs (Airway, Breathing, Circulation) requires the nurse to first support breathing by elevating the head of the bed to maximize lung expansion and immediately obtaining an oxygen saturation reading to quantify the level of hypoxia.

Step-by-Step Solution

1
Analyze the clinical cues
The client is displaying new-onset restlessness, confusion, tachypnea (respiratory rate of 24), and tachycardia (heart rate of 105) alongside subjective shortness of breath.
Identifying abnormal, acute findings is the first step in recognizing physiological deterioration.
2
Apply the ABC (Airway, Breathing, Circulation) prioritization framework
The client's symptoms point to a potential breathing compromise (hypoxia) as the most immediate threat.
The ABC framework dictates that airway and breathing issues must be addressed before circulation or neurological issues.
3
Determine the most appropriate initial nursing intervention
Elevating the head of the bed promotes immediate lung expansion, and obtaining a pulse oximetry reading provides objective data about oxygenation status.
These actions provide immediate relief and essential data without delaying care or acting outside the practical nurse's scope of practice.

Key Concept

Prioritizing interventions based on the ABC (Airway, Breathing, Circulation) framework during acute physiological decompensation.
Question 325Question →

A practical nurse in a long-term care facility is preparing to administer an intermittent enteral tube feeding via a nasogastric tube to a client who is recovering from a cerebrovascular accident (stroke). In what order should the nurse perform the following actions? Arrange the steps from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence for administering an intermittent enteral feeding is to first elevate the head of the bed to prevent aspiration, then aspirate to verify placement and check residuals, return the residuals to the stomach, flush the tube to ensure patency, and finally administer the feeding formula.
The correct sequence prioritizes client safety by first ensuring proper positioning to prevent aspiration. Following positioning, verifying tube placement and assessing gastric residual volume are essential before introducing any fluids. Returning the residual prevents electrolyte loss, and flushing ensures the tube is patent before the formula is administered.

Step-by-Step Solution

1
Elevate the head of the client's bed to at least 30 degrees.
The client is placed in a safe position for enteral intake.
Elevating the head of the bed utilizes gravity to help prevent gastric reflux and aspiration into the airway.
2
Aspirate gastric contents to verify tube placement and measure residual volume.
Tube location in the stomach is confirmed and delayed emptying is assessed.
Ensures the formula will enter the gastrointestinal tract safely and that the client is digesting previous feedings appropriately.
3
Return the aspirated gastric residual volume into the stomach.
Stomach contents are restored.
Prevents the loss of essential gastric electrolytes and fluids, which could lead to metabolic imbalances.
4
Flush the nasogastric tube with 30 mL of water.
The tube is cleared and patency is confirmed.
Flushing prevents tube occlusion and ensures there is no resistance before administering the thicker feeding formula.
5
Administer the prescribed intermittent enteral feeding formula.
The client receives the prescribed nutrition.
This is the final step once safety, placement, and patency have all been systematically verified.

Key Concept

Basic Care and Comfort: Enteral Nutrition Administration Sequence
Question 326Question →

A practical nurse (PN) is collecting data on an older adult client who is 8 hours post-operative following a right femoral-popliteal bypass graft. Which of the following findings indicate that the client is physiologically stable and do NOT require immediate reporting to the registered nurse (RN)? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Capillary refill time of 2 seconds in the toes of the right foot; Incisional pain rated as 4 on a 0 to 10 pain scale that is reduced by repositioning; Oral temperature of 99.1°F (37.3°C) and a respiratory rate of 16 breaths/min

Answer

The expected, stable findings are a capillary refill time of 2 seconds, incisional pain rated as 4 out of 10, and an oral temperature of 99.1°F with normal respirations.
Stable post-operative adaptation includes manageable pain, adequate peripheral perfusion (capillary refill less than 3 seconds), and a mild inflammatory response (temperature up to 100.4°F or 38.0°C in the first 48 hours). These findings show the client is recovering as expected.

