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Physiological Integrity

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Question 421Question →

An older adult resident in a long-term care facility is prescribed daily oral digoxin and hydrochlorothiazide. During the morning assessment, the resident reports a sudden onset of poor appetite, nausea, and severe fatigue. The electronic health record indicates a morning serum potassium level of 3.0 mEq/L3.0\text{ mEq/L}. Which action is most appropriate for the practical nurse to take?

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Answer: Withhold the scheduled digoxin dose and promptly report the findings to the supervising registered nurse.

Answer

Withhold the scheduled digoxin dose and promptly report the findings to the supervising registered nurse.
The correct action is to withhold the medication and escalate the findings. The resident is exhibiting signs of digoxin toxicity (nausea, anorexia, fatigue), which is closely linked to the abnormally low potassium level of 3.0 mEq/L3.0\text{ mEq/L}. Hydrochlorothiazide is a potassium-wasting diuretic that frequently causes hypokalemia. The practical nurse's priority is client safety, which requires holding the dangerous medication and notifying the registered nurse for further assessment.

Step-by-Step Solution

1
Analyze the resident's clinical symptoms.
The resident has a sudden onset of poor appetite, nausea, and severe fatigue.
These are classic early signs of digoxin toxicity, which must be closely monitored in older adults.
2
Evaluate the laboratory values provided in the context of the prescribed medications.
The serum potassium level is 3.0 mEq/L3.0\text{ mEq/L}.
A normal potassium level is 3.5 to 5.0 mEq/L3.5\text{ to }5.0\text{ mEq/L}. A level of 3.0 mEq/L3.0\text{ mEq/L} indicates hypokalemia (likely caused by the hydrochlorothiazide), which significantly increases the heart's sensitivity to digoxin and the risk of toxicity.
3
Determine the appropriate nursing action based on the practical nurse scope of practice.
The nurse must withhold the digoxin and notify the registered nurse.
Administering the medication could cause severe harm. The practical nurse must recognize the abnormal findings, ensure client safety by holding the drug, and escalate the situation to the registered nurse or provider for medical evaluation.

Key Concept

Digoxin Toxicity and Hypokalemia Management
Question 422Question →

A practical nurse (PN) is monitoring a client who had a laparoscopic appendectomy 4 hours ago. The client is resting in bed and states, 'I feel very tired and a little lightheaded.' The PN collects the following vital signs: blood pressure 90/56 mm Hg, heart rate 118 beats/minute, respiratory rate 22 breaths/minute, and oxygen saturation 96% on room air. The client's baseline preoperative blood pressure was 128/78 mm Hg. Which action should the PN take first?

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Answer: Notify the registered nurse (RN) immediately regarding the vital sign changes and the client's symptoms.

Answer

The most appropriate action is to immediately notify the registered nurse (RN) regarding the vital sign changes and the client's symptoms.
The client is demonstrating early indicators of hypovolemic shock or internal hemorrhage, evidenced by tachycardia, hypotension, and lightheadedness following an abdominal surgery. The primary responsibility of the practical nurse in this scenario is to reduce the risk of further complications by immediately recognizing these critical changes and escalating the situation to the registered nurse (RN) or healthcare provider for advanced assessment and medical intervention.

Step-by-Step Solution

1
Analyze the client's vital signs compared to their baseline.
The client has a new onset of tachycardia (118 beats/minute) and hypotension (90/56 mm Hg) compared to their preoperative baseline.
Identifying significant deviations from baseline vital signs is crucial for detecting postoperative complications.
2
Correlate the objective data with the client's subjective symptoms.
The client's reports of fatigue and lightheadedness align with decreased cardiac output and inadequate tissue perfusion.
Combining subjective and objective data helps form a complete clinical picture of early hypovolemic shock.
3
Determine the appropriate nursing intervention based on the practical nurse's scope of practice.
The priority action is to immediately report the findings to the RN or healthcare provider.
Practical nurses must recognize signs of instability and promptly escalate care to ensure patient safety and reduce the risk of further deterioration.

Key Concept

Recognizing and Escalating Early Signs of Postoperative Shock
Question 423Question →

A client with a history of angina is prescribed a daily nitroglycerin transdermal patch. Place the following steps for administering this transdermal medication in the correct chronological order.

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Answer

The correct sequence requires the nurse to first protect themselves by putting on gloves, then remove the old patch, clean both sites, prepare the new patch without touching the adhesive, and finally apply it securely to a new site.
Applying a transdermal patch requires sequential steps to ensure client safety and protect the nurse. The nurse must first put on gloves to avoid absorbing the medication. Next, the old patch is removed and disposed of to prevent an overdose. The skin at both the old and new sites is washed to remove residual medication and ensure proper adhesion. The backing of the new patch is then peeled off carefully, avoiding the adhesive. Finally, the patch is applied to a clean, hairless site and pressed firmly to secure it.

