Physiological Integrity

1313 questions

All types1,313 Multiple choice672 Multiple select289 Numeric68 Ordering284

A practical nurse is preparing to administer prescribed ophthalmic drops to a client diagnosed with glaucoma. Arrange the steps of the procedure in the correct chronological order. All steps must be used.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

First cleanse the eye from inner to outer canthus, then position the client looking up, expose the conjunctival sac, instill the drops into the sac, and finally apply pressure to the nasolacrimal duct.

This chronological sequence ensures optimal medication delivery while prioritizing client safety. Cleaning the eye prevents infection, correct positioning reduces the blink reflex, exposing the sac ensures accurate delivery, and nasolacrimal pressure limits unintended systemic absorption.

Step-by-Step Solution

Cleanse the eyelid and eyelashes.

The eye area is free of drainage and debris.

Wiping from the inner to outer canthus prevents sweeping pathogens into the nasolacrimal duct.

Position the client's head backward and instruct them to look up.

The cornea rotates away from the lower lid.

Looking up decreases the natural blink reflex and prevents the medication drop from directly hitting the sensitive cornea.

Pull the lower eyelid downward.

The conjunctival sac is exposed.

This creates a trough or pocket to safely catch and hold the liquid medication.

Instill the prescribed number of drops into the conjunctival sac.

The medication is delivered to the eye.

Holding the dropper 1 to 2 cm away prevents accidental contact with the eye, which could cause injury or contaminate the dropper.

Apply gentle pressure to the nasolacrimal duct.

The tear duct is temporarily occluded.

Occluding the duct prevents the medication from draining into the nasal cavity and entering the systemic circulation, reducing the risk of systemic side effects.

Key Concept

Safe Administration of Ophthalmic Medications

Question 482Question →

While observing a 75-year-old client admitted earlier today with a closed pelvic fracture, the practical nurse notes the client is newly restless, mildly confused, and repeatedly asking for a drink. The client's current vital signs reveal a blood pressure of 102/66 mm Hg, a heart rate of 108 beats/min, and a respiratory rate of 22 breaths/min. Which of the following actions is the priority for the practical nurse?

Report the client's vital signs and behavioral changes to the registered nurse immediately

Reassure the client's family that mild confusion is a typical reaction to an unfamiliar hospital environment

Administer the prescribed as-needed pain medication to help manage the client's restlessness

Document the data in the electronic health record and recheck vital signs in one hour

Show answer & explanation

Answer: Report the client's vital signs and behavioral changes to the registered nurse immediately

Answer

Report the client's vital signs and behavioral changes to the registered nurse immediately.

The correct action is to report the findings because the client is exhibiting early signs of hypovolemic shock (restlessness, confusion, thirst, tachycardia, and borderline hypotension), a life-threatening complication of pelvic fractures. The practical nurse must prioritize Circulation (ABCs) and immediately escalate these findings to the registered nurse for prompt intervention.

Step-by-Step Solution

Analyze the client's current clinical presentation and vital signs.

The client is restless, confused, thirsty, and has borderline tachycardia (108 beats/min) and lower-end blood pressure (102/66 mm Hg).

Identifying abnormal clinical data is the first step in clinical judgment.

Connect the symptoms to the client's primary diagnosis of a pelvic fracture.

Pelvic fractures carry a high risk for massive internal retroperitoneal hemorrhage.

Understanding the complications associated with the diagnosis guides the interpretation of the symptoms.

Prioritize the required intervention based on the ABCs (Airway, Breathing, Circulation) and scope of practice.

The practical nurse identifies a Circulation emergency and must immediately escalate the findings.

Early hypovolemic shock is a medical emergency that requires rapid RN and provider intervention.

Key Concept

Early Recognition of Hypovolemic Shock

Estimated Time:1m 30s

Question 483Question →

A practical nurse is preparing to administer scheduled morning medications to a client who is nonverbal and experiencing acute delirium. The client's family is not currently present in the room. Which action describes the correct method for verifying this client's identity prior to medication administration?

State the client's full name aloud and observe the client closely for a confirming nod or gesture.

Verify the client's identity by checking the room and bed number listed on the wall above the bed.

Compare the name and date of birth on the client's attached identification band with the electronic medication administration record.

Ask the alert client in the adjacent bed to verbally confirm the confused client's first and last name.

Show answer & explanation

Answer: Compare the name and date of birth on the client's attached identification band with the electronic medication administration record.

Answer

Compare the name and date of birth on the client's attached identification band with the electronic medication administration record.

Safe medication administration requires verifying at least two distinct patient identifiers, such as the client's full name and date of birth. For a client who is nonverbal and confused, the nurse cannot rely on verbal confirmation and must instead use objective, attached identifiers by comparing the client's physical wristband directly to the electronic medication administration record.

Step-by-Step Solution

Assess the client's cognitive and communication status.

The client is identified as nonverbal and experiencing acute delirium.

Determines that the client cannot self-report their name and date of birth.

Determine the acceptable alternative method for patient identification.

Objective, physical identifiers must be used in place of verbal confirmation.

Safety protocols mandate the use of two distinct identifiers regardless of the client's mental status.

Locate the client's physical identification band and compare it to the medication administration record (MAR).

The nurse verifies the client's name and date of birth.

This fulfills the 'right client' requirement of the rights of medication administration.

