Physiological Integrity

1313 questions

All types1,313 Multiple choice672 Multiple select289 Numeric68 Ordering284

A practical nurse is caring for a client who returned 3 hours ago following a percutaneous coronary intervention (PCI) via the right femoral artery approach. The client reports a new, deep aching pain in the right lower back. The right groin dressing is dry and intact, and bilateral pedal pulses are palpable. Current vital signs are: blood pressure 104/64 mm Hg (baseline 132/80 mm Hg), heart rate 102 bpm (baseline 74 bpm), and respiratory rate 18 breaths/min. Which of the following actions should the practical nurse take first?

Notify the supervising registered nurse immediately of the assessment findings.

Administer the prescribed as-needed acetaminophen to relieve the reported back pain.

Document the expected procedural discomfort and continue scheduled vital sign checks.

Assist the client to turn onto the left side to relieve pressure on the lower back.

Show answer & explanation

Answer: Notify the supervising registered nurse immediately of the assessment findings.

Answer

The correct action is to notify the supervising registered nurse immediately of the assessment findings.

The client is exhibiting classic signs of a retroperitoneal hemorrhage, a severe complication of femoral artery catheterization. The combination of new lower back pain and subtle signs of hemodynamic compromise (mild tachycardia and decreased blood pressure from baseline) despite a dry insertion site requires immediate escalation to the registered nurse for rapid medical intervention.

Step-by-Step Solution

Analyze the client's symptoms in the context of the recent invasive procedure.

The client has new deep lower back pain 3 hours after a right femoral artery catheterization.

Back or flank pain after a femoral procedure is a cardinal sign of retroperitoneal hemorrhage, even if the external insertion site appears dry.

Compare the current vital signs against the client's baseline data.

The heart rate has increased from 74 to 102 bpm, and the blood pressure has decreased from 132/80 to 104/64 mm Hg.

Identifying subtle shifts in vital signs helps differentiate benign back pain from early hypovolemic shock caused by internal bleeding.

Synthesize the clinical data to determine the risk level.

The combination of back pain and borderline hypovolemic vital signs indicates a high risk for a life-threatening retroperitoneal hemorrhage.

Recognizing severe complications is necessary for safe risk reduction and prioritization.

Select the appropriate nursing intervention within the practical nurse scope of practice.

The practical nurse must immediately escalate the findings to the registered nurse or provider.

Life-threatening complications require immediate advanced assessment and intervention beyond the practical nurse scope.

Key Concept

Recognizing Retroperitoneal Hemorrhage

Question 22Question →

A practical nurse (PN) is preparing to administer the measles, mumps, and rubella (MMR) live vaccine to an adult female client in a community health clinic. Which of the following actions should the PN take to ensure safe practice? Select all that apply.

Select all that apply

Inquire if the client is currently pregnant or plans to become pregnant within the next four weeks.

Withhold the vaccine and notify the registered nurse if the client is currently receiving immunosuppressive therapy.

Proceed with the immunization without assessing for gelatin or neomycin allergies if the client has received previous vaccines.

Bypass the barcode scanning process because the vaccine is administered as a standard, prepackaged dose.

Calculate the required medication volume to administer by converting the client's current weight from pounds to kilograms.

Accept a delegated task to administer a newly prescribed intravenous (IV) push antibiotic to the client during the same visit.

Show answer & explanation

Answer: Inquire if the client is currently pregnant or plans to become pregnant within the next four weeks.; Withhold the vaccine and notify the registered nurse if the client is currently receiving immunosuppressive therapy.

Answer

The correct actions are to inquire if the client is pregnant or plans to become pregnant, and to withhold the vaccine if the client is receiving immunosuppressive therapy.

The MMR vaccine is a live attenuated virus. It is strictly contraindicated during pregnancy due to the risk of fetal harm, and clients should be advised to avoid pregnancy for at least four weeks after vaccination. Additionally, live vaccines are contraindicated in clients who are severely immunocompromised (such as those receiving immunosuppressive therapy), as they can cause severe or fatal infections. Therefore, the practical nurse must actively screen for these conditions before administration.

Step-by-Step Solution

Identify the medication classification and properties.

The MMR vaccine is a live attenuated viral vaccine.

Understanding that the vaccine contains live viruses helps identify absolute contraindications related to immune function and fetal safety.

Evaluate the client's current health status against known contraindications.

Pregnancy and severe immunosuppression are absolute contraindications for live vaccines.

Live vaccines can cross the placenta or cause severe systemic infection in clients lacking an adequate immune response.

Review the practical nurse (PN) scope of practice and medication safety standards.

The PN must perform all medication rights verification, recognize that adult MMR doses are standardized rather than weight-based, and refuse tasks outside their scope, such as IV push administration.

Adhering to strict safety standards and scope of practice prevents patient harm and professional liability.

Key Concept

Safe administration of live attenuated vaccines and adherence to the practical nurse scope of practice.

Question 23Question →

During the night shift, a nurse is evaluating an 82-year-old client who had a partial gastrectomy 48 hours ago. The client, who was previously resting quietly, is now agitated, confused, and trying to pull off the surgical dressing. Clinical findings include a heart rate of 118 beats/min, a respiratory rate of 26 breaths/min, and a blood pressure of 100/62 mm Hg. The client is rubbing their abdomen and groaning. Which action should the nurse prioritize?

Assess the client's oxygen saturation level and apply prescribed supplemental oxygen.

Administer the prescribed breakthrough analgesic to alleviate the client's abdominal discomfort.

Reorient the client to the hospital environment and dim the room lights to encourage sleep.

Document the current findings and resume hourly monitoring, as the vital signs remain within acceptable post-surgical parameters.

Show answer & explanation

Answer: Assess the client's oxygen saturation level and apply prescribed supplemental oxygen.

Answer

The priority action is to assess the client's oxygen saturation level and apply prescribed supplemental oxygen.

The client is exhibiting early signs of hypoxia and potential shock, indicated by new-onset agitation, tachycardia, tachypnea, and borderline hypotension. In the physiological adaptation phase following surgery, acute changes in mental status combined with these vital signs prioritize the need for immediate respiratory support and oxygenation assessment based on the ABCs.

