Examkin

Physiological Integrity

1313 questions

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Question 361Question →

An adult client is transferred to the step-down unit after undergoing a diagnostic cardiac catheterization utilizing the right femoral artery approach. When managing the client's basic care and comfort during the immediate recovery phase, which positioning intervention should the practical nurse implement?

Show answer & explanation

Answer: Maintain the client in a supine position with the right leg kept completely straight.

Answer

Maintain the client in a supine position with the right leg kept completely straight.
Following a femoral artery catheterization, the most critical intervention is maintaining the affected extremity straight and keeping the client supine (or with the head elevated no more than 30 degrees, depending on facility policy). The femoral artery is a major vessel under high pressure. Flexing the hip or knee can alter the tension on the puncture site, dislodge the newly formed clot, and lead to sudden, life-threatening internal or external arterial hemorrhage.

Step-by-Step Solution

1
Identify the specific procedure and access site from the clinical scenario.
The client had a cardiac catheterization via the right femoral artery.
Different vascular access sites require entirely different postoperative positioning protocols.
2
Determine the necessary positioning requirements for a femoral artery puncture.
The client must remain on strict bed rest with the affected extremity kept entirely extended (straight) and the head of the bed flat or minimally elevated.
Arterial pressure is high. Keeping the leg straight and the hip unflexed prevents dislodgment of the clot at the femoral site, preventing life-threatening hemorrhage.

Key Concept

Post-cardiac catheterization positioning for femoral access
Question 362Question →

Fifteen minutes after receiving an intramuscular injection of ceftriaxone for a respiratory infection, a client suddenly reports feeling dizzy and extremely restless. The practical nurse assesses the client and notes a heart rate of 122122 beats per minute and a blood pressure of 84/50 mmHg84/50\text{ mmHg}. Which action should the nurse take first?

Show answer & explanation

Answer: Activate the rapid response team and remain with the client to monitor their airway and breathing.

Answer

The correct action is to activate the rapid response team and remain with the client to monitor their airway and breathing.
The client's sudden onset of restlessness, dizziness, tachycardia, and hypotension shortly after receiving an antibiotic injection are classic signs of anaphylactic shock. Anaphylaxis is a life-threatening allergic reaction. According to the ABC (Airway, Breathing, Circulation) framework, the nurse must prioritize airway and circulation. The immediate and most appropriate action is to activate the rapid response team or emergency medical services while staying with the client to maintain the airway and provide support until advanced help arrives.

Step-by-Step Solution

1
Analyze the client's presentation and vital signs following the medication administration.
The client has developed tachycardia (122122 beats per minute), hypotension (84/50 mmHg84/50\text{ mmHg}), dizziness, and restlessness.
Identifying abnormal clinical data is the foundational step in recognizing an adverse pharmacological reaction.
2
Correlate the clinical findings with potential complications of the administered antibiotic.
The acute onset of these symptoms indicates anaphylactic shock, a severe and life-threatening allergic reaction to the ceftriaxone.
Antibiotics are a common cause of anaphylaxis, which rapidly compromises circulation and the airway.
3
Determine the priority nursing intervention based on the practical nurse scope of practice and the ABC framework.
The nurse must immediately call for emergency assistance while staying with the client to maintain airway patency.
In emergent situations, securing advanced medical help while providing basic life support is the highest priority.

Key Concept

Recognizing and responding to severe adverse medication reactions using the Airway, Breathing, Circulation (ABC) prioritization framework.
Estimated Time:1m 30s
Question 363Question →

A client who underwent a left total knee replacement yesterday requires assistance with morning care and positioning. Which actions by the practical nurse demonstrate correct understanding of postoperative comfort and safety measures? Select all that apply.

Select all that apply

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Answer: Place a rolled towel under the left lower leg to keep the heel completely suspended off the mattress.; Instruct the client to perform active ankle dorsiflexion and plantar flexion exercises hourly while awake.; Apply a cold therapy pack to the surgical site for 20-minute intervals as prescribed.

Answer

The correct actions are placing a towel under the lower leg to suspend the heel, instructing the client to perform active ankle exercises, and applying a cold therapy pack to the surgical site.
Appropriate postoperative care for a total knee replacement focuses on preventing venous stasis, protecting the skin, minimizing edema, and ensuring the knee heals in an extended position. Suspending the heel prevents pressure injuries while maintaining knee extension. Ankle exercises stimulate blood flow, reducing the risk of a deep vein thrombosis. Cold therapy causes local vasoconstriction, which decreases swelling and provides non-pharmacological pain relief.