Key Concept

Medication Administration Rights: Patient Identification

Question 484Question →

A practical nurse (PN) is assigned to a 78-year-old client who sustained a fractured right femur 24 hours ago. The client, who has a history of mild cognitive impairment, suddenly becomes highly agitated, attempts to pull out the intravenous (IV) line, and develops a respiratory rate of 28 breaths/minute with newly noted petechiae on the upper chest. Which actions should the PN take? Select all that apply.

Select all that apply

Apply a pulse oximeter to measure the client's oxygen saturation.

Request immediate assistance from the registered nurse (RN) to evaluate the client.

Elevate the head of the client's bed to a semi-Fowler's or high-Fowler's position.

Reassure the client and dim the room lights to manage the cognitive impairment.

Administer the client's prescribed as-needed (PRN) oral opioid analgesic for potential fracture pain.

Record the respiratory rate as borderline high and continue monitoring during the next scheduled shift round.

Show answer & explanation

Answer: Apply a pulse oximeter to measure the client's oxygen saturation.; Request immediate assistance from the registered nurse (RN) to evaluate the client.; Elevate the head of the client's bed to a semi-Fowler's or high-Fowler's position.

Answer

The practical nurse should apply a pulse oximeter, request immediate assistance from the registered nurse, and elevate the head of the bed.

The client's presentation of sudden agitation, tachypnea, and a petechial rash on the upper chest 24 hours after a femur fracture is the classic triad of fat embolism syndrome. This is a medical emergency causing severe hypoxia. The practical nurse must immediately address the client's respiratory status (Breathing) by elevating the head of the bed to facilitate lung expansion, applying a pulse oximeter to gather objective data on oxygenation, and urgently notifying the registered nurse to coordinate emergency interventions.

Step-by-Step Solution

Analyze the client's clinical presentation.

The client has a long bone fracture and suddenly presents with acute agitation, tachypnea (28 breaths/min), and chest petechiae.

Identifying these specific cues is necessary to recognize fat embolism syndrome, a life-threatening complication of long bone fractures.

Determine the highest priority of care based on the ABC (Airway, Breathing, Circulation) framework.

The client is exhibiting signs of severe respiratory compromise (Breathing) and acute hypoxia.

Prioritizing ABCs ensures that life-threatening conditions are addressed first.

Select the nursing actions that immediately address the physiological crisis within the PN scope of practice.

Elevating the head of the bed, measuring oxygen saturation, and escalating to the RN are immediate, scope-appropriate actions.

The PN must gather critical respiratory data, position the client to maximize oxygenation, and involve the RN for advanced assessment and collaborative care.

Key Concept

Recognition and immediate management of fat embolism syndrome in clients with long bone fractures, prioritizing airway and breathing.

Question 485Question →

A practical nurse is caring for a client who had a fiberglass cast applied to the right lower leg earlier in the day. The client reports severe, throbbing pain in the right leg that is rated as a 9 on a 0-to-10 scale, despite receiving an oral opioid analgesic one hour ago. The nurse notes that the client's right toes are cool to the touch and capillary refill is 4 seconds. Which action should the nurse take next?

Elevate the casted extremity on pillows above heart level to decrease swelling

Loosen the fiberglass cast using a cast saw to relieve the pressure on the leg

Administer a PRN dose of the prescribed breakthrough pain medication

Communicate the neurovascular findings to the supervising registered nurse right away

Show answer & explanation

Answer: Communicate the neurovascular findings to the supervising registered nurse right away

Answer

The priority action is to immediately communicate the neurovascular findings to the supervising registered nurse or healthcare provider.

The client is exhibiting classic signs of compartment syndrome, which include unrelieved severe pain, cool extremities, and delayed capillary refill. This is a surgical emergency requiring immediate escalation to the registered nurse or healthcare provider to prevent permanent tissue damage and limb loss.

Step-by-Step Solution

Analyze the client's symptoms and physical assessment findings.

The client has severe, unrelenting pain, cool toes, and delayed capillary refill greater than 3 seconds following cast application.

These are cardinal signs of compromised circulation and impending compartment syndrome, which is a medical emergency.

Determine the appropriate scope of practice and priority intervention.

The immediate priority is escalating the critical findings to the registered nurse or provider for urgent intervention.

Practical nurses must recognize limb-threatening complications and promptly report them; independently altering the cast or inappropriately positioning the limb violates safety standards.

Key Concept

Recognizing and Escalating Compartment Syndrome

Estimated Time:1m 0s

Question 486Question →

A practical nurse is caring for a client who is scheduled to receive a morning dose of oral furosemide. During the pre-administration assessment, the nurse notes the client's blood pressure is 86/52 mm Hg, heart rate is 114 beats/min, and the morning serum potassium level is 3.1 mEq/L (3.1 mmol/L). Which action should the practical nurse take?

Withhold the furosemide and immediately report the findings to the registered nurse.

Administer the scheduled dose of furosemide and document the assessment findings in the medical record.

Administer half of the prescribed furosemide dose to prevent further decreases in blood pressure.

Place the client in a supine position, wait one hour, and administer the furosemide if the blood pressure increases.

Show answer & explanation

Answer: Withhold the furosemide and immediately report the findings to the registered nurse.

Answer

The practical nurse should withhold the furosemide and immediately report the findings to the registered nurse.

The correct action is to withhold the medication and notify the registered nurse. Furosemide is a loop diuretic that promotes the excretion of water and potassium. The client is already exhibiting signs of hypovolemia (hypotension and tachycardia) and hypokalemia (potassium 3.1 mEq/L, normal is 3.5-5.0 mEq/L). Administering furosemide would worsen both conditions, potentially leading to severe cardiovascular collapse or lethal dysrhythmias. The practical nurse must recognize these critical findings, withhold the drug, and escalate the situation.