Step-by-Step Solution

Analyze the client's change in mental status and vital signs.

The client exhibits sudden onset agitation, tachycardia (118 beats/min), tachypnea (26 breaths/min), and borderline hypotension (100/62 mm Hg).

Recognizing acute changes is essential for identifying potential life-threatening complications such as shock or hypoxia in the post-operative period.

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

The client's symptoms strongly suggest impaired oxygenation, which takes clinical precedence over pain management or environmental modifications.

The ABC framework guides nurses to address the most critical and immediate threats to life first.

Determine the initial nursing intervention.

Assessing oxygenation status and providing prescribed respiratory support directly addresses the most critical physiological need.

Restoring adequate oxygenation is the immediate priority before treating pain or attempting to reorient a confused client.

Key Concept

Recognizing early signs of physiological decompensation and applying ABC prioritization.

Question 24Question →

The practical nurse (PN) is reviewing the morning assessment data and medication administration record (MAR) for a $65$ -year-old client admitted with chronic kidney disease and hypertension.

Assessment Data	Current Finding
Blood pressure	$142/88$ mmHg
Heart rate	$64$ beats/minute
Respiratory rate	$18$ breaths/minute
Oxygen saturation	$96\%$ on room air
Serum potassium	$5.9$ mEq/L ( $5.9$ mmol/L)

Scheduled Medications:
* Lisinopril $20$ mg PO daily
* Sodium polystyrene sulfonate $15$ g PO stat
* Metoprolol $5$ mg IV push stat
* Influenza virus vaccine (inactivated) $0.5$ mL IM once

Based on this data, which actions by the PN are appropriate? Select all that apply.

Select all that apply

Withhold the scheduled oral lisinopril and immediately report the hyperkalemia to the registered nurse (RN).

Administer the oral sodium polystyrene sulfonate after verifying the client's full name and date of birth.

Notify the charge nurse that the stat IV push metoprolol requires administration by an RN.

Administer the stat IV push metoprolol slowly over

2

minutes while observing the client for hypotension.

Verify the client's identity using their room number and physical location before administering the influenza vaccine.

Withhold the influenza vaccine because the client reports experiencing a mild, localized rash at the injection site after last year's dose.

Show answer & explanation

Answer: Withhold the scheduled oral lisinopril and immediately report the hyperkalemia to the registered nurse (RN).; Administer the oral sodium polystyrene sulfonate after verifying the client's full name and date of birth.; Notify the charge nurse that the stat IV push metoprolol requires administration by an RN.

Answer

The practical nurse should withhold the oral lisinopril and notify the RN, safely administer the oral sodium polystyrene sulfonate using proper client identifiers, and notify the charge nurse that the IV push metoprolol requires RN administration.

The client's serum potassium level of

5.9

mEq/L indicates hyperkalemia. Because ACE inhibitors like lisinopril cause potassium retention, the scheduled dose must be withheld and the registered nurse (RN) notified to prevent cardiac complications. Administering oral sodium polystyrene sulfonate is an appropriate action to treat hyperkalemia, provided the PN verifies the client's identity using two client-specific identifiers (such as full name and date of birth). Furthermore, because administering medications via direct intravenous (IV) push typically exceeds the PN scope of practice, the PN must advocate for client safety by notifying the charge nurse that an RN is required to administer the IV metoprolol.

Step-by-Step Solution

Analyze the client's laboratory results in relation to the prescribed medications.

The serum potassium level is

5.9

mEq/L, indicating hyperkalemia. Lisinopril is an ACE inhibitor that can cause further potassium retention, whereas sodium polystyrene sulfonate is prescribed to lower potassium levels.

Identifying contraindications based on current laboratory data prevents potentially life-threatening adverse events.

Determine the legal boundaries of the practical nurse (PN) scope of practice.

The PN can safely administer oral (PO) and intramuscular (IM) medications, but administering intravenous (IV) push medications must be deferred to the RN.

Nurses must practice strictly within their legal scope to ensure safe, competent client care.

Evaluate the safety principles for medication identification and vaccine contraindications.

Safe administration requires two client-specific identifiers (excluding room numbers). Additionally, a mild localized reaction to a previous vaccine is not a valid contraindication for current administration.

Adhering strictly to medication safety rights and evidence-based immunization guidelines minimizes the risk of clinical errors.

Key Concept

Safe pharmacological therapy requires integrating client laboratory data to withhold contraindicated medications, adhering strictly to the PN scope of practice, and applying evidence-based medication safety standards.

Question 25Question →

Following the morning handoff report, a practical nurse (PN) begins data collection for a group of assigned clients. Which client findings represent acute physiological deterioration and require immediate intervention? Select all that apply.

Select all that apply

A client with a deep vein thrombosis who suddenly develops a cough and rapid breathing.

A client who is 2 hours post-appendectomy and exhibits a steady heart rate increase from 80 to 115 beats per minute.

A client receiving intravenous insulin whose skin becomes pale, cold, and clammy while becoming highly agitated.

A client with a closed tibia fracture who is crying and urgently requesting pain medication.

An older adult client with advanced dementia who is completely unable to state their current location.

A client who is 24 hours postpartum and has saturated one perineal pad over the past 4 hours.

Show answer & explanation

Answer: A client with a deep vein thrombosis who suddenly develops a cough and rapid breathing.; A client who is 2 hours post-appendectomy and exhibits a steady heart rate increase from 80 to 115 beats per minute.; A client receiving intravenous insulin whose skin becomes pale, cold, and clammy while becoming highly agitated.

Answer

The correct findings indicating acute physiological deterioration are the client with a deep vein thrombosis developing a cough and rapid breathing, the post-appendectomy client with a rising heart rate, and the client on insulin exhibiting pale, clammy skin with agitation.

The correct findings all represent acute, life-threatening physiological changes. Sudden respiratory distress in a DVT client suggests a pulmonary embolism. A rising heart rate post-surgery is a classic early sign of internal bleeding and shock. Agitation with cold, clammy skin during insulin therapy indicates profound hypoglycemia. All three require immediate nursing intervention.