Step-by-Step Solution

1
Analyze the clinical scenario and the specific question being asked.
The client is 8 hours post-operative from a vascular bypass graft. The question asks to identify which findings are expected and stable, meaning they do NOT require immediate escalation.
Understanding the timeline helps differentiate normal post-operative physiological responses from acute complications.
2
Evaluate each option to distinguish normal post-operative data from signs of physiological decompensation.
Normal findings include manageable pain, rapid capillary refill, and a low-grade temperature. Abnormal findings include tachycardia with hypotension, low hemoglobin, and new-onset confusion.
Early recognition of shock, bleeding, or hypoxia is critical to preventing adverse outcomes.
3
Select the options that represent stable, expected outcomes.
The correct selections are the normal capillary refill, the moderate pain, and the mild temperature elevation.
These findings reflect expected post-operative adaptation without indicating acute risk to Airway, Breathing, or Circulation.

Key Concept

Differentiating expected post-operative physiological adaptations from early signs of acute decompensation
Question 327Question →

A licensed practical nurse (LPN) is assisting with the care of a client who had a laparoscopic cholecystectomy 4 hours ago. The client is currently agitated and repeatedly asking about their location. Current vital signs include a heart rate of 118 bpm, a respiratory rate of 24 breaths/min, and a blood pressure of 92/56 mm Hg. The client's admission blood pressure was 128/74 mm Hg. Which of the following is the priority action for the LPN?

Show answer & explanation

Answer: Notify the registered nurse (RN) immediately regarding the assessment findings.

Answer

The priority action is to immediately notify the registered nurse (RN) regarding the assessment findings.
The correct action is to notify the RN immediately. The client's sudden agitation, increased heart rate, and decreased blood pressure compared to baseline are classic early signs of hypovolemic shock (potentially from internal bleeding). Within the LPN's scope of practice, recognizing acute physiological deterioration and rapidly escalating the information is the highest priority.

Step-by-Step Solution

1
Analyze the client's current clinical presentation against their baseline.
The client has a new onset of agitation, tachycardia (118 bpm), tachypnea (24 breaths/min), and a significant drop in blood pressure (92/56 mm Hg from 128/74 mm Hg).
Comparing current data to baseline is essential to identify trends indicative of physiological deterioration.
2
Correlate the findings to potential postoperative complications.
The combination of altered mental status, tachycardia, and hypotension strongly suggests early hypovolemic shock, likely due to internal bleeding.
Recognizing early signs of shock is a critical component of physiological adaptation and patient safety.
3
Determine the most appropriate action within the LPN scope of practice.
The LPN must immediately communicate these unstable findings to the RN for further assessment and collaborative intervention.
Acute, life-threatening changes require immediate escalation to ensure timely medical management.

Key Concept

Early recognition of shock and acute decompensation
Question 328Question →

A client is recovering in the rehabilitation unit with right-sided hemiparesis and moderate dysphagia secondary to a recent cerebrovascular accident. Which interventions should the practical nurse implement to promote comfort and safe oral intake during meals? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Assist the client into a high-Fowler's position prior to providing food or liquids; Instruct the client to tuck their chin downward toward the chest while swallowing; Perform oral hygiene care for the client both before and following the meal

Answer

The correct interventions are to position the client upright in a high-Fowler's position, instruct the client to use a chin-tuck maneuver when swallowing, and perform oral hygiene care before and after eating.
Positioning the client upright in a high-Fowler's position uses gravity to help food travel down the esophagus and significantly reduces the risk of it entering the airway. Furthermore, the chin-tuck maneuver narrows the airway opening and widens the esophageal opening, providing mechanical protection against choking. Providing oral hygiene before meals enhances taste and salivary flow, while post-meal oral care is critical to remove any food particles pocketed in the mouth, which could later be aspirated.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has right-sided paralysis and difficulty swallowing (dysphagia).
Understanding the deficits is crucial to identifying interventions that protect the airway and ensure safe nutrition.
2
Determine proper positioning during and after meals.
A high-Fowler's position and the chin-tuck maneuver are identified as necessary safety measures.
These specific anatomical positions utilize gravity and narrowing of the trachea to prevent food and liquid from entering the airway.
3
Identify supportive basic care routines related to feeding.
Providing oral hygiene before and after meals is selected as a priority comfort and safety measure.
Pre-meal oral care improves the sensory experience of eating, while post-meal care removes leftover food that could be silently aspirated.

Key Concept

Dysphagia Management and Aspiration Precautions
Question 329Question →

Following a percutaneous liver biopsy, a client is resting on the medical-surgical unit. The client's pre-procedure baseline showed a blood pressure of 132/82 mm Hg and a heart rate of 72 beats/minute. During an assessment two hours later, the blood pressure measures 108/66 mm Hg with a heart rate of 98 beats/minute, and the client mentions mild aching on the right side. What is the most appropriate next action for the licensed practical nurse to take?