Step-by-Step Solution

1
Perform hand hygiene and put on clean gloves.
The nurse's hands are protected from the medication.
Nitroglycerin is readily absorbed through the skin; gloves prevent the nurse from experiencing adverse effects like headaches or hypotension.
2
Remove the existing transdermal patch and fold it with the adhesive sides together.
The continuous delivery of the previous dose is stopped.
Leaving the old patch on while applying a new one causes medication overdose and severe hypotension.
3
Cleanse the previous application site and the newly selected site with mild soap and water.
Residual medication is removed and the new site is prepared.
This prevents continued absorption from the old site and removes oils or debris from the new site to ensure the patch sticks properly.
4
Peel the protective backing from the new patch without touching the medication surface.
The adhesive is exposed while keeping the dose intact.
Touching the adhesive can rub off some of the medication, leading to an inaccurate dose.
5
Apply the patch to a clean, hairless area of the upper body and press firmly.
The patch is secured for the prescribed duration.
Firm pressure ensures an adequate seal against the skin for steady absorption, while a hairless site prevents the patch from loosening.

Key Concept

Safe Administration of Transdermal Medications
Question 424Question →

A 45-year-old client is 6 hours post-operative following an abdominal hysterectomy. The client reports incisional pain rated as 7 on a 0 to 10 scale and appears increasingly restless. The practical nurse (PN) obtains the following vital signs: heart rate 116 beats/minute, blood pressure 100/60 mm Hg, respiratory rate 20 breaths/minute, and oxygen saturation 96% on room air. Which action should the PN take first?

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Answer: Check the surgical incision site and underneath the client for signs of hemorrhage.

Answer

The priority action is to check the surgical incision site and underneath the client for signs of hemorrhage.
The correct answer correctly prioritizes data collection for a potential life-threatening complication. Tachycardia, restlessness, and borderline low blood pressure are early compensatory signs of hypovolemic shock due to hemorrhage. Following the ABCs (Airway, Breathing, Circulation), the nurse must first check for bleeding (circulation) before taking other actions.

Step-by-Step Solution

1
Analyze the client's vital signs and clinical presentation.
The client presents with tachycardia (116 bpm), borderline hypotension (100/60 mm Hg), and unexpected restlessness 6 hours after major surgery.
Identifying abnormal data points is the essential first step in clinical judgment.
2
Correlate the assessment findings with potential post-operative complications.
The combination of tachycardia, borderline low blood pressure, and restlessness strongly suggests early hypovolemic shock (likely due to internal or external bleeding) rather than just pain or anxiety.
Recognizing physiological adaptation to blood loss allows the nurse to anticipate life-threatening conditions.
3
Determine the priority nursing intervention based on the ABCs (Airway, Breathing, Circulation).
The priority is to assess circulation by checking for active bleeding at the surgical site and pooling under the client.
Data collection regarding the most immediate life-threatening condition (circulation/shock) takes precedence over symptom management like pain relief.

Key Concept

Early recognition of hypovolemic shock and prioritization of circulatory assessment in post-operative clients.
Question 425Question →

A practical nurse is preparing a client who is scheduled for an abdominal paracentesis to treat severe ascites. In what order should the nurse perform the following preparatory actions? Arrange the steps from first to last.

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Answer

The correct sequence of actions is to first verify informed consent, then have the client empty their bladder, followed by obtaining baseline measurements, and finally positioning the client upright.
The standard of care for assisting with a paracentesis dictates a specific logical flow to ensure client safety. Administrative and legal checks (consent) must occur first. Next, the client must empty their bladder while they are still ambulatory or easily movable to eliminate the primary procedural risk (bladder puncture). Once the bladder is empty, true baseline measurements of weight, girth, and vital signs can be taken immediately prior to the intervention. Finally, the client is placed in the optimal anatomical position (upright) for the provider to begin the sterile procedure.

Step-by-Step Solution

1
Verify that the informed consent document has been signed.
Legal and facility requirements for the invasive procedure are met.
Consent is the absolute first prerequisite before any invasive procedure preparations begin.
2
Instruct the client to empty their bladder completely.
The bladder size is reduced, moving it down into the pelvic cavity.
This greatly reduces the risk of accidental bladder perforation during needle insertion, which is a major safety priority.
3
Measure baseline vital signs and abdominal girth.
Accurate pre-procedure data is recorded.
Because fluid removal can cause fluid shifts leading to hypotension or hypovolemic shock, having an immediate pre-procedure baseline is essential for comparison.
4
Assist the client into a sitting position on the edge of the bed.
The client is in the correct position for the healthcare provider to begin.
Gravity pulls the fluid down to the lower abdomen, minimizing the risk of puncturing the bowel or other internal organs.