Step-by-Step Solution

1
Analyze the client's postoperative status
The client is recovering from a left total knee replacement.
Understanding the specific surgical procedure is essential to determine safe joint positioning and expected basic care needs.
2
Evaluate each nursing intervention for appropriateness
Interventions that maintain knee extension, promote circulation, and reduce edema are appropriate. Interventions that promote knee flexion or are designed for different surgeries are inappropriate.
Proper postoperative positioning prevents severe complications such as joint contractures, deep vein thrombosis, and pressure injuries.
3
Select the correct basic care measures
Suspending the heel, performing ankle exercises, and applying cold therapy are the correct and safe measures.
These actions align with evidence-based practices for basic care and comfort following joint replacement surgery.

Key Concept

Postoperative Positioning and Basic Care for Total Knee Arthroplasty
Question 364Question →

A practical nurse is conducting a postoperative assessment on a 76-year-old client who underwent a total abdominal hysterectomy four hours ago. Which assessment findings should the nurse identify as expected physiological responses that can be managed with routine ongoing monitoring? Select all that apply.

Select all that apply

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Answer: Hypoactive bowel sounds auscultated in all four abdominal quadrants; Scant amount of dark red drainage on the intact surgical dressing; Client report of surgical site pain rated as a 4 on a 0 to 10 numeric scale

Answer

The expected postoperative findings that require only routine monitoring are hypoactive bowel sounds, a scant amount of dark red surgical drainage, and mild to moderate localized surgical site pain.
Following a major abdominal surgery, hypoactive bowel sounds are an expected physiological adaptation due to the effects of anesthesia and bowel manipulation. A scant amount of dark red (sanguineous) drainage is typical in the first few hours postoperatively. Mild to moderate localized incisional pain is also anticipated and can be managed with prescribed analgesics without requiring emergency escalation.

Step-by-Step Solution

1
Analyze the clinical scenario and the specific question being asked.
The client is 4 hours post-op from a major abdominal surgery. The question asks to identify expected, stable findings.
Understanding the timeline and surgical type is necessary to differentiate normal physiological adaptation from acute complications.
2
Evaluate each assessment finding against normal postoperative parameters.
Hypoactive bowel sounds, scant sanguineous drainage, and moderate pain are normal. Confusion, tachycardia with hypotension, and hypoxia are abnormal.
Systematic evaluation ensures critical signs of deterioration are not overlooked.
3
Select the options that represent expected, non-emergent findings.
The correct selections are the bowel sounds, the scant drainage, and the expected pain level.
These findings reflect appropriate physiological adaptation to surgery and can be safely managed with routine nursing care.

Key Concept

Differentiating expected postoperative physiological adaptations from early signs of acute complications in the older adult client.
Question 365Question →

An older adult client is recovering in the ambulatory care unit immediately following the surgical removal of a cataract in the right eye. To promote optimal comfort and prevent an increase in intraocular pressure, which positioning intervention should the practical nurse implement?

Show answer & explanation

Answer: Adjust the bed to a Semi-Fowler's position and assist the client to rest on their left side or back.

Answer

Adjust the bed to a Semi-Fowler's position and assist the client to rest on their left side or back.
Following cataract surgery, it is critical to prevent an increase in intraocular pressure. Adjusting the bed to a Semi-Fowler's position (head elevated 30 to 45 degrees) promotes venous drainage from the head, which naturally lowers pressure. Additionally, positioning the client either supine or on the non-operative side (the left side, since the right eye was operated on) prevents direct mechanical pressure on the delicate surgical site.

Step-by-Step Solution

1
Identify the surgical procedure and the affected side.
The client had a cataract removed from the right eye.
Knowing the operative side is essential for determining safe postoperative positioning and preventing direct pressure.
2
Determine the physiological goals following eye surgery.
The primary goals are to prevent an increase in intraocular pressure (IOP) and avoid direct physical contact with the surgical site.
Increased IOP or direct pressure can cause hemorrhage or disrupt the surgical incision, leading to severe complications.
3
Select the position that achieves these goals.
A Semi-Fowler's position facilitates venous drainage, and resting on the back or non-operative (left) side avoids direct pressure on the right eye.
This specific combination of bed elevation and side-lying protects the surgical eye while promoting comfort and safety.

Key Concept

Postoperative Positioning for Eye Surgery
Question 366Question →

A practical nurse (PN) is assigned to care for a client who is 24 hours postoperative following abdominal surgery and has a closed-wound drainage system (Jackson-Pratt drain). The PN is preparing to empty the drainage device. Arrange the following actions in the correct sequence to safely perform this procedure.