Show answer & explanation

Answer: Promptly communicate the changing hemodynamic parameters to the registered nurse.

Answer

The correct action is to promptly communicate the changing hemodynamic parameters to the registered nurse to ensure rapid intervention for potential internal bleeding.
The client's shift in vital signs—a decreasing blood pressure and increasing heart rate—are early compensatory signs of hypovolemic shock. Because the liver is a highly vascular organ, a percutaneous biopsy carries a significant risk of internal bleeding. The nurse must recognize these subtle trends as a potential life-threatening complication and immediately alert the registered nurse for further evaluation and intervention.

Step-by-Step Solution

1
Analyze the client's current vital signs by comparing them to the pre-procedure baseline.
The blood pressure dropped from 132/82 to 108/66 mm Hg, and the heart rate increased from 72 to 98 beats/minute.
Comparing current data to baseline is essential for identifying early physiological changes rather than just relying on standard adult normal ranges.
2
Correlate the vital sign trends with the specific procedural risks associated with a liver biopsy.
The trends indicate early compensatory shock, likely from internal bleeding due to the liver's high vascularity.
Understanding procedural risks helps differentiate expected post-procedure findings from dangerous complications.
3
Determine the appropriate nursing action based on the practical nurse scope of practice.
The nurse must escalate the findings immediately to the registered nurse.
Recognizing and reporting subtle signs of clinical deterioration reduces the risk of severe adverse outcomes.

Key Concept

Recognizing Early Signs of Hemorrhage and Hypovolemic Shock
Question 330Question →

While receiving a continuous enteral tube feeding, a client with a history of stroke suddenly begins to cough forcefully, gasp for air, and develop circumoral cyanosis. The practical nurse (PN) is present at the bedside. Arrange the following actions in the priority order the PN should perform them, from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first turn off the feeding pump, position the client laterally, suction the airway, apply oxygen, and finally alert the RN.
The correct sequence follows the ABC prioritization framework and the principle of mitigating immediate harm. Stopping the feeding immediately halts further aspiration. Positioning the client laterally uses gravity to protect the airway from further fluid entry. Suctioning clears the existing obstruction to establish patency. Oxygenation treats the resulting hypoxia once the airway is clear. Finally, notifying the RN ensures the client receives advanced assessment and ongoing medical management after the immediate crisis is stabilized.

Step-by-Step Solution

1
Identify the immediate life threat.
Recognize that the client is exhibiting signs of active aspiration and airway compromise.
Forceful coughing, gasping, and cyanosis during a tube feeding indicate that formula is entering the respiratory tract.
2
Apply the principle of removing harm.
Determine that stopping the feeding pump is the first action.
Halting the source of the aspiration is the most direct and immediate way to prevent further respiratory compromise.
3
Apply the ABC (Airway, Breathing, Circulation) priority framework to remaining actions.
Order the remaining actions: protect airway (position), clear airway (suction), support breathing (oxygen), and escalate (notify RN).
Airway management physically precedes breathing support. Oxygen is ineffective if the airway is blocked with fluid. Escalation occurs only after immediate bedside stabilization.

Key Concept

Prioritization of Airway Emergencies and Aspiration Precautions
Question 331Question →

During the morning shift on a medical-surgical unit, a practical nurse is assigned to care for several clients requiring pharmacological therapies. Which actions by the practical nurse represent safe practice and adhere to the scope of practice? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Scanning the client's identification band and the medication packaging barcode immediately prior to giving oral metoprolol.; Withholding a scheduled dose of oral warfarin and promptly notifying the registered nurse (RN) after observing a client's INR result of 5.2.; Instructing a client to remain in an upright sitting position for at least 30 minutes after taking oral alendronate.

Answer

The correct actions are scanning the identification band and barcode for metoprolol, withholding warfarin for an INR of 5.2, and ensuring an upright position after administering alendronate.
The correct actions demonstrate a comprehensive understanding of pharmacological safety and legal scope. Utilizing barcodes ensures accurate identification, withholding warfarin for a critically high INR (5.2) prevents severe hemorrhage, and keeping a client upright after alendronate prevents esophagitis. All of these actions fall safely within the practical nurse's scope of monitoring and administration.