Key Concept

Preparation for a paracentesis requires specific risk reduction measures, most notably having the client empty their bladder to prevent accidental puncture, and establishing vital sign baselines to monitor for subsequent hypovolemia.
Estimated Time:1m 0s
Question 426Question →

A practical nurse is evaluating a client who underwent a percutaneous coronary intervention via the right femoral approach two hours ago. The client reports a new sensation of right flank fullness. The client's heart rate is 114 beats per minute and blood pressure is 92/58 mm Hg. The femoral insertion site dressing is completely dry. Which action should the nurse take first?

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Answer: Escalate the clinical findings to the supervising registered nurse without delay.

Answer

The nurse must escalate the clinical findings to the supervising registered nurse without delay.
The correct action is to immediately report the findings. Flank pain, tachycardia, and hypotension following a femoral arterial procedure are classic signs of retroperitoneal hemorrhage. Because the bleeding is internal, the external dressing remains dry. This is a life-threatening emergency that requires immediate medical intervention, making escalation the priority action for a practical nurse.

Step-by-Step Solution

1
Analyze the client's symptoms and vital signs.
The client has right flank fullness, tachycardia (114 beats per minute), and hypotension (92/58 mm Hg).
Identifying abnormal clinical data is the first step in recognizing potential complications.
2
Correlate the findings with the recent procedure (right femoral approach percutaneous coronary intervention).
The combination of flank pain and signs of hypovolemic shock after a femoral procedure strongly suggests retroperitoneal bleeding, even if the external dressing is dry.
Understanding procedural risks allows the nurse to interpret the meaning of the assessment data.
3
Determine the appropriate nursing action within the practical nurse scope of practice.
The practical nurse must immediately report these critical findings to the registered nurse or healthcare provider.
Life-threatening complications require immediate escalation for medical intervention.

Key Concept

Recognizing and escalating signs of retroperitoneal hemorrhage following femoral artery access.
Question 427Question →

A client hospitalized on a medical-surgical unit reports difficulty swallowing and asks the practical nurse to crush their scheduled morning medications. The client's medication administration record includes enteric-coated aspirin, extended-release potassium chloride, and a scored acetaminophen tablet. Which action should the practical nurse take?

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Answer: Crush the scored acetaminophen tablet, withhold the aspirin and potassium chloride, and notify the registered nurse.

Answer

The practical nurse should crush only the scored acetaminophen tablet, withhold the enteric-coated aspirin and extended-release potassium chloride, and notify the registered nurse.
The correct action demonstrates safe pharmacological practice and adherence to the practical nurse's scope. Scored standard tablets like acetaminophen can be crushed. However, crushing enteric-coated aspirin destroys the coating designed to protect the stomach lining, and crushing extended-release potassium chloride causes immediate release of the entire dose, which can lead to life-threatening arrhythmias. The nurse must withhold the uncrushable medications and notify the registered nurse so alternative prescriptions can be obtained.

Step-by-Step Solution

1
Evaluate the pharmacokinetic properties of the prescribed medications.
Identify that acetaminophen is scored and safe to crush, while enteric-coated aspirin and extended-release potassium chloride cannot be crushed.
Crushing enteric-coated pills causes severe gastric irritation, and crushing extended-release pills causes immediate release of the entire dose (dose dumping), which can lead to life-threatening arrhythmias.
2
Determine the appropriate action within the practical nursing scope of practice.
Decide to administer the safe medication (acetaminophen), withhold the unsafe ones, and escalate the issue.
Practical nurses must advocate for client safety and report the need for alternative medication routes or forms to the registered nurse or healthcare provider.

Key Concept

Safe medication administration and the practical nurse's scope of practice regarding uncrushable medications.
Question 428Question →

A client recovering on an orthopedic rehabilitation unit is prescribed a scheduled dose of oral carvedilol. The practical nurse assesses the client and notes a heart rate of 52 beats per minute and a blood pressure of 94/58 mm Hg. The client states, "I feel very lightheaded today." Which action should the practical nurse take?

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Answer: Withhold the carvedilol and promptly report the client's vital signs and symptoms to the registered nurse.

