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Physiological Integrity

1313 questions

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Question 561Question →

While conducting an afternoon assessment on a client who underwent a partial thyroidectomy six hours ago, a licensed practical nurse observes the client's pulse is 114 beats per minute, respirations are 22 per minute, and blood pressure is 94/62 mm Hg. The client states, 'I feel really jittery right now.' What is the priority action for the nurse to take?

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Answer: Alert the registered nurse to the current clinical findings immediately

Answer

The correct action is to immediately alert the registered nurse to the current clinical findings.
The client is exhibiting early signs of shock or potential internal hemorrhage, characterized by tachycardia, borderline hypotension, and restlessness (described as feeling 'jittery'). In the postoperative period, the licensed practical nurse must prioritize client safety by immediately reporting these subtle but critical changes to the registered nurse so that further medical assessment and life-saving interventions can be initiated.

Step-by-Step Solution

1
Analyze the client's vital signs and verbal statements.
The pulse of 114 beats per minute and blood pressure of 94/62 mm Hg are borderline abnormal, and feeling 'jittery' is a classic sign of restlessness.
Identifying subtle deviations from normal baseline values is essential for recognizing early complications.
2
Correlate findings with postoperative risks for a thyroidectomy.
These findings collectively act as early indicators of potential internal hemorrhage or hypovolemic shock, which are critical complications.
Understanding the clinical implications of assessment data guides the urgency of necessary nursing interventions.
3
Determine the priority action within the practical nurse scope of practice.
The absolute priority is to escalate these critical findings to the registered nurse for further assessment and collaborative intervention.
Practical nurses must promptly report rapid changes indicating a severe risk to client safety rather than attempting to manage a potential crisis independently.

Key Concept

Early recognition of shock and appropriate escalation of critical findings
Question 562Question →

A practical nurse is preparing to perform oral hygiene for a client who is unconscious. To prevent aspiration, which is the most appropriate position for the nurse to place the client?

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Answer: Side-lying (lateral) position

Answer

Side-lying (lateral) position
Placing the unconscious client in a side-lying (lateral) position, ideally with the head turned to the side, is the safest method for performing oral care. This position uses gravity to allow saliva, water, and oral care products to drain easily out of the mouth, effectively protecting the airway and preventing aspiration.

Step-by-Step Solution

1
Identify the primary risk during oral care for an unconscious client.
The main risk is aspiration of fluids into the airway.
Unconscious clients lack a functional gag reflex and cannot actively swallow or spit out fluids.
2
Determine the position that best mitigates this risk using basic care principles.
The side-lying position uses gravity to facilitate fluid drainage.
By turning the client to the side, fluids will naturally flow out of the dependent side of the mouth rather than toward the trachea.

Key Concept

Basic Care and Comfort: Prevention of Aspiration
Question 563Question →

A client is receiving care on a surgical unit 48 hours after undergoing a right below-the-knee amputation. To prevent postoperative complications and promote optimal long-term mobility, which of the following positioning measures should the practical nurse (PN) implement?

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Answer: Assist the client to lie in a prone position for 20 to 30 minutes several times a day.

Answer

Assist the client to lie in a prone position for 20 to 30 minutes several times a day.
Following a lower extremity amputation, the prevention of hip flexion contractures is a primary positioning goal. Assisting the client into a prone position (lying on the abdomen) for 20 to 30 minutes, three to four times a day, actively stretches the hip flexor muscles and prevents them from shortening.

Step-by-Step Solution

1
Identify the surgical procedure and the postoperative timeframe.
The client had a below-the-knee amputation 48 hours ago.
Positioning protocols for amputations change significantly after the first 24 hours to transition from edema control to contracture prevention.
2
Determine the primary musculoskeletal complication associated with lower extremity amputations.
Hip flexion contractures are a major risk because the flexor muscles tend to shorten if the limb is kept in a bent position.
Understanding the risk of muscle shortening guides the selection of the correct preventive positioning measure.
3
Evaluate the given positioning options against the goal of preventing contractures.
Prone positioning extends and stretches the hip flexors, whereas elevating the limb on a pillow, sitting in a chair, and semi-Fowler's positioning all promote continuous hip flexion.
Selecting the intervention that directly counteracts muscle shortening ensures evidence-based basic care and protects the client's ability to use a future prosthesis.