Step-by-Step Solution

Evaluate the client with deep vein thrombosis (DVT) for airway and breathing compromise.

The sudden onset of a cough and rapid breathing indicates a potential pulmonary embolism.

DVT clots can dislodge and travel to the lungs, creating a severe, life-threatening respiratory emergency.

Evaluate the post-appendectomy client and the client receiving insulin for systemic instability.

The rising heart rate indicates early hypovolemic shock, and pale, clammy skin with agitation indicates severe hypoglycemia.

Both represent acute, life-threatening circulatory and metabolic changes that demand urgent medical treatment.

Evaluate the remaining clients to differentiate acute deterioration from expected or non-emergent findings.

The clients with the tibia fracture, advanced dementia, and postpartum status have expected or non-life-threatening findings.

Expected pain, baseline cognitive disorientation, and normal lochia flow do not take precedence over ABC emergencies.

Key Concept

Prioritization of Acute Physiological Deterioration

Question 26Question →

An adult client is recovering on the surgical unit 12 hours after a total thyroidectomy. The practical nurse is planning care to prevent and identify potential postoperative emergencies. Which of the following actions should the nurse include? Select all that apply.

Select all that apply

Verify that an emergency tracheostomy kit and functioning suction equipment are present at the bedside.

Monitor the client for reports of numbness or tingling around the mouth and fingertips.

Check the surgical dressing and the back of the client's neck for unexpected pooling of blood.

Maintain the client in a flat, supine position to prevent flexion of the neck.

Administer prescribed intravenous push calcium gluconate immediately if tetany develops.

Document a new resting heart rate of 105 beats per minute without immediately notifying the registered nurse.

Show answer & explanation

Answer: Verify that an emergency tracheostomy kit and functioning suction equipment are present at the bedside.; Monitor the client for reports of numbness or tingling around the mouth and fingertips.; Check the surgical dressing and the back of the client's neck for unexpected pooling of blood.

Answer

The appropriate actions are verifying emergency airway equipment is at the bedside, monitoring for perioral and extremity numbness, and checking the back of the neck for blood pooling.

Appropriate risk reduction following a thyroidectomy includes preparing for potential airway emergencies, assessing for hidden bleeding behind the neck, and closely monitoring for signs of parathyroid gland damage (hypocalcemia), such as perioral tingling.

Step-by-Step Solution

Identify the client's specific surgical risks based on the procedure.

Primary risks include airway obstruction, hidden hemorrhage, and hypocalcemia.

A thyroidectomy involves the anterior neck, placing the airway, major blood vessels, and parathyroid glands at risk.

Evaluate the proposed monitoring actions against these specific risks.

Actions targeting airway preparation, detecting subtle hemorrhage, and recognizing calcium deficit signs are appropriate.

These actions actively reduce the potential for severe complications and align with established protocols.

Identify actions that are outside the scope of practice or clinically contraindicated.

Supine positioning, administering IV push medications, and delaying reports of tachycardia are unsafe.

These actions violate the practical nurse's scope of practice, post-procedure positioning standards, and early escalation requirements.

Key Concept

Reduction of postoperative risks following a thyroidectomy requires anticipating airway compromise, assessing for hidden hemorrhage, monitoring for hypocalcemia, and operating strictly within the practical nursing scope of practice.

Question 27Question →

A licensed practical nurse (LPN) is assisting with the care of a client who is 12 hours postoperative following an open cholecystectomy and has a nasogastric tube connected to low wall suction. Which of the following independent or collaborative actions by the LPN demonstrate appropriate risk reduction strategies? Select all that apply.

Select all that apply

Reporting a morning serum potassium level of 3.1 mEq/L (3.1 mmol/L) to the registered nurse immediately upon viewing the laboratory results.

Attributing a new heart rate of 112 beats per minute and a blood pressure of 98/62 mm Hg to postoperative pain and administering prescribed oral analgesics without further escalation.

Silencing an intravenous infusion pump alarm and hanging a replacement bag of normal saline without rechecking the client's identification band, since the client was verified earlier in the shift.

Verifying the placement of the nasogastric tube by assessing the pH of aspirated gastric contents prior to administering any prescribed enteral medications.

Accepting a delegated task from the charge nurse to perform the initial admission assessment and develop the care plan for a new client transferred from the intensive care unit.

Applying prescribed sequential compression devices (SCDs) to the client's lower extremities while the client is resting in bed.

Show answer & explanation

Answer: Reporting a morning serum potassium level of 3.1 mEq/L (3.1 mmol/L) to the registered nurse immediately upon viewing the laboratory results.; Verifying the placement of the nasogastric tube by assessing the pH of aspirated gastric contents prior to administering any prescribed enteral medications.; Applying prescribed sequential compression devices (SCDs) to the client's lower extremities while the client is resting in bed.

Answer

The correct risk reduction strategies are reporting the low potassium level, verifying nasogastric tube placement via pH aspirate, and applying sequential compression devices for venous thromboembolism prophylaxis.

Appropriate risk reduction requires the practical nurse to proactively identify and mitigate potential client harm. This includes recognizing abnormal laboratory values, such as a hypokalemic potassium level of 3.1 mEq/L caused by gastric suctioning, and immediately reporting them. Furthermore, implementing evidence-based practices like verifying nasogastric tube placement via aspirate pH and applying sequential compression devices directly prevents life-threatening complications such as pulmonary aspiration and deep vein thrombosis.

Step-by-Step Solution

Analyze the client's risk factors based on the clinical presentation.

The client is postoperative and undergoing continuous nasogastric suction, which introduces risks for hypovolemia, electrolyte imbalances (specifically hypokalemia), deep vein thrombosis, and aspiration.

Identifying specific risks based on the surgical procedure and active treatments guides the selection of appropriate preventative interventions.

Evaluate the laboratory finding and vital signs for necessary escalation.

The potassium level of 3.1 mEq/L is below the normal range (3.5-5.0 mEq/L) and must be reported. The vital signs (HR 112, BP 98/62) are borderline and suggest early shock, making it unsafe to attribute them solely to pain.