Drag items to arrange them in the correct order

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Answer

The correct sequence is to first perform hand hygiene and don gloves, then unplug the port, pour the drainage into a measuring container, compress the empty bulb, and finally replace the plug while maintaining compression.
Maintaining a closed-wound drainage system requires strict adherence to infection control and the physical principles of negative pressure. Hand hygiene and gloving are the initial steps to prevent the introduction of pathogens. Opening the port allows the fluid to be emptied and measured, which is an essential nursing responsibility for monitoring postoperative bleeding or fluid shifts to reduce risk potential. Finally, squeezing the bulb and sealing it creates a vacuum, which restores the gentle, continuous suction needed to remove fluid from the surgical site, thereby reducing the risk of hematoma formation and promoting wound healing.

Step-by-Step Solution

1
Perform hand hygiene and put on clean gloves.
Pathogen transmission risk is minimized.
Standard precautions must always be the first step when preparing to handle bodily fluids or invasive devices.
2
Unplug the drainage port on the collection bulb.
The sealed vacuum is released.
The system must be opened to allow the accumulated fluid to be emptied.
3
Pour drainage into a graduated measuring container.
Fluid is collected for accurate measurement.
Careful monitoring of postoperative drainage volume is required to assess for risk of bleeding or excessive fluid loss.
4
Compress the empty bulb fully.
Air is expelled from the bulb.
The bulb must be flattened to prepare for re-establishing negative pressure.
5
Replace the plug into the drainage port while the bulb is compressed.
Negative pressure suction is re-established.
Sealing the flattened bulb creates the gentle vacuum needed to continuously draw fluid away from the surgical site.

Key Concept

Maintaining and Emptying Closed-Wound Drainage Systems
Question 367Question →

An adult client is receiving a scheduled course of subcutaneous enoxaparin. During data collection, the client reports passing dark, tarry stools. The practical nurse notes that the client's latest laboratory results show a platelet count of 82,000/mm382,000/\text{mm}^3, and current vital signs include a heart rate of 112 beats/min112\text{ beats/min} and a blood pressure of 94/58 mmHg94/58\text{ mmHg}. Which of the following is the priority action for the practical nurse?

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Answer: Withhold the enoxaparin dose and urgently notify the registered nurse of the assessment findings.

Answer

The correct action is to withhold the enoxaparin dose and urgently notify the registered nurse of the assessment findings.
The correct answer demonstrates the practical nurse's responsibility to recognize critical pharmacological safety concerns and act strictly within their scope of practice. The client's dark, tarry stools, tachycardia, hypotension, and thrombocytopenia (82,000/mm382,000/\text{mm}^3) are classic signs of gastrointestinal hemorrhage and a severe adverse reaction to enoxaparin. The absolute priority is to withhold the anticoagulant to prevent worsening the hemorrhage and to immediately alert the registered nurse so that emergency medical interventions can be initiated.

Step-by-Step Solution

1
Analyze the client's clinical presentation and laboratory data.
The client presents with dark, tarry stools (melena), tachycardia, borderline hypotension, and a low platelet count (82,000/mm382,000/\text{mm}^3).
Identifying abnormal assessment findings is essential to determine the safety of continuing a prescribed pharmacological therapy.
2
Evaluate the mechanism and adverse effects of the prescribed medication.
Enoxaparin is an anticoagulant; known severe adverse effects include hemorrhage and heparin-induced thrombocytopenia (HIT).
Connecting the medication's physiological effects to the client's symptoms reveals an active, life-threatening complication.
3
Determine the appropriate nursing intervention within the practical nurse's scope of practice.
The practical nurse must withhold the contraindicated medication and immediately escalate the critical findings to the registered nurse or provider.
Practical nurses cannot alter prescribed doses or ignore critical signs of shock; ensuring immediate client safety and proper escalation is the top priority.

Key Concept

Recognizing adverse effects of anticoagulants (active bleeding and thrombocytopenia) and applying appropriate LPN scope of practice actions.
Question 368Question →

A client is recovering in the surgical unit 88 hours after a right total knee arthroplasty. The practical nurse evaluates the client and records a heart rate of 114114 beats/min, a blood pressure of 94/5694/56 mm Hg, and a respiratory rate of 1818 breaths/min. The client states their pain is currently manageable. Based on these findings, which of the following actions should the practical nurse take? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Inspect the surgical dressing and portable wound suction device for excessive blood accumulation.; Escalate the clinical assessment findings to the supervising registered nurse without delay.; Check the client's postoperative laboratory results for recent hemoglobin and hematocrit values.

Answer

The correct actions are to inspect the surgical dressing and wound suction device for bleeding, escalate the findings to the supervising registered nurse without delay, and check the postoperative hemoglobin and hematocrit laboratory results.
The client's tachycardia and hypotension postoperatively are early indicators of hypovolemia or internal bleeding. The practical nurse must prioritize client safety by assessing the surgical site for active bleeding, reviewing recent hemoglobin and hematocrit levels to evaluate blood loss, and immediately escalating these critical findings to the registered nurse for further medical management.