Answer

The practical nurse should withhold the medication and notify the registered nurse.
Carvedilol is a beta-blocker that decreases cardiac output, heart rate, and blood pressure. The client is already experiencing bradycardia, hypotension, and symptomatic lightheadedness, which indicates decreased cerebral perfusion. Administering the medication would exacerbate these issues. The practical nurse must safely withhold the dose and communicate the findings to the supervising registered nurse for further clinical decisions.

Step-by-Step Solution

1
Analyze the client's vital signs and reported symptoms.
The heart rate is 52 bpm (bradycardia), blood pressure is 94/58 mm Hg (hypotension), and the client is lightheaded.
To determine if the scheduled medication is safe to administer based on current physiological parameters.
2
Identify the pharmacological action of carvedilol.
Carvedilol is a beta-blocker that decreases heart rate and blood pressure.
To predict how the drug will affect the client's current compromised cardiovascular status.
3
Determine the appropriate nursing intervention within the practical nurse scope of practice.
The medication must be held, and the abnormal findings must be reported to the RN or provider.
Administering the drug would worsen the condition, and modifying the dose is outside the PN scope of practice.

Key Concept

Safe administration of beta-blockers and practical nurse scope of practice regarding holding medications.
Question 429Question →

A 78-year-old client is receiving treatment for bacterial pneumonia. During afternoon rounds, the practical nurse (PN) observes that the client, who was previously alert, has suddenly become highly restless, confused, and is actively trying to remove their intravenous (IV) catheter. The client's respiratory rate has increased to 26 breaths/min. Which action should the PN take first?

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Answer: Measure the client's current oxygen saturation level.

Answer

The correct action is to measure the client's current oxygen saturation level, as sudden confusion and restlessness strongly indicate acute hypoxia.
The correct action is to measure the client's oxygen saturation because sudden restlessness, confusion, and an increased respiratory rate in a client with pneumonia are classic, early indicators of hypoxia. In the nursing process and ABC prioritization, assessing the client's breathing and oxygenation status is paramount before implementing symptom-management interventions.

Step-by-Step Solution

1
Identify the sudden change in mental status (restlessness and confusion) and increased respiratory rate.
Recognition that the client's condition has acutely decompensated.
Sudden neurological changes often have a physiological, rather than psychological, origin.
2
Correlate the client's diagnosis (bacterial pneumonia) with the new symptoms.
Hypoxia is identified as the most probable cause of the sudden agitation.
Pneumonia impairs gas exchange, leading to decreased oxygen levels in the blood and brain.
3
Prioritize interventions based on the ABCs (Airway, Breathing, Circulation).
Gathering data on the client's oxygenation status is prioritized over managing the behavioral symptoms.
Addressing a potential breathing and oxygenation deficit is critical to preventing severe physiological injury.

Key Concept

Prioritization of ABCs in Acute Hypoxia
Question 430Question →

A practical nurse (PN) is preparing to administer scheduled oral medications to a client. Upon entering the room, the PN notices the client's identification wristband has been removed and is resting on the bedside table. The client is alert and states, "They took it off to start my new IV line." Which action should the PN take first?

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Answer: Obtain a new identification band, attach it to the client, and verify two client identifiers before administration.

Answer

The PN must obtain a new identification band, attach it to the client, and verify two client identifiers before administering any medications.
Safe medication administration requires the nurse to verify the client's identity using two distinct identifiers (such as name and date of birth) against an identification band that is physically attached to the client. Administering medications without an attached band, or scanning a detached band, violates the fundamental 'right client' principle of medication safety.

Step-by-Step Solution

1
Recognize that a detached identification band invalidates the client identification process.
The current identification method is deemed unsafe for medication administration.
A detached band on a table could easily belong to a previous occupant or another client.
2
Follow facility protocol to obtain a new identification band.
A new band is printed and brought to the client's room.
The client must have an attached band for barcode scanning and verification.
3
Attach the new band to the client and verify two distinct identifiers (e.g., name and date of birth) before administering the medication.
The medication is safely administered to the correct client.
This process strictly adheres to the 'right client' principle of medication administration.