Key Concept

Prevention of Hip Flexion Contractures Following Amputation
Question 564Question →

A client with a history of chronic stable angina is scheduled to receive a new transdermal nitroglycerin patch. What is the correct sequence of steps the practical nurse should follow to safely administer this medication? Arrange the actions in the correct chronological order.

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Answer

The correct sequence ensures safety and proper absorption: perform hand hygiene and don gloves, remove the old patch, cleanse the old site, label the new patch, and apply the new patch to a rotated site.
The correct sequence minimizes the risk of medication errors and protects the nurse. Gloves must be worn first to prevent self-medication. The old patch must be removed and the site cleaned to prevent a dangerous overdose. The new patch must be labeled before application to prevent skin trauma or a sudden bolus dose, and then applied to a new, rotated site to prevent skin irritation.

Step-by-Step Solution

1
Perform hand hygiene and don clean gloves.
Nurse and client are protected from exposure.
Gloves prevent the nurse from accidentally absorbing nitroglycerin through the skin, which could cause a severe headache or dangerous hypotension.
2
Remove the old transdermal patch and fold it in half.
Old medication source is safely contained and removed.
Leaving an old patch on while applying a new one can lead to medication toxicity and adverse cardiovascular events.
3
Cleanse the skin of the old site.
Skin is completely free of residual medication.
Nitroglycerin residue left on the skin continues to absorb and may cause unintended dosing if not washed away.
4
Label the new patch.
Patch is identified with date, time, and initials prior to application.
Writing on the patch before applying it prevents pressing down on the client's tissue and inadvertently squeezing out a bolus of medication.
5
Apply the new patch to a new site.
Medication is administered correctly to a fresh area.
Rotating sites prevents contact dermatitis and ensures consistent, reliable systemic absorption of the drug.

Key Concept

Safe administration of transdermal medications
Question 565Question →

A client with persistent asthma is scheduled to receive a dose of inhaled fluticasone propionate using a metered-dose inhaler (MDI) and a spacer device. How should the practical nurse sequence the actions to administer this medication? Arrange the following steps in the correct chronological order.

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Answer

The correct sequence is: Shake the canister, attach it to the spacer, have the client exhale completely, depress the canister while the client inhales, hold the breath for 10 seconds, and finally rinse the mouth with water.
Safe administration of a corticosteroid MDI requires meticulous preparation of the device (shaking and attaching the spacer), optimizing the client's respiratory mechanics (exhaling before inhaling), ensuring medication deposition (holding the breath), and preventing drug-specific adverse effects (rinsing the mouth to prevent thrush).

Step-by-Step Solution

1
Shake the inhaler canister.
The medication and propellant are evenly mixed.
Ensures the prescribed dosage of the active medication is delivered rather than just the propellant.
2
Attach the inhaler to the spacer.
The MDI is secured to the delivery chamber.
Spacers eliminate the need for perfect hand-breath coordination and increase the amount of medication reaching the lungs.
3
Instruct the client to exhale completely.
The client's lungs are emptied of functional reserve air.
Prepares the respiratory tract to take in the maximum volume of medicated air.
4
Depress the canister and have the client inhale.
The medication is drawn deeply into the lower respiratory tract.
A slow, deep inhalation pulls the aerosolized particles past the upper airway and into the bronchioles.
5
Instruct the client to hold their breath for 10 seconds.
The air remains trapped in the lungs momentarily.
Provides time for the medication particles to precipitate out of the air and coat the lung tissue.
6
Have the client rinse their mouth and spit.
Steroid residue is cleared from the oral mucosa.
Prevents localized immunosuppression in the mouth, which can lead to fungal infections such as thrush.