Step-by-Step Solution

Analyze the client's vital signs and laboratory results.

The blood pressure (86/52 mm Hg) and heart rate (114 beats/min) indicate potential hypovolemia. The potassium level (3.1 mEq/L) indicates hypokalemia.

Pre-administration assessment is critical to ensure medication safety and identify contraindications.

Evaluate the pharmacological effects of furosemide against the client's current status.

Furosemide is a loop diuretic that causes fluid loss (lowering blood pressure) and potassium excretion (worsening hypokalemia).

Administering the drug would exacerbate the client's current dangerous physiological state.

Determine the appropriate nursing intervention based on the practical nurse scope of practice.

The safest and most appropriate action is to withhold the medication and escalate the critical findings to the supervising registered nurse or healthcare provider.

Practical nurses must recognize adverse conditions, withhold unsafe medications, and communicate findings promptly.

Key Concept

Pre-administration Assessment and Withholding Criteria for Diuretics

Question 487Question →

A practical nurse (PN) is reviewing their client assignments and preparing to administer medications on a medical-surgical unit. Which of the following planned actions by the PN demonstrate safe pharmacological practice? Select all that apply.

Select all that apply

Administering an initial dose of intravenous (IV) push morphine for a client experiencing severe postoperative pain.

Administering the live attenuated measles, mumps, and rubella (MMR) vaccine to a client who is currently pregnant.

Asking an alert client to state their full name and date of birth while comparing it to the medication administration record.

Identifying a sleeping client by checking the room and bed assignment number before administering a scheduled antibiotic.

Rounding a calculated pediatric liquid medication dose of 2.4 mL up to 3.0 mL to make it easier to draw into the syringe.

Withholding a scheduled oral beta-blocker and notifying the registered nurse when the client's apical heart rate is 50 beats per minute.

Show answer & explanation

Answer: Asking an alert client to state their full name and date of birth while comparing it to the medication administration record.; Withholding a scheduled oral beta-blocker and notifying the registered nurse when the client's apical heart rate is 50 beats per minute.

Answer

The correct actions are verifying the client's identity using their full name and date of birth, and withholding the beta-blocker for a heart rate of 50 beats per minute.

Safe pharmacological practice requires strict adherence to the rights of medication administration and operating within the legal scope of practice. Using two distinct, unique identifiers (like name and date of birth) ensures the medication is given to the correct individual. Additionally, assessing critical vital signs, such as an apical pulse, before administering medications like beta-blockers and withholding the dose if the heart rate is too low prevents dangerous adverse cardiac effects.

Step-by-Step Solution

Analyze each planned medication administration action against the practical nurse scope of practice and general pharmacological safety standards.

Identified that checking two standard identifiers (name and date of birth) and withholding a beta-blocker for bradycardia are appropriate and safe nursing actions.

These actions directly uphold the rights of medication administration and ensure patient safety by preventing errors and adverse drug events.

Evaluate the remaining actions for safety and scope of practice violations.

Identified that IV push administration, giving live vaccines to pregnant clients, using room numbers for identification, and improperly rounding pediatric doses are all unsafe or out of scope.

Recognizing unsafe practices prevents patient harm and ensures adherence to legal guidelines and facility policies regarding safe medication administration.

Key Concept

Safe Medication Administration and PN Scope of Practice

Question 488Question →

A client is recovering on the surgical unit 6 hours after an abdominal hysterectomy. The practical nurse reviews the client's vital sign trends over the course of the shift:

Time	Blood Pressure	Heart Rate	Respiratory Rate
12:00	132/82 mm Hg	74 beats/min	16 breaths/min
15:00	118/74 mm Hg	90 beats/min	18 breaths/min
18:00	100/62 mm Hg	114 beats/min	22 breaths/min

While the nurse is collecting data at 18:00, the client states, 'I feel really dizzy and my stomach feels unusually tight.' Which action should the practical nurse take first?

Elevate the head of the bed to a high Fowler's position

Administer the prescribed as-needed analgesic for the reported abdominal tightness

Document the findings and plan to reassess vital signs in one hour

Notify the registered nurse or charge nurse immediately

Show answer & explanation

Answer: Notify the registered nurse or charge nurse immediately

Answer

The correct action is to notify the registered nurse or charge nurse immediately because the client is exhibiting classic signs of internal hemorrhage and developing hypovolemic shock.

The correct action focuses on immediate escalation. The client's vital signs show a clear trend of increasing heart rate and decreasing blood pressure over 6 hours. When combined with symptoms of dizziness and abdominal tightness following a major abdominal procedure, these are classic indicators of internal bleeding and hypovolemic shock. The practical nurse must rapidly report these findings to the registered nurse so collaborative emergency interventions can be initiated.

Step-by-Step Solution

Analyze the vital sign trends from 12:00 to 18:00.

The blood pressure is steadily decreasing (132/82 mm Hg down to 100/62 mm Hg) while the heart rate is significantly increasing (74 to 114 beats/min).

Identifying trends is crucial for recognizing early physiological instability before a critical event occurs.

Correlate the vital signs with the client's symptoms and surgical history.

The client had a major abdominal surgery (hysterectomy) and now reports dizziness and a tight abdomen, which aligns with the deteriorating vital signs.

These combined findings strongly suggest intra-abdominal bleeding leading to hypovolemic shock.