Risk reduction requires the timely recognition and communication of physiological deterioration.

Review the nursing actions for adherence to safety protocols and scope of practice.

Checking aspirate pH and applying SCDs are correct, safe practices. However, skipping patient identifiers for IV fluids and accepting an initial admission assessment violate core safety standards and the practical nursing scope of practice.

Bypassing established safety protocols or operating outside defined licensure limits directly increases the risk of client harm.

Key Concept

Reduction of Risk Potential requires the practical nurse to proactively identify early signs of complications (like abnormal labs or vital signs), verify the safe functioning of therapeutic devices, and adhere strictly to safety protocols and scope of practice boundaries.

Question 28Question →

A client on a medical-surgical unit is recovering from a partial bowel resection performed 48 hours ago. The morning laboratory results reveal a hemoglobin level of 7.2 g/dL (72 g/L). The client's current vital signs show a heart rate of 114 beats/min, a respiratory rate of 22 breaths/min, and a blood pressure of 98/62 mm Hg. The client reports feeling lightheaded when sitting up in bed. Which action should the practical nurse take first?

Report the assessment findings and laboratory results to the registered nurse immediately.

Document the laboratory results as an expected finding associated with postoperative blood loss.

Provide a warm blanket and plan to reassess the vital signs in one hour.

Increase the rate of the continuous intravenous fluid infusion to treat the hypotension.

Show answer & explanation

Answer: Report the assessment findings and laboratory results to the registered nurse immediately.

Answer

The correct action is to report the assessment findings and laboratory results to the registered nurse immediately.

The client is exhibiting clear signs of symptomatic anemia and potential hypovolemic shock, evidenced by tachycardia, hypotension, dizziness, and a significantly low hemoglobin level. The practical nurse must prioritize client safety by immediately escalating these critical findings to the registered nurse for urgent collaborative intervention, such as a blood transfusion or fluid resuscitation.

Step-by-Step Solution

Analyze the client's clinical data.

The client has a critically low hemoglobin level (7.2 g/dL), tachycardia (114 beats/min), hypotension (98/62 mm Hg), and symptoms of decreased perfusion (lightheadedness).

Identifying abnormal parameters is the first step in recognizing clinical deterioration.

Correlate the findings with potential postoperative complications.

These combined findings strongly suggest active internal bleeding, hypovolemia, or symptomatic anemia.

Connecting laboratory data with vital sign trends determines the severity of the client's risk.

Determine the priority nursing action within the practical nurse's scope of practice.

The priority is to immediately communicate these findings to the registered nurse or healthcare provider.

The client requires urgent interventions (e.g., blood transfusion, fluid resuscitation) that require collaborative management and exceed independent LPN/PN scope.

Key Concept

Reduction of Risk Potential: Recognizing and escalating early signs of hypovolemic shock

Question 29Question →

A client who underwent a subtotal thyroidectomy earlier today calls for assistance due to muscle aching in the neck and shoulders. The practical nurse enters the room to adjust the client's position for optimal comfort and safety. Which of the following positioning methods should the nurse implement?

Elevate the head of the bed to 30 to 45 degrees and support the head with pillows to keep the neck in a neutral position.

Place the client in a flat, supine position to reduce gravitational pressure on the neck and promote deep sleep.

Position a small rolled towel horizontally beneath the client's cervical spine to gently extend the neck and relieve muscle spasms.

Raise the head of the bed to a full 90-degree angle and encourage the client to actively stretch their neck from side to side.

Show answer & explanation

Answer: Elevate the head of the bed to 30 to 45 degrees and support the head with pillows to keep the neck in a neutral position.

Answer

The nurse should elevate the head of the bed to a semi-Fowler's position (30 to 45 degrees) and use pillows to support the client's head and neck in strict neutral alignment.

Following a thyroidectomy, placing the client in a semi-Fowler's position (head of the bed elevated 30 to 45 degrees) with the head and neck supported in a neutral position is the essential standard of care. The elevation promotes venous return and decreases surgical site edema, which is critical for protecting the airway. The supportive pillows provide comfort while preventing neck extension or flexion, which could pull on the suture line, cause severe pain, or trigger bleeding.

Step-by-Step Solution

Assess the client's current position and comfort level, noting the recent subtotal thyroidectomy.

Recognize that the client is at high risk for airway obstruction resulting from postoperative edema or hemorrhage.

Swelling in the anterior neck tissues can quickly compress the trachea, making airway protection the top clinical priority.

Elevate the head of the bed to an angle of 30 to 45 degrees (semi-Fowler's position).

Gravitational pull naturally promotes venous drainage away from the client's head and neck.

Decreasing venous pressure minimizes incisional edema and bleeding, thereby protecting the airway and enhancing overall comfort.

Place supportive pillows or sandbags closely on both sides of the client's head and neck.

The cervical spine is securely maintained in a neutral, aligned position without flexing or hyperextending.

Neutral alignment prevents undue tension on the fresh suture line, prevents wound dehiscence, and helps minimize the muscle spasms commonly experienced after this surgery.

Key Concept

Proper postoperative positioning following a thyroidectomy requires semi-Fowler's elevation and neutral neck alignment to prevent airway compromise, reduce edema, and protect the surgical incision.

Question 30Question →

A licensed practical nurse (LPN) is preparing to collect an aerobic wound culture from a client's sacral pressure injury. To ensure the integrity of the diagnostic test and reduce the risk of inaccurate laboratory results, in which order should the nurse perform the following actions? (Arrange the steps in the correct chronological sequence.)

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence requires exposing the wound, cleansing it with sterile saline, swabbing the viable tissue, securing the specimen, and finally redressing the wound.

The correct sequence ensures that the laboratory culture identifies the specific pathogen actively causing the tissue infection, rather than identifying normal surface skin flora or dead organisms found in surface exudate. Therefore, the wound must always be irrigated with sterile normal saline BEFORE the swab is applied to viable, granulating tissue. Proper sequencing reduces the risk of misdiagnosis and inappropriate antibiotic therapy.

Step-by-Step Solution

Remove the dressing and assess the wound.

The wound is exposed for baseline evaluation.