Key Concept

Medication Administration Rights: Client Identification
Question 431Question →

A practical nurse (PN) is organizing care for a group of clients on a medical-surgical unit. Which of the following nursing actions demonstrate the correct application of risk reduction principles? (Select all that apply)

Select all that apply

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Answer: Escalating a post-liver biopsy client's blood pressure of 94/58 mmHg and heart rate of 112 beats/min to the registered nurse (RN); Verifying nasogastric tube placement by checking the pH of aspirated gastric contents prior to initiating a scheduled enteral feeding; Instructing a client who is recovering from an open abdominal surgery to splint the incision with a pillow while coughing

Answer

The correct actions include escalating borderline vital signs that suggest shock, verifying nasogastric tube placement via pH testing, and instructing a postoperative client to splint their incision.
To reduce the risk of potential complications, the practical nurse must recognize early signs of clinical deterioration and implement evidence-based preventative measures. A borderline low blood pressure with tachycardia after an invasive biopsy suggests early hypovolemic shock and requires immediate escalation. Verifying gastric pH prevents the severe complication of pulmonary aspiration during tube feeding. Splinting an abdominal incision supports the wound and reduces the risk of dehiscence during coughing. These actions directly prioritize client safety.

Step-by-Step Solution

1
Evaluate each nursing action against the principles of risk reduction and safe scope of practice.
Identify which actions proactively prevent complications or appropriately address potentially life-threatening changes.
Risk reduction requires the practical nurse to combine preventative care with the immediate recognition of instability.
2
Analyze the clinical data provided in the options.
A blood pressure of 94/58 mmHg with a heart rate of 112 beats/min indicates potential bleeding. A potassium level of 2.6 mEq/L is critically low. Chest tightness is a potential cardiopulmonary emergency.
Recognizing abnormal parameters is the critical first step before deciding on the appropriate risk-reduction action.
3
Select the actions that correctly mitigate risk.
Escalating the abnormal vital signs, checking gastric pH prior to feeding, and splinting the abdominal incision are correct risk-reduction actions.
These actions directly align with patient safety guidelines and prioritize the client's physiological stability.

Key Concept

Early recognition of complications and implementation of preventative nursing measures.
Estimated Time:1m 30s
Question 432Question →

A licensed practical nurse is tasked with giving a prescribed dose of iron dextran via intramuscular injection using the Z-track method. To ensure client safety and proper medication delivery, in what chronological order should the nurse perform the following procedural steps?

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Answer

The correct sequence is: pull the skin laterally, insert the needle at a 90-degree angle, slowly depress the plunger to instill the medication, wait 10 seconds, and finally withdraw the needle while releasing the skin.
The Z-track method is specifically utilized for intramuscular administration of highly irritating or staining medications, such as iron dextran. The technique physically misaligns the tissue layers by pulling the skin and subcutaneous tissue to the side before insertion. The needle is inserted at a 90-degree angle, followed by slow instillation of the drug. Crucially, the nurse must wait 10 seconds before removing the needle to allow tissue accommodation. Finally, withdrawing the needle and releasing the skin simultaneously creates a broken, zigzag pathway that securely traps the medication deeply within the muscle, preventing tracking into the subcutaneous layer.

Step-by-Step Solution

1
Identify the first distinct step of the Z-track method prior to needle insertion.
Pull the skin and subcutaneous tissue laterally 1 to 1.5 inches from the injection site.
Displacing the tissue is the defining first physical manipulation of the Z-track technique, setting up the shifted pathway.
2
Determine the correct needle insertion technique once the skin is displaced.
Insert the needle at a 90-degree angle to penetrate the deep muscle layer.
The needle must be inserted perpendicularly while the non-dominant hand maintains the tissue displacement.
3
Identify the action for actual drug delivery.
Depress the plunger slowly to instill the medication.
Slow injection minimizes tissue trauma and promotes gradual absorption.
4
Determine the necessary pause before needle removal.
Maintain the needle in the muscle for 10 seconds.
This dwell time provides an opportunity for the medication to disperse locally rather than forcing its way back up the needle track.
5
Identify the final coordinated step to seal the track.
Withdraw the needle smoothly and immediately release the displaced skin.
Releasing the tissue shifts the superficial puncture site away from the muscle puncture site, locking the medication deep within the tissue.

Key Concept

Z-track method for intramuscular injections
Question 433Question →

A practical nurse is completing hourly rounds on a 42-year-old client who returned from a total abdominal hysterectomy six hours ago. The client appears restless and states, "I just cannot seem to settle down." Upon reviewing the electronic flowsheet, the nurse notes the client's heart rate has climbed from 84 to 112 beats/min, and blood pressure has trended down from 126/80 to 102/64 mm Hg over the past two hours. The abdominal surgical dressing is dry and intact. Which action should the practical nurse take first?

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Answer: Notify the supervising registered nurse immediately about the vital sign trends.

