Physiological Integrity

A nursing supervisor is evaluating task delegation on a medical-surgical unit. What specific medication administration task is appropriate for the charge nurse to delegate to the practical nurse?

A practical nurse is assigned to care for an adult client who is receiving intravenous fluid therapy for fluid volume deficit following an episode of gastroenteritis. The client has a heart rate of $108$ bpm and a blood pressure of $98/60$ mmHg. The healthcare provider has prescribed $500$ mL of $0.9\%$ sodium chloride to infuse over $6$ hours. The primary intravenous tubing has a drop factor of $20$ gtt/mL. At how many drops per minute (gtt/min) should the infusion be regulated? Record the answer to the nearest whole number. Do not include units in the answer.

A practical nurse (PN) is evaluating a client who is 6 hours post-operative following an abdominal hysterectomy. The client reports feeling slightly dizzy, exhausted, and having mild abdominal cramping. During the data collection, the PN notes a heart rate of 112 beats/min, a blood pressure of 98/60 mm Hg, and a fully saturated perineal pad with bright red blood. The surgical abdominal dressing remains clean and dry. Which action should the PN take first?

A client who is 2 days post-operative following a right hip replacement suddenly complains of stabbing chest discomfort and difficulty breathing. In what chronological order should the practical nurse (PN) perform the following actions?

During morning rounds, a practical nurse evaluates a $71$-year-old client who takes oral warfarin for atrial fibrillation. The client's most recent laboratory report reveals an International Normalized Ratio (INR) of $5.8$. The current vital signs show a heart rate of $112$ beats per minute and a blood pressure of $92/56\text{ mm Hg}$. The client reports feeling unusually fatigued and dizzy when sitting up. What is the priority action for the nurse?

A practical nurse (PN) enters the room of a client with type 1 diabetes mellitus. The client is pale, diaphoretic, and states, 'I feel very shaky.' The PN checks the capillary blood glucose, which is 42 mg/dL (2.3 mmol/L). The client is conscious and able to swallow. In what order should the PN perform the following actions? (Arrange the items in the correct sequence from first to last.)

A practical nurse (PN) is monitoring a client who underwent a percutaneous liver biopsy $2$ hours ago. The client is currently positioned on their right side. The client reports mild lightheadedness. The PN notes that the client's heart rate has increased from $80$ to $108$ beats/minute, and their blood pressure has decreased from $126/78$ to $108/68$ mmHg over the past hour. The client's skin feels slightly cool and clammy.

Which of the following is the most appropriate initial action for the PN to take?

A client is being monitored on the surgical unit 24 hours after a thoracotomy with a closed chest drainage system in place. Which assessment findings should the practical nurse immediately report to the registered nurse as indicators of a developing tension pneumothorax? Select all that apply.

A practical nurse is preparing to administer a combined dose of NPH insulin and regular insulin in a single syringe for a client with diabetes mellitus. In what order should the nurse perform the following steps to safely mix these medications?

A practical nurse (PN) is assigned to care for a 78-year-old client with a history of chronic kidney disease who is receiving a continuous intravenous (IV) infusion of normal saline at 125 mL/hr. During hourly rounds, the client suddenly becomes restless, repeatedly asks where they are, and exhibits a respiratory rate of 26 breaths/min with a heart rate of 104 beats/min. Which action should the PN take FIRST?

While conducting a morning assessment on a surgical unit, a licensed practical nurse evaluates a client who is $24\text{ hours}$ post-subtotal thyroidectomy. The electronic health record displays a newly resulted serum calcium level of $7.1\text{ mg/dL}$. At the bedside, the client describes a "pins and needles" sensation around their lips and fingers. Assessment reveals a heart rate of $104\text{ beats/min}$, a blood pressure of $96/60\text{ mmHg}$, and mild facial muscle twitching. What is the priority action for the nurse to take?

A practical nurse (PN) is caring for a client who is 4 days post-operative following a colon resection. The client experiences a severe coughing fit and reports, 'I felt something pop in my stomach.' Upon inspection, the PN notes that the surgical incision has separated and loops of bowel are protruding. In what order should the PN perform the following actions? Arrange the actions from first to last.

While reviewing the electronic health record of a client diagnosed with a severe infection, a practical nurse observes a significant change in the client's laboratory results. The morning serum creatinine has increased to 2.9 mg/dL (reference range: 0.6–1.2 mg/dL) from a baseline of 1.0 mg/dL upon admission. The client is prescribed intravenous gentamicin, and the next dose is scheduled to be administered in 15 minutes. Which action should the nurse take?

During afternoon rounds, a client who underwent a percutaneous liver biopsy three hours ago reports feeling unusually thirsty and lightheaded. The practical nurse obtains the following vital signs: heart rate 114 bpm, blood pressure 96/58 mm Hg, and respiratory rate 22 breaths/min. The client's baseline blood pressure prior to the procedure was 128/74 mm Hg. Based on these findings, which action should the nurse take first?

A practical nurse is preparing to administer a prescribed dose of oral amoxicillin suspension to a pediatric client who weighs $14 \text{ kg}$. The provider's prescription states: amoxicillin $40 \text{ mg/kg/day}$ by mouth divided into two equal doses every $12$ hours. The pharmacy dispenses amoxicillin suspension at a concentration of $250 \text{ mg}/5 \text{ mL}$. How many $\text{mL}$ should the nurse administer per dose? (Record your answer to the nearest tenth. Do not include units in your answer.)

An LPN/LVN is assigned to care for a client recovering from a partial colectomy performed earlier in the day. The client's current vital signs reveal a heart rate of $114$ beats/minute, a blood pressure of $96/58$ mm Hg, and a respiratory rate of $22$ breaths/minute. Simultaneously, the electronic health record alerts the nurse to a newly resulted serum hemoglobin level of $7.3$ g/dL. Based on these clinical findings, what is the most appropriate initial action?

An LPN/LVN is assisting a female client with limited mobility in collecting a midstream clean-catch urine specimen. To reduce the risk of sample contamination, arrange the following steps in the correct sequence.

During a shift at a community health clinic, a practical nurse evaluates clients presenting for scheduled immunizations. Which clients can safely undergo their prescribed vaccination therapies today? (Select all that apply)

An older adult client diagnosed with heart failure is prescribed a daily scheduled dose of oral spironolactone. During the morning chart review, the practical nurse notes that the client's most recent serum potassium level is $5.8 \text{ mEq/L}$. Which action should the practical nurse take next?

During a shift on a surgical unit, a practical nurse is evaluating a client who underwent a partial nephrectomy $4\text{ hours}$ ago. The client's current vital signs include a heart rate of $116\text{ beats/min}$ and a blood pressure of $94/58\text{ mm Hg}$. The electronic health record displays a recent postoperative serum hemoglobin level of $11.0\text{ g/dL}$. The client is awake and reporting moderate incisional pain. Which action should the practical nurse take first?