Step-by-Step Solution

1
Analyze the client's vital signs and postoperative timeline.
A heart rate of 114 beats/min and blood pressure of 94/56 mm Hg at 8 hours postoperative indicate potential early hypovolemic or hemorrhagic shock.
Tachycardia and mild hypotension are initial compensatory mechanisms when fluid or blood volume is actively being lost.
2
Determine the priority nursing interventions for suspected hypovolemia.
The nurse must identify the source of potential fluid loss by assessing the surgical site and gathering relevant laboratory data.
Assessing the surgical site for active bleeding and reviewing blood counts (Hgb/Hct) provide crucial data about the severity of blood loss.
3
Evaluate the role and scope of the practical nurse in this scenario.
The practical nurse must report these abnormal, potentially critical findings directly to the registered nurse.
Initiating emergency protocols and modifying the overall medical plan of care falls under the registered nurse's scope, requiring immediate collaboration.

Key Concept

Early recognition of hypovolemic shock and appropriate escalation within the practical nursing scope of practice.
Question 369Question →

While coordinating care on a busy inpatient unit, a practical nurse performs several medication-related tasks throughout the shift. Which of the following actions reflect adherence to established pharmacological safety standards and the appropriate scope of practice? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Verifying a client's most recent serum potassium level prior to dispensing an oral loop diuretic.; Withholding a scheduled dose of metoprolol and notifying the registered nurse when the client's apical pulse is 48 beats per minute.; Asking a client to state their full name and comparing it with their identification band prior to handing them their pills.

Answer

The actions that demonstrate safe pharmacological practice are: verifying the potassium level before giving a loop diuretic, withholding metoprolol for a low heart rate and notifying the RN, and having the client state their name while checking their identification band.
Safe pharmacological therapy requires the practical nurse to operate within their defined scope of practice while strictly adhering to safety checks. This includes verifying relevant lab values (like potassium for diuretics), checking vital signs and knowing when to withhold medication (like heart rate for beta-blockers), and strictly using two acceptable patient identifiers (like asking the client to state their name and checking the ID band).

Step-by-Step Solution

1
Evaluate each action against the 'rights of medication administration' and safety protocols.
Checking identifiers (name/ID band) and verifying relevant lab values (potassium) align with the rights of medication administration.
Standard safety protocols require two active identifiers and pre-administration assessment of pertinent labs.
2
Determine if each action falls within the legal scope of practice for a practical nurse.
Withholding medication for abnormal vitals and reporting to the RN is within scope. Administering IV push medications is out of scope.
Practical nurses must recognize when to hold a medication based on vital sign parameters but are restricted from performing IV push administrations in most jurisdictions.
3
Assess pre-administration screening practices.
Failing to check for allergies before giving a vaccine is a major safety violation.
Immunization protocols mandate allergy screening to prevent anaphylactic reactions.

Key Concept

Medication Safety and Practical Nurse Scope of Practice
Estimated Time:1m 30s
Question 370Question →

A practical nurse is providing basic care for an adolescent client who is on strict bed rest following a spinal fusion surgery for scoliosis. Which of the following actions should the nurse implement to promote comfort and safety? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Keep the client's spine in a straight, neutral alignment during routine care.; Utilize the logrolling technique with the assistance of additional staff when turning the client.; Offer a fracture bedpan for elimination needs to minimize movement of the lower back.

Answer

The appropriate actions are to keep the spine in a straight alignment, utilize the logrolling technique with additional staff assistance, and offer a fracture bedpan.
Following a spinal fusion, it is essential to maintain the spine in a neutral, straight alignment to prevent injury to the surgical site and promote proper healing. Utilizing the logrolling technique with multiple staff members allows the entire body to turn as a single unit, completely avoiding any twisting of the spine. Furthermore, using a fracture bedpan is appropriate for basic care because its flat lip requires significantly less lifting of the pelvis, minimizing stress on the lower back during elimination.

Step-by-Step Solution

1
Analyze the client's condition and post-operative requirements.
The client had a spinal fusion and is on strict bed rest, requiring maintenance of spinal alignment to prevent hardware failure and spinal cord injury.
Spinal fusion requires the vertebral column to remain immobilized and straight during the initial healing phase.
2
Evaluate each intervention for safety, proper body mechanics, and scope of practice.
Logrolling, keeping the spine neutral, and using a fracture bedpan maintain proper alignment. High-Fowler's position, twisting, and delegating assessment are contraindicated.
Improper positioning compromises the surgical site; additionally, assessing incisions falls strictly outside the scope of unlicensed assistive personnel.