Answer

The most critical action is to immediately notify the supervising registered nurse about the client's changing vital signs and symptoms.
The correct action demonstrates an understanding of risk reduction by identifying early indicators of hypovolemic shock (tachycardia, decreasing blood pressure, and restlessness) and immediately escalating the situation. Because the surgical dressing is dry, the nurse must suspect internal hemorrhage, which requires urgent evaluation and intervention beyond the practical nursing scope of practice.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has unexplained restlessness, a steadily rising heart rate (84 to 112 beats/min), and a decreasing blood pressure (126/80 to 102/64 mm Hg).
Recognizing data trends is necessary to differentiate between normal postoperative recovery and emerging complications.
2
Correlate the findings with the surgical history.
Despite a dry and intact external dressing, the vital signs point to internal hemorrhage following major abdominal surgery.
Internal bleeding is a major, life-threatening risk following a total abdominal hysterectomy that requires prompt identification.
3
Determine the priority nursing action within the practical nurse's scope of practice.
The nurse must escalate the findings to the registered nurse (RN) or healthcare provider.
Suspected internal hemorrhage and hypovolemic shock are critical conditions that mandate immediate medical evaluation and advanced RN-level interventions (e.g., rapid IV fluids, blood products).

Key Concept

Early Recognition of Hypovolemic Shock and Internal Hemorrhage
Question 434Question →

A practical nurse (PN) is caring for a client who is receiving continuous enteral tube feedings. The client suddenly begins coughing vigorously, becomes cyanotic, and exhibits intercostal retractions. In what order should the PN perform the following actions? Arrange the actions from first to last.

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Answer

The correct sequence is: Stop the feeding, elevate the head of the bed, obtain vital signs, notify the RN, and then document the event.
In any acute emergency, the practical nurse must follow the Airway, Breathing, Circulation (ABC) framework. When a client receiving an enteral feeding shows signs of respiratory distress (coughing, cyanosis), aspiration is suspected. The absolute first action is to stop the feeding (Airway protection). Next, positioning the client upright assists with Breathing. Once these immediate life-saving interventions are done, the nurse assesses the client (vital signs) to gather data. This data is then reported to the RN for further intervention. Documentation is always the final step after the client's immediate needs are met.

Step-by-Step Solution

1
Stop the continuous enteral tube feeding.
The flow of formula is halted.
This is a potential aspiration event. The Airway must be protected first by removing the source of the aspiration.
2
Elevate the head of the bed to a high-Fowler's position.
The client is sitting upright.
This position facilitates optimal lung expansion, eases work of breathing, and uses gravity to keep stomach contents away from the airway.
3
Obtain current vital signs and oxygen saturation.
Baseline physiological data during the acute event is collected.
Once the immediate airway and breathing interventions are applied, the PN must gather data to determine the severity of the client's respiratory distress.
4
Notify the supervising registered nurse (RN).
The RN is made aware of the emergency.
The PN must report the acute change and the obtained vital signs so the RN can assess the client and coordinate further medical interventions.
5
Document the sudden change in condition and actions taken.
The event is recorded in the medical record.
Accurate documentation is legally and clinically necessary but is always the lowest priority during an active bedside emergency.

Key Concept

Airway, Breathing, Circulation (ABC) Prioritization in Acute Emergencies
Question 435Question →

A practical nurse is caring for an older adult client recovering from a total hip arthroplasty. The client is prescribed scheduled oral oxycodone for pain management. Upon entering the room to administer the morning dose, the nurse finds the client newly confused, lethargic, and exhibiting a respiratory rate of 9 breaths per minute. Which of the following is the priority action for the practical nurse to take?

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Answer: Withhold the dose of oxycodone and immediately report the clinical findings to the registered nurse.

Answer

The practical nurse should withhold the dose of oxycodone and immediately report the clinical findings to the registered nurse.
The client is demonstrating signs of opioid toxicity, specifically central nervous system depression (lethargy, new confusion) and respiratory depression (a respiratory rate less than 12 breaths per minute). The safest and most appropriate action within the practical nurse scope of practice is to withhold the central nervous system depressant and immediately notify the registered nurse, who can conduct a comprehensive assessment and collaborate with the healthcare provider for emergency interventions.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client is exhibiting lethargy, new-onset confusion, and a respiratory rate of 9 breaths per minute.
These are classic signs of opioid-induced respiratory depression and central nervous system depression.
2
Apply the ABCs (Airway, Breathing, Circulation) of prioritization.
The compromised breathing (bradypnea) is identified as a life-threatening priority.
Administering another dose of an opioid would further depress the respiratory drive and endanger the client's life.
3
Determine the appropriate action within the practical nurse scope of practice.
The nurse must withhold the medication and escalate the critical findings to the registered nurse.
The RN must perform a comprehensive assessment, and interventions such as administering intravenous push reversal agents are outside the scope of practice for a practical nurse.