Determine the appropriate practical nurse (PN) scope of practice.

The PN must immediately escalate these critical findings to the registered nurse (RN) or healthcare provider.

The client requires rapid assessment and intervention (e.g., fluid resuscitation, potential return to surgery) that falls outside the independent scope of the PN.

Key Concept

Reduction of Risk Potential: Recognizing Postoperative Complications

Question 489Question →

A practical nurse is caring for a client with heart failure who is receiving prescribed intravenous furosemide therapy. Which of the following assessment findings indicate a potential complication and require immediate escalation to the registered nurse? Select all that apply.

Select all that apply

A serum potassium level of

2.8\text{ mEq/L}

(

2.8\text{ mmol/L}

)

Urine output of

850\text{ mL}

over the past

4\text{ hours}

New-onset premature ventricular contractions noted on the cardiac telemetry monitor

A decrease in blood pressure from

142/86\text{ mmHg}

88/52\text{ mmHg}

A recorded weight loss of

1.5\text{ kg}

(

3.3\text{ lb}

) since admission the previous day

Show answer & explanation

Answer: A serum potassium level of $2.8\text{ mEq/L}$ ( $2.8\text{ mmol/L}$ ); New-onset premature ventricular contractions noted on the cardiac telemetry monitor; A decrease in blood pressure from $142/86\text{ mmHg}$ to $88/52\text{ mmHg}$

Answer

The findings requiring immediate escalation are the critically low serum potassium level, the new-onset premature ventricular contractions, and the significant decrease in blood pressure.

Intravenous furosemide causes rapid fluid and electrolyte shifts. A serum potassium level of

2.8\text{ mEq/L}

indicates severe hypokalemia (normal range is

3.5

5.0\text{ mEq/L}

), placing the client at high risk for life-threatening dysrhythmias, such as the newly noted premature ventricular contractions. Furthermore, a significant drop in blood pressure to

88/52\text{ mmHg}

indicates potential hypovolemia from excessive fluid loss. All three of these findings represent immediate safety risks that fall outside the practical nurse's scope to manage independently and require urgent escalation to the registered nurse.

Step-by-Step Solution

Analyze the prescribed medication and the client's underlying condition.

Furosemide is a potent loop diuretic used to treat fluid overload in heart failure by increasing the renal excretion of water, sodium, and potassium.

Understanding the mechanism of action is necessary to anticipate both the intended therapeutic effects and the potential adverse events.

Evaluate each assessment finding to determine if it is an expected outcome or a dangerous complication.

High urine output and moderate weight loss are expected therapeutic effects. Conversely, severe hypotension, significant hypokalemia, and new-onset dysrhythmias are adverse effects indicating systemic instability.

Distinguishing between expected physiological responses and abnormal, high-risk findings is the core of clinical judgment.

Determine the appropriate nursing action based on the practical nurse scope of practice.

The expected findings are documented and monitored. The adverse findings represent immediate safety risks that must be urgently reported to the registered nurse for medical intervention.

Timely escalation of critical changes reduces the risk potential and ensures the client receives appropriate, advanced care.

Key Concept

Monitoring for and escalating adverse effects of loop diuretics, specifically hypokalemia, hypotension, and cardiac dysrhythmias.

Question 490Question →

Three hours after a total knee arthroplasty, an older adult client becomes newly confused and asks if it is time to go to work. The client's skin appears pale, and current vital signs are: heart rate 108 beats/min, respiratory rate 22 breaths/min, and blood pressure 104/68 mm Hg. Which action should the practical nurse take first?

Inspect the surgical dressing and drainage device for excessive bleeding.

Reorient the client to the hospital environment and provide verbal reassurance.

Document the findings and recheck the vital signs during the next hourly round.

Administer the prescribed as-needed analgesic to manage post-surgical discomfort.

Show answer & explanation

Answer: Inspect the surgical dressing and drainage device for excessive bleeding.

Answer

Inspect the surgical dressing and drainage device for excessive bleeding.

The client's new onset of confusion, pale skin, and slight tachycardia are early clinical indicators of inadequate tissue perfusion and possible hypovolemic shock, which is a major physiological complication following major orthopedic surgery. The priority action for the practical nurse is to assess the client's circulation by inspecting the surgical site and drainage systems for active hemorrhage.

Step-by-Step Solution

Analyze the client's clinical presentation and vital signs.

The client presents with new-onset confusion, pale skin, slight tachycardia (108 beats/min), and a borderline low blood pressure.

Identifying abnormal data is the first step in clinical reasoning and recognizing physiological compromise.

Correlate the assessment findings with potential postoperative complications.

These findings are early compensatory signs of hypovolemic shock, likely caused by postoperative hemorrhage.

Connecting data to potential physiological adaptations determines the severity and urgency of the situation.

Determine the priority nursing action based on the ABCs (Airway, Breathing, Circulation).

The most urgent need is to assess for the source of circulatory compromise by inspecting the surgical site.

Because circulation is compromised, identifying active bleeding is the highest priority before escalating the findings to the RN or provider.

Key Concept

Early recognition of hypovolemic shock involves identifying subtle vital sign changes and altered mental status, requiring immediate assessment for bleeding.

Question 491Question →

A licensed practical nurse (LPN) is reviewing the morning laboratory results for a client who is receiving a continuous intravenous heparin infusion for a deep vein thrombosis. The client's results are as follows:

* Hemoglobin: 13.8 g/dL
* Platelets: 82,000/mm³ (admission baseline: 250,000/mm³)
* Activated partial thromboplastin time (aPTT): 68 seconds (control: 30 seconds)

Based on these findings, which action should the LPN take next?