Allows the nurse to observe the site and identify the best area for specimen collection.

Irrigate with sterile normal saline.

Surface exudate and debris are washed away.

Cleansing prevents normal resident skin flora or dead neutrophils (pus) from contaminating the sample and causing inaccurate lab results.

Swab viable granulating tissue.

A clean pathogen sample is obtained.

Actively replicating microorganisms causing the deep tissue infection reside in the healthy-looking, granulating tissue.

Insert the swab into the sterile transport tube.

The specimen is secured and preserved.

Maintains a sterile environment and prevents external contamination during transport to the laboratory.

Apply a fresh dressing and document.

The wound is protected and the medical record is updated.

Completes the procedure by re-establishing a protective barrier over the injury.

Key Concept

Diagnostic test preparation: Aerobic wound culture collection technique

Estimated Time:1m 30s

Question 31Question →

During a routine rounding shift, a client who sustained a complete T4 spinal cord injury three months ago suddenly complains of blurred vision and an intense, pounding headache. Assessment reveals a blood pressure reading of 215/115 mm Hg, a heart rate of 52 beats per minute, and heavy diaphoresis on the face and neck. Determine the correct priority sequence for the interventions the nurse must implement. (Place the most urgent action at the top and the final action at the bottom.)

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct priority sequence is to first elevate the head of the bed, then loosen any restrictive clothing, followed by inspecting the urinary catheter for obstructions, and finally notifying the registered nurse.

In autonomic dysreflexia, the client experiences a life-threatening hypertensive crisis due to an exaggerated sympathetic response to a noxious stimulus below the level of the spinal cord injury (typically T6 or higher). The absolute first priority is to elevate the head of the bed to a sitting position, which uses gravity to induce orthostatic hypotension and rapidly lower the blood pressure. Next, the nurse should loosen any restrictive clothing, as this serves as a quick removal of an external noxious stimulus. Third, the nurse must assess for and remove the most common internal trigger, which is a distended bladder (e.g., checking the catheter for kinks). Finally, the RN must be notified so that pharmacological interventions can be prepared if the symptoms persist despite these initial nursing actions.

Step-by-Step Solution

Recognize the clinical emergency.

The client is identified as experiencing autonomic dysreflexia.

The combination of a T4 spinal cord injury, sudden profound hypertension, bradycardia, headache, and diaphoresis above the injury level are hallmark signs of this life-threatening syndrome.

Prioritize immediate physiological stabilization to prevent a stroke.

Elevate the head of the bed to a sitting position.

Sitting the client upright induces orthostatic hypotension, which is the fastest non-pharmacological method to reduce the dangerously high blood pressure.

Remove external noxious stimuli.

Loosen any tight or restrictive clothing.

Constrictive clothing can act as an external irritant that fuels the uninhibited sympathetic response below the level of the spinal cord injury.

Identify and resolve internal noxious stimuli.

Inspect the urinary catheter and drainage tubing for kinks.

Bladder distention is the most frequent internal trigger for autonomic dysreflexia. Relieving an obstruction removes the primary stimulus causing the hypertensive crisis.

Escalate care.

Notify the registered nurse (RN).

If nursing interventions fail to remove the stimulus or lower the blood pressure, the RN and healthcare provider must initiate pharmacological interventions (e.g., administering nifedipine or nitrates).

Key Concept

Autonomic dysreflexia is a medical emergency requiring strict sequential interventions: immediate upright positioning to lower blood pressure, removal of noxious stimuli (external then internal), and rapid escalation of care.

Question 32Question →

While organizing the shift workload on an acute medical-surgical unit, a licensed practical nurse reviews the status of four assigned individuals. Which action represents the highest priority to mitigate a potential life-threatening complication?

Independently developing and documenting the initial comprehensive discharge education plan for an individual recently diagnosed with congestive heart failure

Withholding a scheduled dose of oral furosemide and contacting the healthcare provider because the client's morning serum potassium level is 4.5 mEq/L (4.5 mmol/L)

Notifying the charge nurse about a postoperative client who has developed new-onset restlessness, a heart rate of 116 beats per minute, and a blood pressure of 94/58 mm Hg

Bypassing the electronic barcode medication administration system to quickly administer a routine daily supplement before the client leaves for a therapy session

Show answer & explanation

Answer: Notifying the charge nurse about a postoperative client who has developed new-onset restlessness, a heart rate of 116 beats per minute, and a blood pressure of 94/58 mm Hg

Answer

The most critical action is notifying the charge nurse about the postoperative client exhibiting new-onset restlessness, tachycardia, and hypotension, as these are clear indicators of impending shock.

The postoperative client is exhibiting early signs of hypovolemic or hemorrhagic shock, characterized by restlessness (due to decreased cerebral perfusion), tachycardia (a compensatory mechanism to maintain cardiac output), and hypotension. Immediate escalation to the charge nurse or provider is required to initiate interventions and prevent cardiovascular collapse. Addressing this immediate physiological threat directly reduces the most severe risk of potential harm.

Step-by-Step Solution

Analyze the postoperative client's assessment data, specifically the combination of restlessness, a heart rate of 116 bpm, and a blood pressure of 94/58 mm Hg.

Identify these systemic changes as classic early indicators of hemorrhagic or hypovolemic shock.

Postoperative clients carry a high risk of internal bleeding. Early detection of shock symptoms allows for prompt fluid resuscitation before irreversible tissue damage occurs.

Evaluate the clinical significance of the laboratory values in the diuretic scenario.

Determine that a potassium level of 4.5 mEq/L is strictly normal.

While loop diuretics deplete potassium, administering them when the baseline is firmly within the normal range of 3.5 to 5.0 mEq/L is standard and safe practice.

Assess the remaining scenarios against the practical nurse scope of practice and standard safety guidelines.

Recognize that developing initial care plans is an RN-only responsibility, and bypassing barcode scanners is a severe safety violation.

Adhering to scope boundaries and medication administration rights is foundational to general risk reduction, whereas addressing shock is an immediate life-saving priority.