Key Concept

Opioid toxicity monitoring and practical nurse scope of practice regarding critical client deterioration
Question 436Question →

A practical nurse is initiating a 24-hour urine collection for a client to evaluate kidney function. In what order should the nurse perform the following actions to ensure an accurate diagnostic test result?

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Answer

The correct sequence is to first have the client empty their bladder and discard the urine, record that exact time as the start, collect all subsequent voids on ice, ask for one final void at the 24-hour mark, and finally add that void to the container to send to the lab.
A 24-hour urine collection must reflect exactly 24 hours of kidney function. By discarding the first void, the nurse ensures the bladder is empty at the exact start time. Documenting the time establishes the 24-hour clock. Keeping subsequent voids on ice prevents specimen degradation. The final void at exactly 24 hours ensures the bladder is emptied at the end of the collection period, completing the exact timeframe before the specimen is sent to the laboratory.

Step-by-Step Solution

1
Instruct the client to empty their bladder and discard the initial urine.
The bladder is completely empty, ensuring no previously formed urine is included.
The 24-hour collection period must begin with an empty bladder to maintain an accurate measurement of urine output and concentration over the exact time frame.
2
Document the exact time of the discarded void.
A clear, precise 24-hour clock is initiated.
Recording the start time prevents timing errors and ensures the diagnostic test is not artificially shortened or extended.
3
Collect all subsequent urine in a container kept on ice.
All urine produced during the 24 hours is preserved.
Chilling the container prevents bacterial growth and degradation of the biochemical substances being measured by the laboratory.
4
Have the client void one last time exactly 24 hours after the start time.
The final amount of urine produced in the period is obtained.
This captures the final fraction of urine for the exact 24-hour window, ensuring the collection is fully complete.
5
Add the final void to the main container and send to the laboratory.
The collection is finalized and ready for processing.
Immediate transport prevents further degradation of the sample once the collection timeframe ends.

Key Concept

Accurate Specimen Collection and Diagnostic Preparation
Estimated Time:1m 30s
Question 437Question →

A practical nurse is preparing to administer cephalexin oral suspension to a pediatric client who weighs 39.6 lb. The healthcare provider's prescription is for 15 mg/kg/dose to be administered every 12 hours. The pharmacy dispenses a cephalexin suspension concentration of 125 mg/5 mL. How many mL should the practical nurse administer per dose? (Record your answer to the nearest tenth. Do not include units in your answer.)

Show answer & explanation

Answer: 10.8

Answer

10.8
To determine the correct volume, first convert the weight to kilograms (39.6 ÷ 2.2 = 18 kg). Next, find the required dose in milligrams (18 kg × 15 mg/kg = 270 mg). Finally, use the formula (Desired / Have) × Volume to find the correct volume to administer ((270 mg / 125 mg) × 5 mL = 10.8 mL).

Step-by-Step Solution

1
Convert the client's weight from pounds to kilograms.
39.6 lb ÷ 2.2 lb/kg = 18 kg
The medication dosage is prescribed based on the client's weight in kilograms.
2
Calculate the desired dose in milligrams.
18 kg × 15 mg/kg = 270 mg/dose
This determines the exact amount of medication the client needs for one single administration.
3
Calculate the volume of medication to administer.
(270 mg / 125 mg) × 5 mL = 2.16 × 5 mL = 10.8 mL
Using the dose calculation formula determines the correct liquid amount to draw up.

Key Concept

Weight-based medication dosage calculation and liquid volume conversion
Question 438Question →

A practical nurse (PN) is caring for a client who has a nasogastric (NG) tube connected to low continuous suction. The client's morning comprehensive metabolic panel reveals a serum potassium level of 2.8 mEq/L. The client's current vital signs are: blood pressure 98/58 mm Hg, heart rate 114 beats/min, and respiratory rate 18 breaths/min. The client is scheduled to receive an oral dose of digoxin in 30 minutes. Which action is the priority for the PN?

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Answer: Withhold the scheduled digoxin and immediately report the potassium level and vital signs to the registered nurse.

Answer

The priority action is to withhold the scheduled digoxin and immediately report the critical laboratory findings and vital signs to the registered nurse.
The correct answer identifies that a serum potassium level of 2.8 mEq/L is critically low (hypokalemia). Because hypokalemia significantly increases the risk of digoxin toxicity, administering the medication could provoke life-threatening cardiac dysrhythmias. The client's borderline hypotension and tachycardia further indicate physiological compromise. The safest and most appropriate action for the practical nurse is to withhold the dose and immediately notify the registered nurse for further intervention.