Step-by-Step Solution

1
Analyze each pharmacological action for adherence to the fundamental rights of medication administration.
Barcode scanning meets safety criteria; using room numbers does not.
Safe medication administration requires reliable and unique client identifiers to prevent medication errors.
2
Evaluate each intervention against the practical nurse's legal and ethical scope of practice.
Administering oral medications and holding medications for critical laboratory values are within scope; administering IV push medications is out of scope.
Intravenous push medications typically necessitate immediate RN-level assessment and intervention due to their rapid onset of action.
3
Review specific pharmacological safety protocols for the mentioned drug classes.
Warfarin requires withholding for an INR substantially over the therapeutic range; alendronate requires an upright position for 30 minutes.
Applying drug-specific knowledge is essential to prevent severe adverse effects such as hemorrhage or esophageal ulceration.

Key Concept

Safe pharmacological practice for the practical nurse involves adhering to the rights of medication administration, recognizing the boundaries of the practical nursing scope of practice, escalating critical laboratory values, and implementing drug-specific safety protocols.
Question 332Question →

An adolescent client is resting in a clinic observation room immediately following a diagnostic lumbar puncture. To minimize the risk of a post-procedure headache and promote comfort, which position should the nurse maintain the client in?

Show answer & explanation

Answer: Supine with the bed completely flat.

Answer

Supine with the bed completely flat.
Following a lumbar puncture, maintaining the client in a flat, supine position for several hours is a standard standard nursing intervention. This flat alignment prevents a rapid decrease in cerebrospinal fluid pressure at the dural puncture site, thereby significantly reducing the likelihood that the client will develop a debilitating spinal headache.

Step-by-Step Solution

1
Identify the specific procedure the client just underwent.
The client had a diagnostic lumbar puncture.
Different diagnostic procedures require specific postoperative positioning to prevent targeted complications.
2
Recall the most common and significant complication associated with this procedure.
A post-lumbar puncture headache (spinal headache) caused by the continued leakage of cerebrospinal fluid from the puncture site.
Understanding the potential complication directly dictates the prophylactic care required.
3
Determine the correct body position to minimize this specific risk.
A flat position keeps cerebrospinal fluid pressure evenly distributed, minimizing leakage.
Evidence-based practice requires keeping the client supine and flat for a prescribed period following the puncture.

Key Concept

Post-Procedure Positioning: Lumbar Puncture
Question 333Question →

An older adult client is receiving continuous intravenous heparin for a deep vein thrombosis. During hourly rounds, the client reports sudden, severe lower back pain and mild dizziness. The client appears restless and the skin is cool to the touch. Which action should the practical nurse take first?

Show answer & explanation

Answer: Measure the client's current blood pressure and heart rate.

Answer

Measure the client's current blood pressure and heart rate.
The correct action is to measure the blood pressure and heart rate. A client on continuous heparin experiencing sudden back pain accompanied by dizziness, restlessness, and cool skin is exhibiting classic signs of a retroperitoneal hemorrhage and early hypovolemic shock. Assessing circulatory status by collecting vital signs is the immediate priority for the practical nurse to confirm the complication and promptly report the findings to the registered nurse.

Step-by-Step Solution

1
Analyze the client's new symptoms in the context of their current therapy.
The client is on heparin (high bleeding risk). Sudden back pain, dizziness, restlessness, and cool skin are indicative of a retroperitoneal hemorrhage and early hypovolemic shock.
To identify potential life-threatening complications requiring immediate intervention.
2
Apply the ABC (Airway, Breathing, Circulation) priority framework to the clinical picture.
The symptoms point to a critical circulation issue, which takes precedence over comfort measures or routine documentation.
Airway, breathing, and circulation are always the highest priorities in acute care.
3
Determine the appropriate initial action within the practical nursing scope of practice.
Obtaining a current set of vital signs provides objective data about the client's hemodynamic status.
Current vital signs are necessary to confirm circulatory compromise and properly escalate the situation to the registered nurse or healthcare provider.

Key Concept

Prioritization of care and early recognition of hypovolemic shock in clients receiving anticoagulants.
Question 334Question →

During a shift on an acute care medical-surgical unit, a practical nurse (PN) is tasked with managing care for several clients. Which of the following nursing actions demonstrate appropriate risk reduction and adherence to safe practice guidelines? (Select all that apply.)

Select all that apply

Show answer & explanation

Answer: Implementing daily weights and strict intake and output monitoring for a client admitted with an acute exacerbation of heart failure.; Verifying the client's ability to swallow effectively before providing oral fluids following an acute ischemic stroke.