Key Concept

Post-operative basic care, positioning, and safety following spinal fusion surgery.
Question 371Question →

During a shift, a practical nurse reviews the medication administration record for a client being treated for a pulmonary embolism. The client weighs 165 lb165\text{ lb}. The provider has prescribed a subcutaneous injection of enoxaparin sodium at 1 mg/kg1\text{ mg/kg} every 12 hours12\text{ hours}. The medication is supplied in a prefilled syringe containing 100 mg/1 mL100\text{ mg}/1\text{ mL}. How many mL\text{mL} should the nurse administer? Record your answer to the nearest hundredth. Do not include units in your answer.

Show answer & explanation

Answer: 0.75

Answer

0.75
To determine the correct volume to administer, first convert the client's weight to kilograms (165÷2.2=75 kg165 \div 2.2 = 75\text{ kg}). Next, determine the total dose required by multiplying the weight by the prescribed rate (75×1=75 mg75 \times 1 = 75\text{ mg}). Finally, divide the required dose by the available concentration to find the volume in milliliters (75÷100=0.75 mL75 \div 100 = 0.75\text{ mL}).

Step-by-Step Solution

1
Convert the client's weight to kilograms
75 kg75\text{ kg}
The prescription is weight-based in kilograms, so the pounds must be converted (165÷2.2=75165 \div 2.2 = 75).
2
Calculate the required medication dose
75 mg75\text{ mg}
Multiply the client's weight in kilograms by the prescribed dosage rate (75×1=7575 \times 1 = 75).
3
Calculate the volume to administer
0.75 mL0.75\text{ mL}
Divide the desired dose by the available concentration to find the required liquid volume (75÷100×1=0.7575 \div 100 \times 1 = 0.75).

Key Concept

Weight-based medication dosage and volume calculation
Question 372Question →

A practical nurse receives a client who just returned to the nursing unit following a diagnostic lumbar puncture. To prevent a common post-procedure complication and promote client comfort, which positioning action should the nurse implement?

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Answer: Maintain the client in a flat, supine position for several hours.

Answer

The client should be maintained in a flat, supine position for several hours following a lumbar puncture.
Following a lumbar puncture, the client must remain flat in a supine position for a prescribed period, usually 4 to 8 hours. This neutral, horizontal alignment prevents the leakage of cerebrospinal fluid (CSF) from the puncture site, which is the primary cause of severe, debilitating spinal headaches.

Step-by-Step Solution

1
Identify the procedure the client just underwent.
The client had a diagnostic lumbar puncture.
Different diagnostic procedures require specific postoperative positioning to prevent complications.
2
Determine the primary post-procedure complication associated with a lumbar puncture.
The main complication is a post-dural puncture headache (spinal headache) caused by cerebrospinal fluid (CSF) leakage.
Understanding the physiological risk guides the choice of nursing interventions.
3
Select the appropriate positioning to prevent this complication.
Keeping the client flat and supine helps maintain equalized pressure in the central nervous system, minimizing CSF leakage.
Gravity causes more CSF to leak from the puncture site if the head is elevated.

Key Concept

Post-procedure Positioning for Lumbar Puncture
Estimated Time:1m 0s
Question 373Question →

While performing an afternoon assessment on a client who underwent a total thyroidectomy earlier in the day, the licensed practical nurse notes the client has become visibly restless. The client's voice is increasingly hoarse, and they mention a new sensation of tightness in the anterior neck area. Current vital signs show a heart rate of 114 beats/min and a respiratory rate of 24 breaths/min. Which action should the nurse take first?

Show answer & explanation

Answer: Alert the registered nurse immediately and verify that an emergency tracheostomy tray is at the bedside.

Answer

The nurse should immediately alert the registered nurse and ensure emergency airway equipment is present.
Following a thyroidectomy, a new sensation of neck tightness, hoarseness, restlessness, tachycardia, and tachypnea are classic early indicators of a developing hematoma or laryngeal edema. This is a life-threatening complication that can rapidly occlude the airway. The practical nurse must prioritize airway management by immediately escalating these findings to the registered nurse and ensuring emergency equipment (such as a tracheostomy tray) is readily available to mitigate the risk of respiratory arrest.

Step-by-Step Solution

1
Analyze the client's new symptoms: restlessness, hoarseness, neck tightness, tachycardia (114 beats/min), and tachypnea (24 breaths/min).
Recognize these findings as indicative of a developing neck hematoma or laryngeal edema.
Following a thyroidectomy, bleeding into the tissue spaces can rapidly compress the trachea, presenting initially as local pressure and subtle respiratory distress.
2
Determine the appropriate priority intervention based on the practical nursing scope of practice.
Identify that the situation represents a life-threatening airway emergency requiring immediate escalation.
Airway compromise requires advanced assessment, potential rapid response team activation, and possible emergency surgical intervention.
3
Select the action that protects the client's safety.
Notify the RN immediately and confirm the availability of a tracheostomy tray.
This action ensures the team is aware of the critical change and is prepared for immediate advanced airway management.