Document the activated partial thromboplastin time as therapeutic and proceed with routine care.

Discontinue the continuous intravenous heparin infusion to prevent further platelet destruction.

Notify the registered nurse immediately regarding the significant decrease in the platelet count.

Administer the client's scheduled medications after checking the name and room number.

Show answer & explanation

Answer: Notify the registered nurse immediately regarding the significant decrease in the platelet count.

Answer

The correct action is to notify the registered nurse immediately regarding the significant decrease in the platelet count.

The client's platelet count has dropped by more than 50% from the baseline, which is a strong clinical indicator of heparin-induced thrombocytopenia (HIT). While the aPTT is therapeutic, the critical drop in platelets requires immediate escalation to the registered nurse or healthcare provider. HIT is a life-threatening complication that necessitates stopping the heparin and starting an alternative anticoagulant, an intervention that must be coordinated by the registered nurse and provider.

Step-by-Step Solution

Analyze the provided laboratory results.

The hemoglobin is normal, and the aPTT is within the therapeutic range for a heparin infusion (1.5 to 2.5 times the control). However, the platelet count has dropped significantly from the admission baseline.

Identifying abnormal or critical laboratory values is a fundamental step in risk reduction.

Identify the potential clinical complication.

A sudden, drastic drop in platelets (more than 50% from baseline) in a client receiving heparin indicates a high probability of heparin-induced thrombocytopenia (HIT), a life-threatening complication.

Recognizing early signs of life-threatening trends is essential for client safety.

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

The LPN must immediately report this critical laboratory finding to the registered nurse (RN) or healthcare provider for further intervention, as the heparin infusion will likely need to be discontinued.

Practical nurses are responsible for data collection and the prompt escalation of critical findings to the directing RN.

Key Concept

Escalating Critical Laboratory Values and Recognizing Heparin-Induced Thrombocytopenia

Question 492Question →

A practical nurse is preparing to administer a newly prescribed transdermal nitroglycerin patch to a client with a history of stable angina. Arrange the steps of this medication administration procedure in the correct chronological sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first don clean gloves, remove the old patch and clean the site, label the new patch, apply it to a suitable hairless area, and finally press it firmly into place without massaging.

Safe application of a transdermal nitroglycerin patch requires a systematic approach to protect both the client and the nurse. The nurse must first wear gloves to prevent self-dosing, then remove the previous patch to prevent overdose. Labeling the new patch prior to application ensures proper documentation without pressing a pen into the client. Finally, selecting a hairless site and pressing without massaging ensures the drug is absorbed at a safe, controlled rate.

Step-by-Step Solution

Protect the nurse from unintended medication exposure.

Don clean gloves.

Nitroglycerin is readily absorbed through the skin. Handling the patch with bare hands can cause the nurse to experience adverse effects.

Prepare the client for the new dose.

Remove the old patch and wash the old site.

Leaving an old patch on while applying a new one leads to toxicity and nitrate tolerance. Washing removes leftover medication residue.

Prepare the new medication for tracking.

Label the new patch with the date, time, and initials.

Writing on the patch before applying it ensures necessary communication with the healthcare team and prevents applying pressure from a pen directly onto the client's body.

Administer the medication.

Place the patch on a hairless, intact area of skin.

Scar tissue, cuts, or thick hair can alter the absorption rate of the transdermal medication.

Secure the medication.

Press firmly for 10 seconds without rubbing.

Friction from massaging increases local circulation, which can cause an unsafe, rapid absorption of the vasodilator.

Key Concept

Safe administration of transdermal medications

Question 493Question →

A practical nurse (PN) is caring for an 82-year-old client who is receiving a continuous intravenous heparin infusion for a right leg deep vein thrombosis (DVT). The client suddenly becomes highly restless, reports feeling short of breath, and exhibits a respiratory rate of 28 breaths/min. Which of the following actions should the PN take? (Select all that apply)

Select all that apply

Elevate the head of the client's bed.

Administer the prescribed as-needed oral analgesic for leg discomfort.

Notify the registered nurse (RN) immediately.

Inform the family that sudden restlessness is a normal reaction to hospitalization in older adults.

Obtain the client's pulse oximetry reading and complete vital signs.

Document the findings and reassess the respiratory rate in 30 minutes to establish a trend.

Show answer & explanation

Answer: Elevate the head of the client's bed.; Notify the registered nurse (RN) immediately.; Obtain the client's pulse oximetry reading and complete vital signs.

Answer

The correct actions are to elevate the head of the client's bed, immediately notify the registered nurse, and obtain the client's pulse oximetry and complete vital signs.

The client is exhibiting signs of acute hypoxia, potentially due to a pulmonary embolism arising from the deep vein thrombosis. Immediate interventions must focus on Airway, Breathing, and Circulation (ABC). Elevating the head of the bed facilitates lung expansion. Obtaining full vital signs provides critical data, and notifying the RN ensures the client receives prompt emergency medical management.

Step-by-Step Solution

Analyze the client's clinical presentation.

The client has sudden shortness of breath, tachypnea (28 breaths/min), and new-onset restlessness.

These are hallmark manifestations of a pulmonary embolism, a life-threatening complication of deep vein thrombosis causing acute hypoxia.

Determine the priority interventions based on the ABC framework.

Airway and Breathing must be addressed immediately.