Answer

The correct actions are implementing daily weights and strict intake/output monitoring for the client with heart failure, and verifying the swallowing ability of the client who experienced a stroke.
Safe risk reduction involves implementing evidence-based basic care (such as daily weights for heart failure to monitor fluid status) and preventing complications (such as assessing swallowing after a stroke to prevent aspiration). Both actions fall safely within the practical nurse's scope of practice and directly protect the client from harm.

Step-by-Step Solution

1
Evaluate the heart failure intervention.
Daily weights and intake/output monitoring are identified as appropriate.
These are standard, evidence-based practices to reduce the risk of fluid volume overload complications.
2
Evaluate the stroke intervention.
Verifying swallowing ability is identified as appropriate.
This is a necessary risk reduction measure to prevent aspiration before introducing oral intake.
3
Analyze the IV titration assignment.
Identified as an unsafe practice.
Managing continuous IV antiarrhythmic drips exceeds the practical nurse scope and requires RN-level monitoring.
4
Analyze the medication verification method.
Identified as a safety violation.
Using only one identifier (verbal name) breaches medication safety protocols; two distinct identifiers are always required.
5
Review the handling of the lab report.
Identified as a failure to escalate.
A sodium level of 118 mEq/L is critically low and requires immediate verbal notification, not passive charting.
6
Analyze the vital signs interpretation.
Identified as a missed clinical warning.
Tachycardia with borderline hypotension are early signs of shock and must be reported immediately, rather than assumed to be pain.

Key Concept

Identifying clinical risks and escalating care appropriately within the practical nurse scope of practice.
Question 335Question →

A practical nurse is providing oral care to a client who is unconscious and unable to swallow. Arrange the following nursing actions in the correct chronological sequence to ensure client safety and hygiene. (Place the first action at the top and the last action at the bottom.)

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence begins with protecting the airway by positioning the client in a side-lying position. Next, the nurse places a towel and emesis basin to catch fluids. The mouth is then safely opened using a padded tongue blade, followed by cleaning the oral cavity with a moistened sponge swab. Finally, the nurse applies a water-soluble lubricant to the client's lips.
Safety is the highest clinical priority when providing care to an unconscious client who has lost their protective swallow and gag reflexes. The nurse must first secure the airway by placing the client in a side-lying position to prevent aspiration. Once the airway is protected, the nurse prepares the immediate environment for cleanliness. The mouth is safely accessed using appropriate equipment (a padded tongue blade) to prevent injury, the hygiene is performed, and finally, comfort measures (lubricant) are applied to the lips.

Step-by-Step Solution

1
Position the client in a side-lying or lateral position.
The client's airway is protected from aspiration.
Gravity allows saliva and cleaning fluids to pool in the cheek and drain out of the mouth rather than sliding back into the pharynx.
2
Place a towel under the chin and position the emesis basin.
The area is prepared to manage fluid drainage.
This maintains cleanliness and dignity by preventing the client's gown and bed linens from becoming soiled during the procedure.
3
Open the mouth using a padded tongue blade.
The oral cavity is safely accessed.
Unconscious clients may have an unpredictable bite reflex. A padded blade protects both the client's oral mucosa and the nurse's fingers.
4
Swab the teeth, gums, and tongue.
The oral cavity is cleansed of debris and bacteria.
Regular cleaning prevents halitosis, oral infections, and the buildup of thick secretions.
5
Apply water-soluble lubricant to the lips.
The lips are moisturized and protected.
Unconscious clients often breathe through their mouths, leading to severely dry and cracked lips if not properly lubricated.

Key Concept

Oral Care for the Unconscious Client
Question 336Question →

A client diagnosed with bipolar disorder has been taking lithium carbonate for several months. During a clinic visit, the client reports experiencing persistent nausea, vomiting, and severe diarrhea for the past 48 hours. The practical nurse observes that the client is mildly disoriented and has a resting heart rate of 115 beats per minute. Which action should the practical nurse take first?

Show answer & explanation

Answer: Withhold any upcoming doses of the medication and immediately inform the registered nurse of the client's status.

