Physiological Integrity

A young adult arrives at an outpatient clinic for a routine wellness check and is scheduled to receive the measles, mumps, and rubella (MMR) immunization. While filling out the pre-assessment questionnaire, the client mentions missing her last menstrual cycle and having a positive home pregnancy test three days ago. Based on these findings, which action should the practical nurse implement?

A practical nurse is evaluating an adult client who underwent a percutaneous liver biopsy $2$ hours prior. The client's baseline vital signs included a blood pressure of $124/78\text{ mm Hg}$ and a heart rate of $76\text{ beats/min}$. The nurse's current assessment reveals a blood pressure of $92/56\text{ mm Hg}$ and a heart rate of $112\text{ beats/min}$. The client reports feeling dizzy and having mild right shoulder pain. What is the priority nursing action?

A practical nurse is preparing a client for a scheduled abdominal surgery. To reduce the risk of perioperative complications, which actions must the nurse ensure are completed before the client is transported to the operating room? Select all that apply.

A practical nurse (PN) is providing morning basic care for an older adult client on the third day following a partial gastrectomy. The client is receiving continuous enteral nutrition via a jejunostomy tube, requires extensive assistance with all personal hygiene, and has a documented history of early-stage dementia. Which interventions should the PN include in the client's plan of care? Select all that apply.

A client is prescribed ibuprofen $400\text{ mg}$ orally every $6$ hours for musculoskeletal pain. The available medication is an oral suspension labeled $100\text{ mg}/5\text{ mL}$. How many milliliters ($\text{mL}$) should the practical nurse administer per dose? Record your answer as a whole number. Do not include units in your answer.

An older adult client residing in a long-term care facility receives daily oral prednisone for rheumatoid arthritis. The healthcare provider newly prescribes oral levofloxacin to treat a respiratory infection. Which actions should the practical nurse implement to ensure safe pharmacological management? Select all that apply.

A practical nurse is caring for a client with congestive heart failure who is scheduled to receive a morning dose of oral digoxin. The client's morning laboratory results show a serum potassium level of $3.0\text{ mEq/L}$ ($3.0\text{ mmol/L}$) and a serum digoxin level of $1.4\text{ ng/mL}$ ($1.8\text{ nmol/L}$). The client's apical pulse is $64\text{ beats/min}$. During the morning assessment, the client reports new-onset severe nausea and seeing yellow halos around the lights in the room. Which action should the practical nurse take first?

A practical nurse is preparing to administer scheduled morning medications to a client diagnosed with hypothyroidism. The primary health care provider has prescribed levothyroxine $0.125\text{ mg}$ orally once daily. The pharmacy supplies levothyroxine as scored tablets containing $50\text{ mcg}$ per tablet. How many tablets should the nurse administer?

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

A practical nurse (PN) enters the room of a client who has a T4 spinal cord injury. The client reports a sudden, severe pounding headache and blurred vision. The PN observes profuse diaphoresis above the level of the spinal injury and measures a blood pressure of 210/110 mm Hg. In which order should the PN perform the following actions? (Arrange the actions from first to last)

An unlicensed assistive personnel (UAP) urgently calls the practical nurse (PN) to the room of an 81-year-old client who underwent a total knee arthroplasty the previous day. The UAP reports the client has become suddenly agitated, is speaking incoherently, and is trying to remove their intravenous (IV) line. The client was previously alert and oriented. Current vital signs are a heart rate of 112 bpm, blood pressure of 98/62 mm Hg, and a respiratory rate of 26 breaths/min. Which action is the priority for the PN to take?

A client with left-sided weakness is scheduled to sit in a chair for their morning meal. The client is currently lying in bed. In what order should the nurse complete the following actions to safely transfer the client to a wheelchair?

A practical nurse (PN) is reviewing the electronic health record of a client receiving a continuous intravenous heparin infusion for a pulmonary embolism. Which finding poses the greatest physiological risk to the client and requires immediate notification to the registered nurse?

While assisting a postoperative client who underwent abdominal surgery earlier in the day, a practical nurse obtains the following vital signs: temperature 98.8°F (37.1°C), heart rate 116 beats/min, respiratory rate 20 breaths/min, and blood pressure 92/54 mm Hg. The client's admission baseline blood pressure was 128/74 mm Hg. Which action should the nurse prioritize?

An unconscious client requires morning oral hygiene. To prevent aspiration and ensure safety, in what order should the practical nurse complete the following steps? Arrange the actions in the correct chronological sequence.

During a shift assessment on an orthopedic unit, a practical nurse evaluates a client with a newly applied plaster cast on the lower left leg. The client describes an intense, throbbing pain that has worsened significantly despite receiving a scheduled intravenous analgesic one hour ago. The nurse observes that the client's toes are cool to the touch and the pedal pulse is weak. While the charge nurse is notifying the healthcare provider of these findings, which action should the practical nurse implement?

During a pediatric clinic visit, a child weighing $37.4\text{ lb}$ is diagnosed with acute otitis media. The primary health care provider prescribes cefdinir oral suspension at the maximum recommended dosage of $14\text{ mg/kg/day}$, to be administered in equally divided doses every $12\text{ hours}$. The clinic pharmacy dispenses a multi-dose bottle of cefdinir powder with the following label instructions: "Reconstitute by adding $38\text{ mL}$ of sterile water to yield $60\text{ mL}$ of oral suspension with a concentration of $250\text{ mg}/5\text{ mL}$."

The practical nurse is reinforcing medication administration instructions with the child's parents. How many milliliters ($\text{mL}$) should the nurse instruct the parents to administer for a single dose? (Record the answer to the nearest tenth. Do not include units in the answer.)

A practical nurse is assisting with the preparation of a client with severe hepatic cirrhosis who is scheduled for a bedside paracentesis. In what order should the nurse perform the following actions to minimize the risk of procedural complications, such as bladder perforation?

An older adult client is recovering on the medical-surgical unit 90 minutes after an image-guided percutaneous liver biopsy. The client is currently positioned on the right side with a rolled towel under the lower ribs. During a routine check, the client's blood pressure is 108/68 mm Hg, heart rate is 92 beats/minute, and they report a sudden onset of mild but persistent right shoulder pain. What is the priority action for the practical nurse to take?

A practical nurse is assessing a client who is $24\text{ hours}$ post-operative following a right total knee arthroplasty. Which of the following findings should the practical nurse identify as potential complications requiring immediate notification of the registered nurse? Select all that apply.

A practical nurse is assisting with the admission of a client who has just returned to the nursing unit after a percutaneous liver biopsy. Which of the following positions is most appropriate for the nurse to place the client in to prevent post-procedure complications?