Key Concept

Early Recognition of Hypovolemic Shock and Adherence to Scope of Practice

Question 33Question →

A practical nurse (PN) is reviewing the morning data for four assigned clients on a medical-surgical unit. Which client should the PN evaluate first?

A client admitted overnight following a motor vehicle crash with a pelvic fracture, who has a resting heart rate of 114 bpm and a blood pressure of 106/64 mmHg

A client recovering from a laparoscopic appendectomy performed yesterday, who reports right shoulder pain rated as 5 on a 0 to 10 scale

An 84-year-old client with a history of vascular dementia who is wandering the hallway and looking for a misplaced purse

A client receiving treatment for essential hypertension who has a morning blood pressure reading of 158/86 mmHg

Show answer & explanation

Answer: A client admitted overnight following a motor vehicle crash with a pelvic fracture, who has a resting heart rate of 114 bpm and a blood pressure of 106/64 mmHg

Answer

The client admitted overnight following a motor vehicle crash with a pelvic fracture, who has a resting heart rate of 114 bpm and a blood pressure of 106/64 mmHg.

The correct answer is the client with a pelvic fracture because a heart rate of 114 bpm and a borderline blood pressure of 106/64 mmHg are early, compensatory signs of hypovolemic shock. Pelvic fractures carry a notoriously high risk of massive internal retroperitoneal bleeding. This client is physiologically unstable and requires immediate evaluation and escalation to the registered nurse (RN).

Step-by-Step Solution

Analyze the clinical data for each assigned client to identify acute, life-threatening conditions.

The trauma client exhibits tachycardia (heart rate 114 bpm) and borderline hypotension (106/64 mmHg).

Prioritization requires identifying the most physiologically unstable client first.

Apply the ABCs (Airway, Breathing, Circulation) framework.

The trauma client's vital signs indicate a potential circulation compromise (hypovolemia/hemorrhage).

Circulation issues take strict priority over pain management, chronic confusion, or stable hypertension.

Compare the urgency of all client presentations.

The potential for massive internal hemorrhage in the pelvic fracture client is the most immediate threat.

Early recognition of shock allows for prompt intervention to prevent irreversible cardiovascular collapse.

Key Concept

Recognizing early signs of hypovolemic shock and applying the ABC prioritization framework.

Question 34Question →

A practical nurse is preparing to administer amoxicillin oral suspension to a pediatric client diagnosed with acute otitis media. The client weighs $44$ lb. The healthcare provider has prescribed $45\text{ mg/kg/day}$ to be divided into three equal doses administered every $8$ hours. The pharmacy supplies amoxicillin suspension at a concentration of $250\text{ mg}/5\text{ mL}$ . How many milliliters (mL) should the nurse administer for a single dose? (Record answer to the nearest whole number. Do not include units in answer.)

Show answer & explanation

Answer: 6

Answer

To determine the correct dose, the nurse must first convert the weight from pounds to kilograms by dividing by

2.2

(

44 \div 2.2 = 20\text{ kg}

). Next, calculate the total daily dose by multiplying the weight by the prescribed dose (

20\text{ kg} \times 45\text{ mg/kg} = 900\text{ mg/day}

). Since the medication is divided into three equal doses (every 8 hours), each individual dose is

300\text{ mg}

(

900 \div 3

). Finally, using the supplied concentration of

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

, calculate the required volume:

(300\text{ mg} \div 250\text{ mg}) \times 5\text{ mL} = 6\text{ mL}

Step-by-Step Solution

Convert the client's weight from pounds to kilograms.

44\text{ lb} \div 2.2\text{ lb/kg} = 20\text{ kg}

Weight-based medication dosages require the client's weight to be in kilograms.

Calculate the total daily dose prescribed.

20\text{ kg} \times 45\text{ mg/kg} = 900\text{ mg/day}

This establishes the total amount of medication the client should receive over a 24-hour period.

Determine the amount required for a single dose.

900\text{ mg} \div 3\text{ doses} = 300\text{ mg/dose}

The prescription states the daily dose must be divided into three equal doses (every 8 hours).

Calculate the volume of liquid to administer per dose.

\frac{300\text{ mg}}{250\text{ mg}} \times 5\text{ mL} = 6\text{ mL}

This uses the supplied concentration (

250\text{ mg}

per

5\text{ mL}

) to find the correct liquid volume to administer.

Key Concept

Pediatric weight-based dosage calculation and safe medication administration

Question 35Question →

A practical nurse (PN) is reviewing the medication administration record (MAR) and current vital signs for a client who is 24 hours postoperative following a bowel resection. The client is scheduled to receive a dose of oral metoprolol. The client's vital signs are: temperature 98.6°F (37.0°C), heart rate 118 beats/minute, respiratory rate 22 breaths/minute, and blood pressure 88/54 mm Hg. The client reports mild dizziness. Which action is the priority for the PN?

Administer the metoprolol as prescribed to help reduce the client's elevated heart rate.

Administer the medication with a small sip of water and instruct the client to remain in bed to prevent falls.

Withhold the metoprolol and immediately report the client's vital signs to the registered nurse.

Verify the client using two distinct identifiers and the barcode scanner before giving the medication.

Show answer & explanation

Answer: Withhold the metoprolol and immediately report the client's vital signs to the registered nurse.

Answer

The priority action is to withhold the metoprolol and immediately report the client's vital signs to the registered nurse.

The client is exhibiting signs of potential hypovolemic shock (hypotension, compensatory tachycardia, dizziness) following major surgery. Metoprolol is a beta-blocker that lowers both heart rate and blood pressure. Administering this medication would eliminate the body's compensatory mechanism (tachycardia) and further decrease the blood pressure, potentially leading to cardiovascular collapse. Within the practical nursing scope of practice, the nurse must withhold the medication and immediately escalate these critical findings to the registered nurse for urgent assessment and intervention.

Step-by-Step Solution

Analyze the client's vital signs and postoperative status.

The client is 24 hours post-op with tachycardia (118 bpm), hypotension (88/54 mm Hg), and dizziness, indicating possible hypovolemia, bleeding, or early shock.

Identifying physiological instability is the first step in safe medication administration.

Evaluate the pharmacological action of the scheduled medication.