Elevating the head of the bed maximizes chest expansion and provides immediate mechanical support for oxygenation.

Identify appropriate data collection and escalation protocols.

The PN must obtain full vital signs and escalate the situation to the RN.

The RN must perform an advanced assessment and collaborate with the healthcare provider for emergency medical interventions, while the PN assists by providing critical physiological data.

Key Concept

Prioritization of Airway, Breathing, and Circulation (ABCs) during acute respiratory distress.

Question 494Question →

A practical nurse (PN) is preparing to discontinue a peripheral intravenous (IV) catheter for a client who is receiving continuous anticoagulant therapy. The IV infusion has already been stopped. Arrange the following steps in the correct sequence to safely remove the catheter and minimize the risk of complications. All options must be used.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to perform hand hygiene and don gloves, remove the dressing while stabilizing the hub, place gauze lightly over the site, withdraw the catheter parallel to the skin, and finally apply firm pressure for at least 5 minutes.

Safely discontinuing an IV catheter requires standard precautions, careful site exposure, atraumatic removal, and adequate hemostasis. For a client on anticoagulant therapy, the critical risk reduction modification is applying continuous pressure for a longer duration (at least 5 minutes) immediately after the catheter is fully withdrawn to prevent excessive bleeding or hematoma formation.

Step-by-Step Solution

Perform hand hygiene and don clean gloves.

Prevents the introduction of pathogens.

Standard infection control practices must be established prior to client contact.

Gently remove the securement dressing while stabilizing the catheter hub.

Exposes the insertion site without dislodging the catheter.

Stabilizing the hub prevents mechanical trauma to the vein and accidental premature removal.

Place a dry, sterile gauze pad lightly over the insertion site.

Prepares the site for immediate pressure upon removal.

Applying pressure before the catheter is fully removed can damage the vein lining.

Withdraw the catheter smoothly in a direction parallel to the skin.

Removes the foreign body safely.

Keeping the catheter parallel avoids puncturing the posterior wall of the vein.

Apply firm, continuous pressure to the site for at least 5 minutes.

Achieves hemostasis.

Clients on anticoagulants have prolonged bleeding times and require extended pressure to prevent hemorrhage or hematoma formation.

Key Concept

Discontinuation of a peripheral IV and bleeding risk reduction.

Question 495Question →

An older adult client in an inpatient rehabilitation facility is prescribed oral extended-release morphine for chronic pain management. When the practical nurse approaches the client to administer the morning dose, the client is difficult to awaken and has a respiratory rate of 9 breaths per minute. Which action should the nurse take first?

Withhold the medication and urgently notify the supervising registered nurse.

Administer the scheduled analgesic to ensure the client's pain remains consistently controlled.

Document the difficult arousal as an expected age-related change and continue routine monitoring.

Scan the medication barcode but bypass checking the client's identification band to avoid disturbing their rest.

Show answer & explanation

Answer: Withhold the medication and urgently notify the supervising registered nurse.

Answer

The correct action is to withhold the medication and urgently notify the supervising registered nurse.

The correct answer requires the nurse to withhold the medication and notify the registered nurse. A respiratory rate of 9 breaths per minute indicates respiratory depression, a critical adverse effect of morphine. Administering the medication would worsen the condition. The practical nurse must ensure client safety by holding the offending agent and escalating the unstable assessment findings to the supervising RN for urgent medical intervention.

Step-by-Step Solution

Evaluate the older adult client's clinical presentation before proceeding with medication administration.

The client is difficult to arouse and exhibits a depressed respiratory rate of 9 breaths per minute (normal adult rate is 12-20 breaths per minute).

Identifying significant deviations from baseline vital signs is necessary to ensure it is safe to administer pharmacological therapies.

Analyze the assessment findings in relation to the prescribed medication.

Morphine is a potent opioid analgesic that carries a high risk for central nervous system and respiratory depression.

Connecting the client's symptoms to the known adverse effects of the prescribed drug dictates the immediate clinical response.

Determine the safest nursing intervention based on clinical prioritization and the practical nurse scope of practice.

The nurse must withhold the opioid dose to prevent further respiratory compromise and immediately escalate the situation to the registered nurse.

Airway and breathing are the highest priorities. An unstable client experiencing respiratory depression requires urgent RN-level assessment and potential medical interventions, such as administering an opioid antagonist.

Key Concept

Recognizing and managing opioid-induced respiratory depression within the practical nurse scope of practice.

Question 496Question →

A practical nurse is preparing to administer ibuprofen oral suspension to a toddler who weighs $28.6$ lb. The health care provider prescribes $10$ mg/kg/dose every $6$ hours PRN for fever. The pharmacy provides ibuprofen oral suspension with a concentration of $100$ mg / $5$ mL. How many milliliters should the nurse administer for one dose? (Record answer to the nearest tenth. Do not include units in answer.)

Show answer & explanation

Answer: 6.5

Answer

6.5

To determine the correct volume to administer, the nurse must first convert the child's weight to kilograms (

28.6 \text{ lb} \div 2.2 = 13 \text{ kg}

). Next, calculate the required dose by multiplying the weight by the prescribed weight-based amount (

13 \text{ kg} \times 10 \text{ mg/kg} = 130 \text{ mg}

). Finally, calculate the volume using the medication concentration provided by the pharmacy (

130 \text{ mg} \div 100 \text{ mg} \times 5 \text{ mL} = 6.5 \text{ mL}

Step-by-Step Solution

Convert weight from pounds to kilograms.