Key Concept

Pharmacological Therapies: Safe Administration of Inhaled Corticosteroids via MDI
Estimated Time:1m 30s
Question 566Question →

During rounds, a client receiving continuous enteral tube feeding suddenly begins to cough vigorously, displays audible wheezing, and appears acutely dyspneic. In which order should the practical nurse (PN) perform the following actions? Arrange the interventions from highest priority (first) to lowest priority (last).

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Answer

The correct sequence prioritizes immediate airway protection: stop the feeding, position the client, suction the airway, obtain vital signs, and finally notify the registered nurse.
When managing an acute aspiration event, the nurse must immediately apply the airway, breathing, and circulation (ABC) prioritization framework. The absolute first priority is to stop the source of the aspiration. Next, physically positioning the client and clearing the airway take precedence over diagnostic assessment (vital signs) and communication (notifying the RN).

Step-by-Step Solution

1
Stop the continuous enteral tube feeding pump.
Further aspiration of formula is prevented.
Removing the source of harm is always the first action in an aspiration emergency.
2
Place the client in a high Fowler's or side-lying position.
The airway is physically protected using gravity.
Elevating the head of the bed or turning the client to the side prevents further aspiration of stomach contents and maximizes chest expansion.
3
Suction the client's oropharyngeal airway.
Aspirated formula and mucus are cleared from the upper airway.
Clearing the airway resolves the immediate physical obstruction to breathing.
4
Obtain the client's vital signs and oxygen saturation.
Objective data regarding the client's respiratory compromise is collected.
Assessment data is necessary to determine the severity of the hypoxia and need for further interventions like supplemental oxygen.
5
Notify the supervising registered nurse (RN) of the event.
The healthcare team is alerted to the critical change in condition.
Medical evaluation is required to assess for complications such as aspiration pneumonia and to order subsequent treatments.

Key Concept

Prioritization of Airway, Breathing, and Circulation (ABC) during aspiration emergencies
Question 567Question →

A practical nurse (PN) is collecting data on an older adult client who underwent a transurethral resection of the prostate (TURP) 12 hours ago and is receiving continuous bladder irrigation (CBI). Which of the following findings should the PN report to the registered nurse (RN) immediately? Select all that apply.

Select all that apply

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Answer: The client becomes increasingly restless and repeatedly asks staff members where they are.; The client's blood pressure is 174/98 mm Hg with a heart rate of 54 beats/min.; The client reports a new, severe headache accompanied by an episode of emesis.

Answer

The correct findings to report immediately are the client becoming increasingly restless and disoriented, the blood pressure of 174/98 mm Hg with a heart rate of 54 beats/min, and the new, severe headache accompanied by emesis.
The correct findings (restlessness/confusion, hypertension with bradycardia, and headache/emesis) are classic manifestations of TURP syndrome. This life-threatening complication occurs when the body absorbs a large volume of the irrigation fluid used during the procedure, leading to severe fluid volume overload and dilutional hyponatremia. The fluid overload causes hypertension and reflex bradycardia, while the acute hyponatremia causes cerebral edema, manifesting as restlessness, confusion, headache, and vomiting. These findings represent a failure of physiological adaptation and require immediate reporting to the RN for emergency medical intervention.

Step-by-Step Solution

1
Analyze the client's clinical context and current treatment.
The client is 12 hours post-TURP with continuous bladder irrigation (CBI).
Understanding the procedure helps anticipate specific complications, such as hemorrhage, bladder spasms, and TURP syndrome.
2
Evaluate each finding to distinguish expected postoperative occurrences from life-threatening complications.
Restlessness, hypertension with bradycardia, and headache with emesis are abnormal and indicate a systemic crisis. Bladder spasms and small blood clots are expected findings.
The PN must prioritize findings that threaten the client's airway, breathing, circulation, or neurological status.
3
Synthesize the abnormal findings to identify the underlying physiological adaptation failure.
The combination of neurological changes (restlessness, confusion, headache, emesis) and hemodynamic changes (hypertension, bradycardia) points to dilutional hyponatremia and fluid volume overload (TURP syndrome).
During a TURP, irrigation fluid can be rapidly absorbed into the venous system, causing severe fluid shifts and electrolyte imbalances that require immediate emergency intervention.