Answer

The practical nurse should withhold any upcoming doses of the medication and immediately inform the registered nurse.
Lithium carbonate is a medication with a narrow therapeutic index. Conditions that cause dehydration and sodium depletion, such as severe vomiting and diarrhea, reduce the kidneys' ability to excrete lithium, rapidly leading to toxicity. The client's clinical presentation (tachycardia, gastrointestinal distress, and disorientation) strongly points to lithium toxicity and potential hypovolemia. The practical nurse must act safely by withholding the next dose and immediately escalating these critical findings to the registered nurse or healthcare provider for immediate medical intervention.

Step-by-Step Solution

1
Analyze the client's clinical presentation in the context of their medication therapy.
The client taking lithium has severe gastrointestinal fluid loss (vomiting, diarrhea), tachycardia, and disorientation.
Identifying abnormal findings is the first step in clinical data collection and determining client safety.
2
Correlate the symptoms with potential pharmacological complications.
Fluid and sodium loss lead to decreased renal excretion of lithium. The symptoms presented strongly indicate acute lithium toxicity.
Lithium has a very narrow therapeutic index, meaning the difference between a safe dose and a toxic dose is small.
3
Determine the safest, scope-appropriate action.
The nurse must withhold the dangerous medication and immediately escalate the critical findings to the RN or provider.
Practical nurses must prioritize client safety and recognize when a client's condition requires RN-level assessment and intervention.

Key Concept

Recognizing early signs of lithium toxicity and acting within the practical nursing scope of practice to ensure client safety.
Question 337Question →

A practical nurse (PN) is caring for a client who returned 2 hours ago from a diagnostic cardiac catheterization performed via the right femoral artery. The client's pre-procedure vital signs were a blood pressure of 138/76 mmHg and a heart rate of 72 beats/min. The client now reports a new onset of dull, aching pain in the lower right back. Current vital signs are blood pressure 102/58 mmHg, heart rate 108 beats/min, and respiratory rate 18 breaths/min. Which of the following actions is the priority for the PN to take?

Show answer & explanation

Answer: Immediately report the assessment findings to the registered nurse.

Answer

Immediately report the assessment findings to the registered nurse.
The client's new-onset tachycardia, relative hypotension, and lower back pain strongly indicate retroperitoneal bleeding, a severe and potentially life-threatening complication of a femoral cardiac catheterization. The practical nurse must prioritize client safety by immediately reporting these alarming findings to the registered nurse so that timely medical intervention can be initiated.

Step-by-Step Solution

1
Compare the client's current vital signs to their pre-procedure baseline.
Blood pressure has dropped significantly from 138/76 to 102/58 mmHg, and heart rate has increased from 72 to 108 beats/min.
To identify early hemodynamic instability indicative of hypovolemia or shock.
2
Correlate the vital sign changes with the client's reported symptom of new lower right back pain.
The combination of back pain, hypotension, and tachycardia suggests retroperitoneal bleeding, a known and severe complication of femoral artery access.
Back or flank pain following a femoral catheterization is a classic clinical indicator of internal retroperitoneal hemorrhage.
3
Determine the appropriate action based on the PN scope of practice.
The PN must notify the registered nurse (RN) immediately rather than independently managing the complication.
The client is experiencing a potentially life-threatening complication that requires RN-level assessment, clinical judgment, and immediate provider notification.

Key Concept

Recognizing Complications of Diagnostic Procedures
Question 338Question →

An 80-year-old client is admitted to the medical-surgical unit with an acute gastrointestinal hemorrhage. The client has a peripheral intravenous line infusing 0.9% sodium chloride. Which actions by the practical nurse demonstrate safe and effective prioritization of the client's physiological adaptation? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Elevating the head of the bed and verifying airway patency if the client begins vomiting active red blood.; Notifying the registered nurse immediately when the client's resting heart rate increases to 112 beats/min with a blood pressure of 100/64 mm Hg.; Applying a pulse oximeter to check oxygen saturation when the client becomes newly restless and diaphoretic.

Answer

The correct actions include elevating the head of the bed during vomiting, notifying the registered nurse of early shock vitals, and checking oxygen saturation for sudden restlessness.
The correct actions focus on maintaining airway patency during emesis, promptly recognizing and reporting early compensatory signs of hypovolemic shock (tachycardia, borderline hypotension), and assessing for hypoxia when neurological changes occur. These interventions align with the practical nurse's scope of practice for prioritizing physiological safety.