28.6 \div 2.2 = 13

The prescribed dosage is ordered in mg/kg, requiring the client's weight to be in kilograms.

Determine the total milligrams required for one dose.

13 \times 10 = 130

Multiply the client's weight in kg by the prescribed dose of

10

mg/kg.

Calculate the volume (mL) to administer.

\frac{130}{100} \times 5 = 6.5

Use the formula (Desired / Have) x Quantity to find the required volume.

Key Concept

Weight-based pediatric dosage calculation

Question 497Question →

A practical nurse is assigned to care for a client who is $6$ hours post-operative following a right total knee arthroplasty. The nurse observes that the client is becoming increasingly restless and reports feeling dizzy. The current vital signs are: heart rate $114$ beats/min, respiratory rate $24$ breaths/min, and blood pressure $100/64$ mm Hg (pre-operative baseline $136/82$ mm Hg). The morning hematocrit level is $26\%$ , a significant decrease from the pre-operative level of $39\%$ . Which of the following is the most appropriate action for the practical nurse to take?

Administer a prescribed intravenous push sedative to help manage the client's new onset of restlessness and confusion.

Reassess the vital signs in one hour, as mild tachycardia and decreased blood pressure are expected effects of anesthesia.

Immediately report the changes in vital signs and the decreased hematocrit level to the registered nurse.

Document the hematocrit level in the medical record, noting that this decrease is a standard outcome following joint replacement.

Show answer & explanation

Answer: Immediately report the changes in vital signs and the decreased hematocrit level to the registered nurse.

Answer

The practical nurse should immediately escalate the findings to the registered nurse due to the clear indicators of hypovolemic shock.

The client is exhibiting restlessness, tachycardia, hypotension, and a significantly decreased hematocrit level, which are classic signs of internal bleeding and early hypovolemic shock following major orthopedic surgery. Recognizing these life-threatening complications and immediately escalating the findings to the registered nurse is the highest priority. This ensures the client will receive timely, advanced interventions such as aggressive fluid resuscitation or a blood transfusion.

Step-by-Step Solution

Analyze the client's clinical presentation and vital signs.

The client shows restlessness, dizziness, tachycardia (

114

beats/min), and hypotension (

100/64

mm Hg from a baseline of

136/82

mm Hg).

These are classic early indicators of poor tissue perfusion and compensatory mechanisms for blood loss.

Evaluate the laboratory results against expected post-operative ranges.

The hematocrit has dropped significantly from

39\%

26\%

While some blood loss is expected after major joint arthroplasty, a

13\%

drop in hematocrit is critical and indicates severe hemorrhage.

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

The immediate priority is to notify the registered nurse and the healthcare provider.

The client is experiencing a life-threatening complication that requires advanced assessment, fluid resuscitation, or a potential blood transfusion, which necessitates registered nurse and provider collaboration.

Key Concept

Early Recognition of Shock and Scope of Practice

Estimated Time:1m 30s

Question 498Question →

A practical nurse is caring for a client with type 2 diabetes mellitus who is scheduled for an abdominal computed tomography (CT) scan and has been prescribed NPO (nothing by mouth) status since midnight. The morning medication administration record includes prescriptions for oral glipizide and subcutaneous insulin lispro. The client's point-of-care blood glucose level is $64$ mg/dL. Which of the following actions should the practical nurse take?

Administer the subcutaneous insulin lispro to maintain basal glycemic control but withhold the oral glipizide.

Administer the oral glipizide with a minimal sip of water and hold the insulin lispro until after the scan.

Withhold both the glipizide and the insulin lispro, and immediately notify the registered nurse or healthcare provider.

Provide four ounces of apple juice to correct the blood glucose, then administer both medications.

Show answer & explanation

Answer: Withhold both the glipizide and the insulin lispro, and immediately notify the registered nurse or healthcare provider.

Answer

The practical nurse should withhold both the oral glipizide and the subcutaneous insulin lispro, and immediately notify the registered nurse or healthcare provider.

The client is experiencing hypoglycemia (blood glucose less than

70

mg/dL) and is NPO for a diagnostic procedure. Administering either glipizide (a sulfonylurea) or insulin lispro (a rapid-acting insulin) without food will exacerbate the hypoglycemia, potentially leading to seizures or coma. Furthermore, the practical nurse must escalate this critical laboratory finding to the registered nurse or provider, as the client's hypoglycemia requires treatment that may conflict with the NPO order (e.g., administering intravenous dextrose instead of oral juice).

Step-by-Step Solution

Identify the client's current physiological status.

The client is NPO, has a low blood glucose of

64

mg/dL (hypoglycemia), and is awaiting a diagnostic procedure.

Establishing the baseline condition is necessary before safely administering any pharmacological therapy.

Analyze the prescribed medications' onset and mechanisms of action.

Glipizide stimulates insulin release, and insulin lispro is a rapid-acting insulin. Both require adequate food intake to prevent severe hypoglycemia.

Understanding pharmacokinetics ensures safe medication administration and prevents adverse drug events.

Determine the appropriate nursing action based on the practical nurse scope of practice.

The medications must be withheld to prevent life-threatening hypoglycemia, and the registered nurse or provider must be notified to determine the next steps for treating the hypoglycemia while managing the NPO status.

Practical nurses must escalate critical laboratory findings and recognize contraindications to delegated medications.