Step-by-Step Solution

1
Analyze the laboratory values.
The serum potassium level is 2.8 mEq/L, which indicates severe hypokalemia (normal is 3.5 to 5.0 mEq/L).
Nasogastric suction removes potassium-rich gastric fluids, leading to depletion.
2
Evaluate the clinical risks associated with the medications.
The client is scheduled to receive digoxin. Hypokalemia drastically increases the risk of digoxin toxicity.
Digoxin toxicity can precipitate life-threatening cardiac dysrhythmias, especially when potassium is low.
3
Assess the vital signs.
The blood pressure (98/58 mm Hg) and heart rate (114 beats/min) are abnormal.
These borderline vital signs indicate early cardiovascular compromise, hypovolemia, or developing dysrhythmia.
4
Determine the safest nursing action within the PN scope of practice.
The PN must withhold the digoxin and immediately escalate the situation.
Administering the medication could cause harm, and the client requires immediate RN and provider intervention for electrolyte replacement and stabilization.

Key Concept

Reduction of Risk Potential: Recognizing critical laboratory values (hypokalemia) and preventing medication complications (digoxin toxicity).
Question 439Question →

While conducting a scheduled assessment on an older adult client two days after an intestinal resection, the practical nurse observes that the client has become suddenly restless and disoriented. The client's vital signs are a heart rate of 118 beats per minute, a blood pressure of 96/58 mm Hg, and a respiratory rate of 26 breaths per minute. Which interventions should the practical nurse implement? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Alert the charge registered nurse immediately about the acute changes in mental status and hemodynamics; Examine the surgical incision site and any drainage systems for evidence of hemorrhage; Verify that the client's airway is clear and initiate supplemental oxygen therapy per facility protocol

Answer

The correct interventions are to alert the charge registered nurse, examine the surgical site for bleeding, and verify airway patency while preparing to administer oxygen.
The client is exhibiting classic early signs of hypovolemic shock, likely due to postoperative hemorrhage. These signs include unexplained restlessness, tachycardia, tachypnea, and borderline hypotension. The practical nurse must prioritize airway and oxygenation, assess for the source of bleeding at the surgical site, and immediately escalate the situation to the registered nurse for advanced medical orders.

Step-by-Step Solution

1
Analyze the client's new-onset symptoms: restlessness, disorientation, tachycardia, tachypnea, and borderline hypotension.
Identify these as classic compensatory signs of early hypovolemic shock, likely due to internal bleeding following the recent intestinal surgery.
Recognizing early shock is critical because delaying intervention until blood pressure profoundly drops can lead to irreversible organ damage.
2
Determine the appropriate priority nursing interventions within the practical nurse scope of practice.
Select actions that support airway and breathing (oxygen), assess the source of the problem (checking the surgical site), and escalate the critical situation (notifying the registered nurse).
The practical nurse must immediately address life-threatening physiological adaptations before attending to routine tasks or assuming findings are benign.

Key Concept

Early Recognition and Prioritization of Hypovolemic Shock
Estimated Time:1m 30s
Question 440Question →

A practical nurse (PN) is caring for a client who underwent a right total hip arthroplasty (posterior approach) 24 hours ago. Which of the following nursing actions should the PN implement to reduce the risk of postoperative complications? (Select all that apply.)

Select all that apply

Show answer & explanation

Answer: Maintain the client's right leg in an abducted position using a designated wedge pillow.; Notify the registered nurse (RN) regarding a morning hemoglobin level of 7.9 g/dL.; Encourage the client to use the incentive spirometer 10 times every hour while awake.

Answer

The correct actions are maintaining the leg in an abducted position, notifying the RN of the critical hemoglobin level, and encouraging incentive spirometry.
Maintaining abduction prevents hip dislocation. Notifying the RN of a low hemoglobin level ensures timely intervention for potential hemorrhage. Incentive spirometry prevents respiratory complications like atelectasis.

Step-by-Step Solution

1
Evaluate each action for its safety and effectiveness in preventing postoperative complications.
Identified that abduction, lung expansion, and reporting critical labs are safe and necessary actions.
Postoperative care requires interventions that directly address risks such as dislocation, atelectasis, and hemorrhage.
2
Analyze the remaining actions for safety hazards or contraindications.
Identified that acute hip flexion, ignoring shock indicators, and bypassing proper medication verification are unsafe.
These actions increase the client's risk for dislocation, delayed treatment of shock, and medication administration errors.

Key Concept

Postoperative Risk Reduction and Patient Safety
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