Key Concept

TURP syndrome (dilutional hyponatremia and fluid volume overload)
Question 568Question →

A 54-year-old client is receiving continuous intravenous normal saline and has a nasogastric tube set to low intermittent suction to manage a mechanical bowel obstruction. The practical nurse reviews the morning laboratory results, noting a serum potassium level of 2.8 mEq/L and a serum sodium level of 138 mEq/L. The client reports severe muscle weakness and a "racing" heartbeat. Which action should the practical nurse take first?

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Answer: Notify the registered nurse immediately regarding the laboratory results and cardiac symptoms.

Answer

Notify the registered nurse immediately regarding the laboratory results and cardiac symptoms.
A serum potassium level of 2.8 mEq/L is critically low (normal is 3.5-5.0 mEq/L) and places the client at immediate risk for life-threatening cardiac dysrhythmias, which is evidenced by the client's report of a racing heartbeat. The practical nurse must prioritize communicating this critical finding to the registered nurse or healthcare provider to facilitate immediate medical intervention.

Step-by-Step Solution

1
Analyze the laboratory results provided in the scenario.
The serum sodium of 138 mEq/L is normal, but the serum potassium of 2.8 mEq/L is critically low (the normal range is typically 3.5 to 5.0 mEq/L).
Identifying abnormal data is the first step in recognizing risk potential and prioritizing client care.
2
Correlate the client's symptoms with the abnormal laboratory findings.
The client's muscle weakness and racing heartbeat are classic signs of severe hypokalemia, indicating potential cardiac dysrhythmias.
Connecting physiological symptoms to laboratory data determines the clinical urgency of the situation.
3
Determine the priority nursing action based on the practical nurse's scope of practice.
The practical nurse must immediately escalate this critical finding to the registered nurse or healthcare provider.
Prompt communication is required to initiate life-saving medical interventions, such as controlled potassium replacement and continuous cardiac monitoring.

Key Concept

Recognizing and Escalating Critical Laboratory Values
Question 569Question →

A practical nurse is preparing to administer a prescribed liquid medication via a percutaneous endoscopic gastrostomy (PEG) tube to a client receiving continuous enteral feedings. The continuous feeding has been paused. Arrange the following steps for medication administration in the correct chronological order.

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Answer

The correct sequence is: 1) Elevate the head of the bed, 2) Aspirate to check residual, 3) Flush with water, 4) Administer the medication, and 5) Flush again with water.
To safely administer a medication via a PEG tube, the practical nurse must prioritize airway protection by first elevating the head of the bed. Next, verifying the residual volume ensures the stomach is not dangerously full. Flushing with water then clears the tube and confirms patency before pouring the medication into the syringe barrel for gravity administration. Finally, a concluding flush ensures all the medication reaches the stomach and keeps the tube clear of residue.

Step-by-Step Solution

1
Elevate the head of the bed.
The client is positioned safely.
Maintaining an upright position of at least 30 degrees minimizes the risk of aspiration during and after administration.
2
Aspirate stomach contents.
Gastric residual volume is measured.
Checking residual volume ensures the stomach is not overly distended, which could lead to vomiting or regurgitation.
3
Flush the tube with 30 mL of sterile water.
The tube is cleared of feeding formula.
Flushing establishes patency and prevents chemical interactions between the feeding formula and the medication.
4
Administer the liquid medication.
The medication enters the stomach via gravity.
Gravity administration prevents excessive pressure that could damage the tube or cause discomfort.
5
Flush the tube again with 15 to 30 mL of sterile water.
The tube is completely cleared of the medication.
The final flush delivers the remaining medication in the tube into the stomach and prevents future occlusions.