Step-by-Step Solution

1
Analyze the client's clinical condition and associated risks.
The client has a gastrointestinal hemorrhage, placing them at high risk for hypovolemic shock, airway compromise (from vomiting blood), and hypoxia.
Understanding the primary diagnosis helps the nurse anticipate potential life-threatening physiological complications.
2
Evaluate each nursing action against the ABC (Airway, Breathing, Circulation) priority framework.
Elevating the bed protects the airway; checking oxygenation prioritizes breathing; reporting tachycardia and borderline hypotension addresses circulation.
The ABC framework dictates the immediate survival priorities in acute physiological adaptation scenarios.
3
Differentiate expected baseline gerontological findings from signs of acute physiological deterioration.
Sudden confusion is an acute change indicating hypoxia or shock, not normal aging. Borderline low blood pressure is an early warning sign of hemorrhage, not an expected stable finding.
Failing to recognize subtle changes delays life-saving interventions and compromises client safety.

Key Concept

Prioritization of care and recognition of early signs of hypovolemic shock in a bleeding client.
Question 339Question →

During the first postoperative day after a right total hip arthroplasty (posterior approach), a client requires assistance with repositioning and morning hygiene. Which action by the practical nurse (PN) is most appropriate to promote safety and comfort?

Show answer & explanation

Answer: Maintain an abduction wedge between the client's legs when turning them onto their left side.

Answer

Maintain an abduction wedge between the client's legs when turning them onto their left side.
Following a total hip arthroplasty with a posterior approach, the client is at high risk for hip dislocation. Keeping the legs abducted using a wedge, especially when turning the client onto the unaffected side, prevents the operative leg from crossing the midline (adduction) and maintains proper joint alignment.

Step-by-Step Solution

1
Identify the surgical procedure and the associated physiological risks.
The client had a right total hip arthroplasty via a posterior approach, which carries a high risk of hip dislocation if the joint is flexed greater than 90 degrees or adducted.
Understanding specific postoperative mobility constraints is essential for providing safe basic care.
2
Evaluate each potential nursing intervention for safety and appropriateness.
Elevating the bed to 90 degrees causes dangerous flexion; massaging calves risks causing a pulmonary embolism; and delegating assessments is outside the UAP's scope of practice.
Actions that compromise safety, ABCs, or legal scope of practice must be eliminated.
3
Select the action that safely promotes comfort and mobility within the prescribed limits.
Using an abduction wedge while turning the client onto the unaffected side maintains proper joint alignment and prevents dislocation.
This action directly satisfies the requirement for safe positioning and comfort care.

Key Concept

Postoperative positioning and mobility precautions for total hip arthroplasty
Question 340Question →

A practical nurse is preparing to administer prescribed otic drops to an adult client diagnosed with otitis externa. Arrange the following actions for administering this medication in the correct chronological sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: Position the client laterally, straighten the auditory canal by pulling the pinna upward and backward, instill the drops, apply gentle pressure to the tragus, and instruct the client to remain in the lateral position.
The correct chronological sequence ensures patient safety, anatomical alignment, and maximum medication efficacy. First, positioning the client uses gravity to direct the drops. Second, pulling the adult pinna upward and backward properly straightens the naturally curved ear canal. Third, instilling the drops while avoiding physical contact maintains sterility. Fourth, pressing the tragus actively moves the fluid inward toward the tympanic membrane. Finally, having the client remain in position prevents the medication from prematurely leaking out of the ear.

Step-by-Step Solution

1
Establish the correct patient position.
The client is lying on their side with the affected ear facing the ceiling.
Gravity is required to keep the instilled liquid inside the ear canal.
2
Prepare the anatomical pathway.
The ear canal is straightened by pulling the pinna upward and backward.
Adult ear canals have a natural curve; straightening them ensures the medication reaches deep into the canal rather than resting on the outer walls.
3
Administer the medication.
The prescribed drops are instilled into the ear.
Instillation immediately follows anatomical preparation. Avoiding contact between the dropper and the ear prevents contamination.
4
Facilitate medication transit.
Gentle pressure is applied to the tragus.
This creates an inward pumping mechanism that moves the drops past any air pockets toward the eardrum.
5
Maintain medication placement.
The client remains on their side for several minutes.
This dwell time prevents the medication from leaking out when the client sits up.

Key Concept

Administration of Otic Medications in Adults
PreviousPage 17 / 66Next
Physiological Integrity Practice Questions — NCLEX-PN — Page 17 | Examkin