Key Concept

Recognizing and Escalating Early Signs of Postoperative Complications
Question 374Question →

A client is recovering from a subtotal thyroidectomy performed earlier in the day. During routine data collection, the practical nurse notes the client's heart rate is 108 beats/min and blood pressure is 102/64 mm Hg. The client states, "My neck feels very tight, and it is getting a little hard to swallow." Which action should the practical nurse take immediately?

Show answer & explanation

Answer: Inspect the surgical dressing and the back of the client's neck for swelling or excessive bleeding.

Answer

The practical nurse should immediately inspect the surgical dressing and the back of the client's neck for swelling or excessive bleeding.
After a thyroidectomy, a feeling of neck tightness, difficulty swallowing, tachycardia, and a dropping blood pressure are classic signs of a surgical site hemorrhage and expanding hematoma. This life-threatening emergency can quickly compress the trachea and block the airway. The practical nurse must immediately inspect the dressing and the back of the neck (where blood can pool dependently) to gather data before promptly notifying the registered nurse or rapid response team.

Step-by-Step Solution

1
Analyze the client's vital signs and reported symptoms.
The client has tachycardia (108 beats/min), borderline hypotension (102/64 mm Hg), neck tightness, and difficulty swallowing.
Identifying abnormal data is the critical first step in recognizing a sudden clinical change.
2
Correlate the findings with potential postoperative complications of a thyroidectomy.
These findings point to an expanding hematoma, which can cause both hypovolemic shock (tachycardia, low blood pressure) and airway compression (neck tightness, difficulty swallowing).
Connecting signs and symptoms to underlying pathophysiological complications determines the severity of the situation.
3
Determine the priority nursing action based on the Airway, Breathing, and Circulation (ABC) framework.
The immediate priority is to visually assess the surgical site for bleeding and swelling before quickly escalating to the RN or provider.
Focused data collection must occur to confirm the complication and guide life-saving emergency interventions.

Key Concept

Recognition of postoperative hemorrhage and airway compromise
Question 375Question →

A client arrives at the medical-surgical unit after undergoing a percutaneous liver biopsy. The registered nurse has completed the initial admission assessment and delegates ongoing care to the licensed practical nurse. Which actions are essential for the practical nurse to perform to minimize the risk of complications? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Position the client in a right lateral decubitus position using a small pillow or rolled towel under the costal margin.; Assess the client's vital signs every 15 minutes during the first hour and compare them to the pre-procedure baseline.; Inspect the biopsy puncture site and surrounding skin for overt bleeding or expanding hematoma during each assessment.

Answer

The correct actions include positioning the client on the right side to apply pressure to the liver, monitoring vital signs every 15 minutes initially, and frequently inspecting the puncture site for bleeding.
Following a percutaneous liver biopsy, the primary risk is hemorrhage because the liver is a highly vascular organ. Positioning the client on the right side compresses the liver capsule against the chest wall, promoting hemostasis. Frequent vital sign monitoring (every 15 minutes for the first hour) and direct inspection of the puncture site are critical to rapidly identify signs of bleeding or hypovolemic shock.

Step-by-Step Solution

1
Analyze the client's clinical situation and procedure.
The client has just undergone a percutaneous liver biopsy.
The liver is a highly vascular organ, making severe hemorrhage the most critical potential complication following a biopsy.
2
Evaluate each nursing action for its impact on reducing the risk of hemorrhage.
Right-sided positioning, frequent vital sign checks, and direct site inspection actively mitigate or detect bleeding.
Applying external pressure and closely monitoring for early signs of shock are evidence-based standards of care for this procedure.
3
Identify actions that fall outside the LPN scope of practice or actively increase risk.
Delegating the initial assessment to UAP, ignoring borderline vital signs, and placing the client in a high-Fowler's position are incorrect and unsafe actions.
These actions fail to appropriately monitor the client or position them to prevent bleeding.

Key Concept

Reduction of Risk Potential: Post-Procedure Liver Biopsy Care
Question 376Question →

A practical nurse is reinforcing teaching for a client who is non-weight-bearing on the right leg and is learning to ascend stairs using crutches without a handrail. In what order should the practical nurse instruct the client to perform the following actions? Arrange the actions in the correct chronological sequence.