Key Concept

Safe enteral medication administration requires verifying placement, ensuring patency, preventing formula-drug interactions, and minimizing aspiration risk.
Question 570Question →

An 82-year-old client was admitted to the medical unit two days ago for treatment of a severe urinary tract infection. The client, who had been completely alert and oriented since admission, is suddenly restless, unable to state their current location, and attempting to pull out their intravenous (IV) catheter. The client's baseline blood pressure on admission was 142/84 mm Hg. Current data collection reveals a blood pressure of 100/60 mm Hg, heart rate of 112 beats/min, respiratory rate of 24 breaths/min, and a temperature of 97.2°F (36.2°C). Which action is the priority for the practical nurse?

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Answer: Notify the registered nurse immediately regarding the acute change in mental status and vital sign trends.

Answer

Notify the registered nurse immediately regarding the acute change in mental status and vital sign trends.
The correct action is to immediately notify the registered nurse. The client is demonstrating classic signs of early septic shock: a significant decrease in blood pressure from their baseline, tachycardia, tachypnea, and a sudden alteration in mental status. In older adults, sudden restlessness or confusion is frequently the first presenting sign of a severe physiological complication like systemic infection or hypoxia. The practical nurse must prioritize recognizing these subtle but critical cues and escalating care to prevent complete hemodynamic collapse.

Step-by-Step Solution

1
Analyze the client's current mental status against their baseline.
The client has transitioned from alert and oriented to confused and restless.
Sudden changes in level of consciousness in older adults are critical early indicators of systemic issues like hypoxia, infection, or decreased cerebral perfusion.
2
Compare the current vital signs to the admission baseline data.
The blood pressure has dropped significantly (systolic down 42 points), heart rate is elevated (112), and respiratory rate is elevated (24). Temperature is slightly subnormal, which can occur in sepsis.
Recognizing relative hypotension (a drop from the client's specific baseline) is essential, rather than relying solely on standard reference ranges.
3
Synthesize the data to determine the underlying physiological process.
The combination of the UTI history, altered mental status, relative hypotension, tachycardia, and tachypnea strongly suggests the client is entering early septic shock.
Identifying the pattern of impending shock determines the urgency of the required response.
4
Determine the priority nursing intervention within the practical nurse scope of practice.
The situation requires immediate escalation to the registered nurse or rapid response team.
Hemodynamic instability requires rapid assessment, fluid resuscitation, and potential medication administration that falls under RN and provider responsibilities.

Key Concept

Recognition of Early Septic Shock and Borderline Vitals in Older Adults
Question 571Question →

A practical nurse is preparing to administer a prescribed bolus enteral feeding via a gastrostomy tube to an adult client. Arrange the following actions in the correct chronological sequence.

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Answer

The correct sequence is to first elevate the head of the bed, then check the gastric residual, flush the tube, administer the feeding formula, and finally flush the tube again.
Safe administration of enteral feedings requires a strict sequence to prevent complications, primarily aspiration. The client must first be positioned upright. Next, the nurse must assess gastrointestinal tolerance by checking residual volume. Once tolerance is established, the tube is flushed to ensure patency. The feeding is then administered, followed immediately by a final flush to maintain tube patency and hygiene.

Step-by-Step Solution

1
Elevate the head of the bed.
The client is placed in a semi-Fowler's or Fowler's position.
This utilizes gravity to keep gastric contents in the stomach, minimizing the risk of reflux and aspiration during the procedure.
2
Check gastric residual volume.
The nurse determines how much formula remains in the stomach from prior feedings.
This assesses gastrointestinal tolerance; a high residual indicates delayed emptying and a high risk for aspiration if more feeding is added.
3
Perform the initial flush.
The tube is cleared with water.
This verifies that the tube is patent and functioning properly before administering a thicker substance.
4
Administer the feeding formula.
The client receives the prescribed nutrition.
Gravity feeding allows for a controlled rate, reducing the risk of nausea, cramping, and diarrhea.
5
Perform the final flush.
The tube is cleared of formula residue.
Formula left in the tube can solidify, causing blockages, and provides a medium for bacterial proliferation.