Key Concept

Pre-administration withholding criteria and medication safety for hypoglycemic, NPO clients

Question 499Question →

A licensed practical nurse (LPN) is assisting with the care of a client who is $4\text{ hours}$ post-operative following an open cholecystectomy and is currently receiving a packed red blood cell (PRBC) transfusion. Which of the following actions by the LPN demonstrate appropriate risk reduction strategies? Select all that apply.

Select all that apply

Stopping the transfusion immediately if the client develops a sudden onset of lower back pain and dyspnea.

Verifying the client's identity, blood type, and the packed red blood cell unit with the registered nurse (RN) at the bedside before administration.

Obtaining and documenting the client's baseline vital signs immediately prior to the initiation of the transfusion.

Waiting until the end of the shift to report a post-operative hemoglobin level of

6.4\text{ g/dL}

because the client is currently receiving blood.

Documenting a mid-transfusion heart rate of

118\text{ bpm}

and a blood pressure of

92/58\text{ mm Hg}

as expected findings without notifying the RN.

Accepting a delegation from the RN to independently spike the blood bag and initiate the transfusion using the existing intravenous line.

Show answer & explanation

Answer: Stopping the transfusion immediately if the client develops a sudden onset of lower back pain and dyspnea.; Verifying the client's identity, blood type, and the packed red blood cell unit with the registered nurse (RN) at the bedside before administration.; Obtaining and documenting the client's baseline vital signs immediately prior to the initiation of the transfusion.

Answer

The appropriate risk reduction strategies are stopping the transfusion for signs of a hemolytic reaction (back pain and dyspnea), verifying the client and blood product with an RN at the bedside, and obtaining baseline vital signs immediately prior to the transfusion.

Stopping the transfusion for signs of a hemolytic reaction, verifying the blood product with an RN, and obtaining baseline vital signs are essential risk reduction strategies. These actions ensure the right patient receives the right blood product, establish a baseline to identify adverse reactions, and prevent severe harm if an acute reaction occurs.

Step-by-Step Solution

Analyze the role of the LPN in blood product administration.

The LPN can assist with monitoring and verifying but cannot independently initiate blood transfusions.

Blood administration requires RN-level assessment and initiation due to the high risk of life-threatening reactions.

Identify signs of acute transfusion reactions.

Lower back pain and dyspnea indicate an acute hemolytic reaction.

Cellular destruction during a hemolytic reaction causes kidney damage (back pain) and systemic shock, requiring immediate cessation of the infusion.

Evaluate the incorrect clinical actions.

Failing to report critical labs, ignoring borderline vital signs, and accepting out-of-scope delegations compromise client safety.

Risk reduction requires prompt escalation of abnormal findings and strict adherence to the LPN scope of practice.

Key Concept

Reduction of Risk Potential During Blood Administration

Question 500Question →

The nursing team is providing care for a client diagnosed with heart failure who is prescribed oral digoxin and a potassium-wasting diuretic. Which interventions are appropriate for the practical nurse (PN) to perform regarding this client's pharmacological management? Select all that apply.

Select all that apply

Auscultate the client's apical pulse for a full

60

seconds prior to administering the digoxin.

Proceed with administering the morning digoxin dose after reviewing a serum digoxin level of

3.2

ng/mL.

Withhold the diuretic and notify the registered nurse immediately when the morning metabolic panel reveals a potassium level of

2.5

mEq/L.

Administer a supplemental dose of intravenous push (IVP) furosemide as delegated by the unit charge nurse.

Verify the client's identity by checking the room and bed number on the door since the client is sleeping and wearing a damaged ID band.

Ask the client to state their full name and date of birth while verifying the information against the medication administration record.

Show answer & explanation

Answer: Auscultate the client's apical pulse for a full $60$ seconds prior to administering the digoxin.; Withhold the diuretic and notify the registered nurse immediately when the morning metabolic panel reveals a potassium level of $2.5$ mEq/L.; Ask the client to state their full name and date of birth while verifying the information against the medication administration record.

Answer

The appropriate actions are auscultating the apical pulse for 60 seconds, withholding the diuretic for a critically low potassium level of 2.5 mEq/L, and actively verifying the client's name and date of birth.

Safe pharmacological management for a client on digoxin and diuretics requires strict adherence to safety protocols. This includes verifying patient identity using two valid identifiers (name and date of birth), assessing the apical pulse for a full minute to detect bradycardia, and recognizing that critical laboratory values, such as severe hypokalemia (which exacerbates digoxin toxicity), require immediate escalation and the withholding of the diuretic.

Step-by-Step Solution

Analyze the prescribed medications and identify required safety parameters.

Digoxin requires assessing the apical pulse for one minute and monitoring for toxicity. Potassium-wasting diuretics require monitoring serum potassium to prevent hypokalemia, which worsens digoxin toxicity.

Understanding the pharmacokinetics and interactions of the drugs ensures safe administration.

Evaluate the clinical data provided in the options against established norms.

A digoxin level of 3.2 ng/mL is toxic (normal is typically 0.5-2.0 ng/mL). A potassium level of 2.5 mEq/L is hypokalemic (normal is typically 3.5-5.0 mEq/L).

Nurses must recognize critical laboratory values to safely withhold medications and alert the care team.

Assess the procedural interventions against the practical nurse (PN) scope of practice and the medication rights.

Intravenous push (IVP) administration is out of scope. Room numbers are invalid identifiers. Direct questioning of name and date of birth aligns with strict medication administration rights.

Maintaining practice boundaries and adhering to universal safety protocols prevents adverse events.

Key Concept

Pharmacological Therapies, Safe Medication Administration, and PN Scope of Practice

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