Drag items to arrange them in the correct order

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Answer

The correct sequence is: Assume the tripod position, transfer body weight to the crutches, advance the unaffected leg up onto the step, shift body weight to the unaffected leg, and finally bring the affected leg and both crutches up to the step.
When ascending stairs with crutches, the standard safety protocol is 'up with the good, down with the bad.' The client must first establish balance in the tripod position and transfer weight to the crutches. This allows the unaffected (strong) leg to be lifted onto the step safely. Once the strong leg is on the step, the client shifts their weight onto it, using the strong leg to power the body upward while simultaneously bringing the crutches and the affected (weak) leg up to the same step.

Step-by-Step Solution

1
Assume the tripod position at the bottom of the stairs.
The client achieves a stable base of support.
Provides necessary balance before initiating any upward movement.
2
Transfer body weight entirely onto the crutches.
The legs are freed from bearing weight.
Allows the unaffected leg to be lifted without the client losing balance.
3
Advance the unaffected leg up onto the step.
The strong leg is positioned on the higher level.
The unaffected leg must lead when going up to provide the power to lift the body (often remembered as 'up with the good').
4
Shift body weight from the crutches to the unaffected leg.
The strong leg now supports the entire body weight.
Frees the arms and crutches so they can be lifted to the next step.
5
Bring the affected leg and both crutches up to the step.
The client successfully completes one step ascent.
Completes the motion while safely keeping the affected leg non-weight-bearing.

Key Concept

Ascending stairs with crutches (non-weight-bearing)
Question 377Question →

During morning rounds, a practical nurse (PN) evaluates a client who had an open appendectomy 6 hours earlier. The baseline vital signs recorded upon transfer from the post-anesthesia care unit were a blood pressure of 122/78 mm Hg and a heart rate of 76 beats/min. The current vital signs show a blood pressure of 100/64 mm Hg and a heart rate of 108 beats/min. The client complains of feeling slightly dizzy. Which action should the PN take first?

Show answer & explanation

Answer: Report the assessment findings to the supervising registered nurse (RN).

Answer

Report the assessment findings to the supervising registered nurse (RN).
The client is exhibiting early signs of compensatory shock, likely due to postoperative hemorrhage or hypovolemia. The combination of a decreasing blood pressure, an increasing heart rate, and dizziness requires immediate escalation to the RN or provider for further assessment and intervention to prevent clinical deterioration.

Step-by-Step Solution

1
Analyze the client's current vital signs compared to the baseline.
The blood pressure has dropped, and the heart rate has increased significantly.
Comparing current data to baseline helps identify downward trends.
2
Interpret the clinical significance of the findings.
Tachycardia, hypotension, and dizziness in a postoperative client are early indicators of hypovolemia or hemorrhage.
Recognizing postoperative complications is a key aspect of reducing risk potential.
3
Determine the appropriate scope of practice for the PN.
The PN must report these abnormal findings to the RN for comprehensive assessment and medical intervention.
Abnormal physiological trends that indicate instability require immediate escalation.

Key Concept

Early Recognition of Postoperative Hypovolemia
Question 378Question →

A practical nurse (PN) is reviewing the medication administration record for an adult client with a history of heart failure. The client is scheduled to receive oral digoxin and oral furosemide. Additionally, a new prescription for intravenous (IV) push furosemide was just added to the chart. The client's morning vital signs include a heart rate of 56 beats/min56\text{ beats/min} and a blood pressure of 118/74 mm Hg118/74\text{ mm Hg}. The morning serum potassium level is 3.1 mEq/L3.1\text{ mEq/L}. Which of the following actions should the PN take? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Withhold the scheduled dose of oral digoxin.; Notify the registered nurse (RN) regarding the client's vital signs and laboratory results.; Document the withheld medications and the clinical reasons for withholding them in the electronic health record.

Answer

The correct actions are to withhold the scheduled dose of oral digoxin, notify the registered nurse (RN) regarding the vital signs and laboratory results, and document the withheld medications and the reasons for withholding them in the electronic health record.
The practical nurse must apply clinical knowledge and strictly adhere to their scope of practice. Oral digoxin should be withheld because the client's heart rate is below 60 beats/min, and the presence of hypokalemia (potassium 3.1 mEq/L) dangerously increases the risk of digoxin toxicity. Oral furosemide must also be withheld because it is a potassium-wasting diuretic that would exacerbate the low potassium level. The RN must be immediately notified of these critical findings so the provider can adjust the treatment plan. Finally, standard nursing practice requires thorough documentation whenever a scheduled medication is withheld, including the rationale.