Key Concept

Enteral Nutrition Administration and Aspiration Precautions
Question 572Question →

A client is transferred to the surgical unit after undergoing a right modified radical mastectomy with axillary lymph node dissection. When assisting the client into a resting position in bed, which action regarding the right arm is most appropriate?

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Answer: Support the arm on pillows so it rests higher than the level of the heart.

Answer

Support the arm on pillows so it rests higher than the level of the heart.
The correct action is to elevate the affected arm on pillows above the level of the heart. Because axillary lymph nodes have been removed, normal lymphatic drainage is severely compromised. Elevating the arm uses gravity to promote venous and lymphatic return, which prevents painful swelling (lymphedema) and enhances overall client comfort.

Step-by-Step Solution

1
Identify the physiological impact of the surgical procedure.
An axillary lymph node dissection disrupts the normal lymphatic drainage pathways in the affected arm, predisposing the client to lymphedema.
Understanding the anatomical changes helps prioritize the correct preventative care measure.
2
Determine the basic care and comfort goal for this specific postoperative period.
The goal is to prevent fluid pooling, minimize swelling, and maintain joint mobility without causing strain.
Excessive swelling causes severe discomfort, compromises tissue healing, and can lead to long-term complications.
3
Select the positioning technique that best achieves this goal.
Elevating the arm above the level of the right atrium (heart) enlists gravity to assist the compromised lymphatic system in returning fluid to central circulation.
Gravity is the most effective passive mechanism to reduce peripheral edema when normal lymphatic pathways are absent or healing.

Key Concept

Post-Mastectomy Care and Lymphedema Prevention
Question 573Question →

A practical nurse is preparing to administer a scheduled dose of oral digoxin to an adult client. Prior to administration, the nurse auscultates the client's apical pulse and notes a rate of 5454 beats per minute. Which of the following actions should the practical nurse take?

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Answer: Withhold the medication and report the heart rate to the registered nurse.

Answer

Withhold the medication and report the heart rate to the registered nurse.
Digoxin is a cardiac glycoside that slows the heart rate. The standard nursing safety protocol is to withhold the medication and notify the supervising registered nurse or healthcare provider if an adult client's apical pulse is less than 6060 beats per minute, as administering it could cause severe, symptomatic bradycardia or indicate medication toxicity.

Step-by-Step Solution

1
Analyze the client's pre-administration clinical data.
The client has an apical pulse of 5454 beats per minute.
Cardiac glycosides like digoxin require a current heart rate assessment before every dose.
2
Compare the assessment finding to standard safe administration parameters.
The heart rate of 5454 beats per minute is below the standard adult minimum threshold of 6060 beats per minute.
Digoxin exerts a negative chronotropic effect, meaning it further slows down the heart rate.
3
Identify the safest action within the practical nurse's scope of practice.
The nurse must safely withhold the medication and escalate the finding.
Administering the medication could cause harm, and altering the dose is outside the PN scope. The RN or provider must evaluate the client.

Key Concept

Pre-administration Assessment and Safe Medication Practices for Cardiac Glycosides
Question 574Question →

A client in an outpatient clinic has a new prescription for amoxicillin oral suspension 400 mg400\text{ mg} twice daily. The clinic stock contains amoxicillin in a concentration of 250 mg/5 mL250\text{ mg} / 5\text{ mL}. How many mL will the practical nurse administer for a single dose? (Record the answer to the nearest whole number. Do not include units in the answer.)

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Answer: 8

Answer

8
The practical nurse uses the standard dosage calculation formula: Desired doseAvailable dose×Quantity\frac{\text{Desired dose}}{\text{Available dose}} \times \text{Quantity}. The prescribed dose is 400 mg400\text{ mg}, and the available concentration is 250 mg250\text{ mg} per 5 mL5\text{ mL}. Plugging these values into the formula gives 400250×5=1.6×5=8 mL\frac{400}{250} \times 5 = 1.6 \times 5 = 8\text{ mL}. The nurse should administer 8 mL8\text{ mL} for a single dose.

