Physiological Integrity

During the evening shift, a practical nurse answers a call light for a client who underwent a subtotal thyroidectomy earlier that morning. The client is experiencing mild incisional aching and requests assistance with getting comfortable for sleep. Which nursing action is the priority for ensuring this client's safety and comfort?

A practical nurse (PN) is preparing to perform open tracheostomy suctioning for a stable adult client. In what order should the PN perform the following actions to reduce the risk of hypoxia and airway trauma? Arrange the steps in the correct chronological sequence.

During afternoon rounds, a 71-year-old client hospitalized for bacterial pneumonia suddenly becomes restless, rubs their chest, and asks to speak with a deceased relative. The client's family states the client was completely lucid just an hour ago. Current vital signs reveal a heart rate of 114 beats per minute, a respiratory rate of 26 breaths per minute, and a blood pressure of 102/60 mm Hg. Which action should the nurse prioritize?

While walking past a client's room, a practical nurse observes a client who is receiving continuous enteral tube feeding suddenly coughing vigorously and struggling to breathe. Which sequence of actions should the practical nurse implement? Arrange the actions in the correct order from first to last.

Following a right-sided carotid endarterectomy, a client requires careful positioning to ensure physiological safety and comfort. Which basic care actions should the practical nurse take to support this client? Select all that apply.

A licensed practical nurse (LPN) is caring for a client who is 6 hours postoperative following a total abdominal hysterectomy. The client reports feeling dizzy. The LPN assesses the client and notes a blood pressure of 96/58 mm Hg and a heart rate of 112 beats/minute. The client's preoperative baseline blood pressure was 132/74 mm Hg and heart rate was 76 beats/minute. Which of the following actions should the LPN take next?

A practical nurse (PN) is reviewing the morning laboratory results for several assigned clients on a medical-surgical unit. Which of the following laboratory findings indicate an immediate risk for complications and should be reported to the registered nurse (RN) without delay? Select all that apply.

A practical nurse is caring for a 78-year-old client who was admitted with severe gastroenteritis and prolonged vomiting. The client is receiving continuous intravenous fluids. Which assessment findings should the nurse identify as early indications that the client is developing hypovolemic shock? Select all that apply.

A practical nurse is caring for an adult client who is prescribed daily oral furosemide and a daily oral potassium chloride supplement. While reviewing the morning laboratory results, the nurse notes a serum potassium level of 6.2 mEq/L (mmol/L). Which of the following is the most appropriate action for the nurse to take?

An older adult client admitted with community-acquired pneumonia has a scheduled dose of intravenous levofloxacin. The medication arrives from the pharmacy as a $500 \text{ mg}$ dose premixed in a $100 \text{ mL}$ bag of $5\% \text{ Dextrose}$ in Water ($\text{D}_5\text{W}$). According to the administration instructions, the medication must infuse steadily over $90$ minutes.

At what rate, in $\text{mL/hr}$, should the infusion pump be programmed?

Record answer to the nearest tenth. Do not include units in answer.

A licensed practical nurse (LPN) enters a client's room and observes them beginning to experience a generalized tonic-clonic seizure while sitting in a bedside armchair. Arrange the following nursing actions in the correct sequence of priority.

A practical nurse (PN) is preparing to collect a sterile urine specimen for culture and sensitivity from a client who has a closed indwelling urinary catheter system. After performing hand hygiene and donning clean gloves, in what order should the PN perform the following actions to reduce the risk of infection and ensure an accurate laboratory sample? (Arrange the steps in the correct sequence from first to last.)

Following a surgical repair of a fractured tibia 24 hours ago, a 65-year-old client suddenly develops severe restlessness and acute confusion. The client's respiratory rate has increased to 24 breaths per minute. Which action should the practical nurse take first?

A practical nurse (PN) is prioritizing care and performing interventions for several clients on a medical-surgical unit. Which of the following actions by the PN demonstrate safe practice and appropriately reduce the risk of client harm? (Select all that apply.)

While assigned to a medical-surgical unit, a practical nurse prepares to administer medications to multiple clients. Which actions represent safe pharmacological practices within the practical nursing scope of practice? Select all that apply.

A practical nurse is caring for an older adult client admitted with a suspected upper gastrointestinal bleed. During data collection, the nurse notes that the client appears increasingly restless and newly confused. The client's vital signs are: blood pressure 104/72 mm Hg, heart rate 112 beats/minute, and respiratory rate 22 breaths/minute. Which of the following actions should the nurse take? Select all that apply.

A 30-year-old client is admitted to the medical-surgical unit with acute pancreatitis. The client is receiving continuous intravenous normal saline at 100 mL/hr. During a routine check, the client appears restless and anxious. Current vital signs are: pulse 124 beats per minute, blood pressure 88/54 mm Hg, and respirations 24 breaths per minute. Total urine output over the previous 4 hours is 55 mL.

What is the most appropriate initial action for the practical nurse to take?

A practical nurse is assigned to care for an adult client who has dysphagia following a recent stroke. The client receives continuous enteral nutrition via an established gastrostomy tube. The client's morning vital signs include a blood pressure of 118/76 mm Hg, heart rate of 78 beats/minute, and respiratory rate of 16 breaths/minute. The client has no known drug allergies. The practical nurse is preparing to administer a scheduled dose of a liquid multivitamin via the gastrostomy tube. Which of the following actions should the practical nurse take to ensure safe medication administration?

A practical nurse (PN) is caring for an alert and conscious client with type 1 diabetes mellitus who suddenly reports feeling shaky, dizzy, and diaphoretic. The PN performs a capillary blood glucose test, which reads 48 mg/dL (2.7 mmol/L). In which order should the PN perform the following actions? (Arrange the actions from first to last.)

During a morning assessment, a practical nurse evaluates a client who is 12 hours postoperative following a right total hip arthroplasty. The client appears mildly restless and reports a pain level of 4 on a 0 to 10 scale at the operative site. The current vital signs are a blood pressure of 104/64 mm Hg (baseline 134/78 mm Hg), a heart rate of 104 bpm, and a respiratory rate of 20/min. The morning hemoglobin level is reported as 6.9 g/dL (69 g/L). Which of the following is the most appropriate initial action for the nurse?