Step-by-Step Solution

1
Evaluate the client's vital signs against medication parameters.
The heart rate is 56 beats/min. Digoxin must be held for a heart rate less than 60 beats/min in an adult.
Digoxin has a negative chronotropic effect (slows heart rate) and could cause symptomatic bradycardia.
2
Evaluate the client's laboratory results against the scheduled medications.
The serum potassium is 3.1 mEq/L (normal: 3.5-5.0 mEq/L). Furosemide wastes potassium and must be held. Hypokalemia also increases the risk of digoxin toxicity.
Administering furosemide will exacerbate the hypokalemia, and the low potassium makes the heart muscle more sensitive to digoxin, increasing toxicity risk.
3
Determine the practical nurse's scope of practice for the new IV push prescription.
IV push furosemide cannot be administered by the PN.
The administration of IV push medications requires advanced assessment and clinical judgment reserved for the RN scope of practice.
4
Formulate a safe clinical response.
Hold the oral digoxin and furosemide, decline the IV push medication, notify the RN, and accurately document the withheld medications.
This comprehensively ensures client safety, maintains adherence to the scope of practice, and fulfills legal documentation standards.

Key Concept

Medication administration safety, LPN/VN scope of practice, and critical lab value interpretation
Question 379Question →

A practical nurse (PN) is collecting data on an 82-year-old client who is receiving intravenous antibiotics for severe pyelonephritis. Which of the following assessment findings should the PN identify as early indicators of systemic decompensation and potential septic shock that require immediate notification to the registered nurse (RN)? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Heart rate of 118 beats per minute; New-onset confusion and restlessness; Respiratory rate of 28 breaths per minute

Answer

The findings that indicate early systemic decompensation and require immediate RN notification are a heart rate of 118 beats per minute, new-onset confusion and restlessness, and a respiratory rate of 28 breaths per minute.
In the early (compensatory) stages of septic shock and systemic inflammatory response syndrome (SIRS), the body attempts to maintain cardiac output and oxygen delivery to tissues. This physiological adaptation results in an increased heart rate (tachycardia) and an increased respiratory rate (tachypnea). Additionally, older adults are highly sensitive to slight decreases in cerebral oxygenation and perfusion, making new-onset confusion or restlessness one of the earliest and most reliable indicators of systemic deterioration. These findings require immediate intervention to prevent irreversible organ damage.

Step-by-Step Solution

1
Identify the client's current diagnosis and primary risks.
The client has severe pyelonephritis (a kidney infection), which places them at high risk for systemic inflammatory response syndrome (SIRS) and septic shock.
Understanding the clinical context helps distinguish between expected disease symptoms and life-threatening complications.
2
Evaluate the assessment findings to distinguish between localized expected symptoms and systemic emergency signs.
Flank pain and cloudy urine are expected local signs. Tachycardia, tachypnea, and altered mental status are abnormal systemic signs.
The PN must differentiate baseline or expected disease manifestations from acute changes that indicate deterioration.
3
Prioritize the findings based on Airway, Breathing, and Circulation (ABC) principles.
The elevated heart rate, elevated respiratory rate, and new-onset confusion represent early circulatory and respiratory compromise (shock) and must be reported immediately.
Systemic shock is a life-threatening emergency that takes precedence over expected localized infection signs or routine pain management.

Key Concept

Early Recognition of Septic Shock and SIRS
Estimated Time:1m 30s
Question 380Question →

A practical nurse is caring for a client with atrial fibrillation who is prescribed a daily dose of oral warfarin. The client is also scheduled to receive a seasonal influenza vaccine. Upon reviewing the morning laboratory results, the nurse notes an international normalized ratio (INR) of 6.56.5. Which of the following actions is the priority for the practical nurse?

Show answer & explanation

Answer: Withhold the scheduled oral warfarin and immediately report the INR result to the registered nurse.

Answer

The priority action is to withhold the scheduled oral warfarin and immediately report the critical INR result to the registered nurse.
The client's international normalized ratio (INR) of 6.56.5 is significantly elevated above the standard therapeutic range of 2.0 to 3.0 for a client with atrial fibrillation, indicating a critical risk for hemorrhage. The priority action for the practical nurse is to ensure client safety by withholding the scheduled warfarin and immediately escalating this critical laboratory value to the registered nurse or provider for further medical orders.

Step-by-Step Solution

1
Evaluate the client's morning laboratory results against the scheduled medications.
The INR of 6.5 is identified as critically high compared to the normal therapeutic range.
Safe medication administration requires verifying that relevant laboratory values are within safe limits prior to administration.
2
Determine the appropriate clinical intervention based on the abnormal finding.
The scheduled dose of warfarin must be withheld.
Administering additional warfarin would further increase the INR and place the client at an extreme risk for spontaneous hemorrhage.
3
Identify the correct action within the practical nurse scope of practice.
The nurse must report the critical value to the supervising registered nurse or provider.
Practical nurses are responsible for monitoring client data, recognizing critical abnormalities, and escalating them appropriately to ensure client safety.

Key Concept

Monitoring for adverse effects and escalating critical laboratory values associated with pharmacological therapies.
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