Metoprolol is a beta-adrenergic blocker that decreases heart rate, blood pressure, and myocardial contractility.

Understanding the drug's mechanism is essential to predict its effect on the current clinical picture.

Synthesize the data to determine the appropriate nursing action.

Administering metoprolol will block the client's compensatory tachycardia and worsen the hypotension. The medication must be withheld and the RN notified.

The practical nursing scope of practice requires withholding contraindicated medications and escalating critical findings to the RN for comprehensive assessment.

Key Concept

Safe Medication Administration: Recognizing Contraindications and Scope of Practice

Estimated Time:1m 15s

Question 36Question →

An older adult client is receiving care on the surgical unit one day after a transurethral resection of the prostate (TURP). The client is currently restless and denies having any pain. The practical nurse obtains vital signs, noting a blood pressure of 96/60 mm Hg and a heart rate of 112 beats/minute. The client's preoperative baseline blood pressure was 138/82 mm Hg with a heart rate of 74 beats/minute. Which action should the nurse take first?

Notify the supervising registered nurse immediately about the assessment findings.

Document the vital signs in the electronic health record and continue routine monitoring.

Increase the rate of the maintenance intravenous fluids to correct the hypotension.

Administer a prescribed as-needed sedative to manage the client's restlessness.

Show answer & explanation

Answer: Notify the supervising registered nurse immediately about the assessment findings.

Answer

The most appropriate initial action is to notify the supervising registered nurse immediately about the assessment findings.

The correct action is to notify the registered nurse immediately. A decreasing blood pressure, increasing heart rate, and new-onset restlessness in a postoperative client are classic early indicators of hypovolemic shock, likely due to bleeding. The practical nurse's role is to promptly identify these risk factors and escalate the situation to ensure client safety.

Step-by-Step Solution

Analyze the client's current vital signs compared to the baseline.

The blood pressure has dropped significantly (from 138/82 to 96/60 mm Hg) and the heart rate has increased (from 74 to 112 beats/minute).

Recognizing trends in vital signs is essential to identify early physiological deterioration.

Evaluate the clinical significance of the physical assessment findings.

The client's unexplained restlessness, combined with tachycardia and hypotension, points to poor tissue perfusion.

Restlessness is often the earliest sign of hypoxia or hypovolemia, especially when the client denies pain.

Determine the priority nursing action within the practical nurse scope of practice.

The findings must be escalated to the registered nurse immediately.

The practical nurse must recognize signs of potential postoperative hemorrhage and shock, which require RN assessment and intervention.

Key Concept

Recognizing early signs of hypovolemic shock and prioritizing escalation of care within the practical nurse scope of practice.

Estimated Time:1m 15s

Question 37Question →

A practical nurse receives a hand-off report for a client who returned to the medical-surgical unit one hour ago following a percutaneous liver biopsy. The client is currently stable and reports mild tenderness at the biopsy site. Which positioning strategy is essential for the nurse to maintain during this immediate post-procedure period?

Assisting the client into a high-Fowler's position to encourage deep breathing and lung expansion.

Placing the client in a left lateral position with a pillow situated between the knees for spinal alignment.

Maintaining the client in a right side-lying position with a small rolled blanket under the puncture site.

Keeping the client in a flat supine position with the lower extremities elevated on pillows.

Show answer & explanation

Answer: Maintaining the client in a right side-lying position with a small rolled blanket under the puncture site.

Answer

Maintaining the client in a right side-lying position with a small rolled blanket under the puncture site.

Following a percutaneous liver biopsy, the client must be positioned on their right side (the operative side). This position, often supplemented by placing a rolled blanket or towel under the puncture site, utilizes the client's own body weight to apply direct, continuous external pressure to the liver capsule. This pressure is critical to achieve hemostasis and prevent internal hemorrhage from the highly vascular liver tissue.

Step-by-Step Solution

Identify the procedure performed and its anatomical location.

The client had a percutaneous liver biopsy. The liver is a highly vascular organ located on the right side of the abdomen.

Understanding the anatomy and the nature of the procedure is essential for determining post-procedure risks.

Determine the primary physiological risk following this specific procedure.

The greatest immediate risk following a liver biopsy is internal hemorrhage due to the liver's extensive blood supply.

Nursing care must prioritize basic comfort and safety interventions that mitigate the most severe risks.

Select the nursing intervention that directly addresses the risk of hemorrhage.

Applying external pressure to the puncture site achieves hemostasis.

Direct pressure prevents bleeding from the puncture wound.

Identify the correct physical position to achieve this goal.

Placing the client in a right side-lying position with a rolled blanket or towel directly under the costal margin uses the client's own body weight to apply continuous pressure.

This specific basic care measure is the standard protocol for post-liver biopsy positioning.

Key Concept

Post-procedure therapeutic positioning

Question 38Question →

A practical nurse (PN) is reviewing the morning data for an older adult client who takes scheduled oral atorvastatin for hyperlipidemia. Three days ago, the client was started on a course of oral clarithromycin for a respiratory infection. During the morning assessment, the client reports profound, generalized muscle aching. The PN observes that the client's urine in the collection device is dark and tea-colored. The morning laboratory results reveal a blood urea nitrogen (BUN) of $35\text{ mg/dL}$ ( $12.5\text{ mmol/L}$ ) and a serum creatinine of $2.4\text{ mg/dL}$ ( $212\text{ \mu mol/L}$ ). Which of the following is the priority action for the PN?

Withhold the atorvastatin and clarithromycin, and immediately report the clinical findings and laboratory results to the registered nurse (RN).

Administer the scheduled medications and encourage the client to drink additional fluids to help lower the elevated serum creatinine.

Administer a prescribed PRN analgesic for the muscle pain and reposition the client for comfort, delaying the scheduled medications.

Bypass routine barcode scanning to expedite the administration of the clarithromycin, as treating the acute infection is the priority.

Show answer & explanation

Answer: Withhold the atorvastatin and clarithromycin, and immediately report the clinical findings and laboratory results to the registered nurse (RN).

Answer

The priority action is to withhold both the atorvastatin and clarithromycin and immediately escalate the clinical findings and laboratory results to the supervising registered nurse (RN).

The correct action demonstrates an understanding of a severe drug-drug interaction. Clarithromycin inhibits the metabolism of atorvastatin, leading to toxic accumulation. The client's symptoms (muscle pain, dark urine) and laboratory values (elevated BUN and creatinine) indicate rhabdomyolysis and acute kidney injury. Within the PN scope of practice, the immediate priority is to ensure safety by withholding the medications and escalating the critical findings to the RN for medical intervention.

Step-by-Step Solution

Analyze the client's medication regimen for potential interactions.

The client is taking atorvastatin (a statin) and clarithromycin (a macrolide antibiotic). Clarithromycin strongly inhibits the CYP3A4 enzyme, which metabolizes atorvastatin. This leads to toxic levels of the statin.

Identifying drug-drug interactions is a critical step before administering any medication.

Evaluate the client's clinical symptoms and laboratory findings against known adverse effects.

Severe muscle aching, dark tea-colored urine (myoglobinuria), elevated BUN, and elevated serum creatinine indicate rhabdomyolysis and resulting acute kidney injury.

Recognizing severe adverse reactions ensures the nurse does not administer a medication that will cause further harm.

Determine the priority nursing intervention within the practical nurse (PN) scope of practice.

The PN must withhold the offending medications and immediately notify the RN and healthcare provider so that emergent medical interventions can be initiated.

The PN's primary responsibility in an adverse event is to maintain client safety by stopping the harm and escalating to the RN or provider for advanced clinical judgment.

Key Concept

Recognizing severe drug interactions leading to rhabdomyolysis, and executing the PN role to withhold medications and report critical findings.

Question 39Question →

An older adult client is hospitalized for observation following a mechanical fall that caused blunt abdominal trauma. During the night shift, the nurse notes that the client has become restless and mildly confused about their current location. Vital signs demonstrate a heart rate of 114 beats per minute, a blood pressure of 102/74 mm Hg, and a respiratory rate of 22 breaths per minute. The client's peripheral pulses are weak and extremities are cool. Which action should the nurse take first?

Implement advanced fall precautions and gently reorient the client to the hospital room.

Administer the prescribed as-needed analgesic, anticipating that the restlessness is caused by underlying pain.

Palpate the abdomen for firmness or distention and notify the charge nurse immediately.

Record the current vital signs and maintain routine monitoring as the blood pressure remains adequate.

Show answer & explanation

Answer: Palpate the abdomen for firmness or distention and notify the charge nurse immediately.

Answer

The nurse should immediately assess the abdomen for signs of internal bleeding (firmness or distention) and notify the charge nurse.

The correct answer identifies that the client is exhibiting early signs of compensated hypovolemic shock due to internal bleeding. The combination of tachycardia, tachypnea, cool extremities, weak pulses, and new-onset confusion in a trauma client are critical indicators of decreased perfusion. The practical nurse must immediately collect targeted data regarding the abdomen and escalate these findings to the charge nurse for prompt medical intervention.

Step-by-Step Solution

Analyze the client's history and current assessment data.

The client has a history of blunt abdominal trauma and is now exhibiting tachycardia, tachypnea, weak pulses, cool extremities, and new-onset confusion.

Identifying the complete clinical picture is necessary to determine the underlying physiological process.

Correlate the physical findings with potential complications.

The combination of these symptoms indicates activation of the sympathetic nervous system, pointing to early compensated hypovolemic shock.

Recognizing shock early is critical before the client's blood pressure drops and they become hemodynamically unstable.

Determine the priority nursing intervention within the practical nurse scope of practice.

The priority is to gather targeted data regarding the suspected source of bleeding (the abdomen) and immediately escalate the findings.

Addressing circulation (the 'C' in ABCs) takes precedence over pain management, routine monitoring, or treating the confusion as an isolated behavioral issue.

Key Concept

Recognizing Early Compensated Shock

Question 40Question →

During a routine morning assessment, a client receiving pharmacological therapy for heart failure states, "I feel sick to my stomach, and all the lights have a strange yellow glow around them." The client's medication profile includes daily oral digoxin and furosemide. A review of today's laboratory results reveals a serum digoxin level of $2.8\text{ ng/mL}$ . Which action should the practical nurse implement?

Administer the scheduled digoxin dose as prescribed, recognizing that the serum level is within the expected therapeutic range.

Bypass the medication barcode scan to quickly administer an as-needed antiemetic to relieve the client's nausea.

Withhold the upcoming dose of digoxin and immediately notify the registered nurse of the clinical findings.

Accept a delegated task from the registered nurse to administer an intravenous push medication to manage potential dysrhythmias.

Show answer & explanation

Answer: Withhold the upcoming dose of digoxin and immediately notify the registered nurse of the clinical findings.

Answer

The correct action is to withhold the upcoming dose of digoxin and immediately notify the registered nurse of the clinical findings.

The client is exhibiting both subjective symptoms (nausea, visual halos) and objective data (a serum digoxin level of

2.8\text{ ng/mL}

) that clearly indicate severe digoxin toxicity. The normal therapeutic range is

0.8

2.0\text{ ng/mL}

. Safe nursing practice dictates that the practical nurse must hold the offending medication to prevent further toxicity and immediately alert the supervising registered nurse or healthcare provider to initiate corrective treatment.

Step-by-Step Solution

Evaluate the subjective clinical manifestations reported by the client.

The client reports nausea and seeing yellow halos around lights.

Gastrointestinal distress and visual disturbances are classic early signs of digoxin toxicity.

Analyze the objective laboratory data provided in the electronic health record.

The serum digoxin level is

2.8\text{ ng/mL}

Comparing the client's level against the normal therapeutic range (

0.8

2.0\text{ ng/mL}

) confirms that the level is toxic.

Determine the safest and most appropriate nursing intervention within the PN scope of practice.

The medication administration must be halted and the supervising nurse notified.

Preventing further harm by holding the toxic medication and escalating critical labs ensures patient safety and adheres to the chain of command.

Key Concept

Digoxin Toxicity Recognition and Management

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