Step-by-Step Solution

1
Identify the prescribed (desired) dose.
400 mg400\text{ mg}
This is the amount of medication the provider has ordered for one dose.
2
Identify the concentration of the medication on hand (have) and the volume it comes in (quantity).
250 mg250\text{ mg} per 5 mL5\text{ mL}
This determines the strength of the available liquid medication.
3
Apply the dosage calculation formula: DesiredHave×Quantity\frac{\text{Desired}}{\text{Have}} \times \text{Quantity}.
400250×5=8 mL\frac{400}{250} \times 5 = 8\text{ mL}
This calculation yields the exact volume needed to deliver the prescribed 400 mg400\text{ mg} dose.

Key Concept

Dosage calculation for oral liquid medications
Question 575Question →

A practical nurse is preparing to provide oral hygiene to a client who remains unconscious following a prolonged surgical procedure. Arrange the following actions in the chronological order they must be performed to maintain client safety. (Assume hand hygiene and donning of gloves are complete.)

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Answer

The correct sequence prioritizes airway safety: position the client side-lying, place protective linens/basin, safely open the mouth with a tongue blade, perform the oral cleansing, and finally moisturize the lips.
When providing basic care to an unconscious client, the absolute priority is maintaining a patent airway and preventing aspiration. Placing the client in a side-lying position must occur before any other step. After safety is established, the nurse protects the bed and clothing, safely gains access to the mouth to avoid reflex injuries, performs the actual cleansing, and completes the procedure by applying moisturizer for comfort.

Step-by-Step Solution

1
Ensure an open and safe airway.
The client is positioned on their side.
A side-lying position uses gravity to help oral secretions and cleaning fluids drain out of the mouth, significantly reducing the risk of aspiration into the lungs.
2
Protect the client and bedding.
A towel and emesis basin are placed in position.
Gathering and placing supplies keeps the client clean, dry, and comfortable during the procedure.
3
Gain safe access to the oral cavity.
A padded tongue blade is used to separate the upper and lower teeth.
An unconscious client may have a strong involuntary bite reflex. A padded tongue blade safely keeps the mouth open without risking injury to the nurse's fingers or the client's teeth.
4
Perform the hygiene procedure.
The oral cavity is cleansed.
Thorough cleaning removes plaque and bacteria, which prevents hospital-acquired infections like pneumonia.
5
Provide final skin care.
Water-soluble moisturizer is applied to the lips.
Unconscious clients often breathe through their mouths, leading to dry and cracked lips. A water-soluble product provides safe moisture.

Key Concept

Prioritization of Airway Protection During Basic Care
Estimated Time:1m 30s
Question 576Question →

A practical nurse is providing basic care for a client who is on prolonged bed rest following an abdominal surgery. Which nursing actions will best promote client comfort and maintain skin integrity? Select all that apply.

Select all that apply

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Answer: Keep the bottom bed sheets tight and free of wrinkles.; Reposition the client from side to side at least every two hours.; Place a pillow under the client's lower legs to suspend the heels off the mattress.

Answer

The correct actions are keeping bed sheets tight and wrinkle-free, repositioning every two hours, and placing a pillow under the lower legs to suspend the heels.
Promoting client comfort and skin integrity involves minimizing pressure, friction, and shearing forces. Keeping bed linens tight and wrinkle-free eliminates physical irritants that can damage fragile skin. Turning and repositioning the client at least every two hours ensures that blood flow is restored to tissues overlying bony prominences. Placing a pillow under the calves effectively floats the heels, completely removing pressure from this highly vulnerable area.

Step-by-Step Solution

1
Identify the goal of care based on the stem.
The goal is to promote comfort and maintain skin integrity for a bedbound postoperative client.
Understanding the primary objective helps filter out actions that might cause harm or are ineffective.
2
Evaluate each option against basic care principles for skin integrity and safety.
Wrinkle-free sheets, frequent turning, and heel suspension are established, safe methods for preventing pressure injuries.
Evidence-based practice dictates these standard interventions for immobile clients.
3
Identify contraindicated positioning techniques.
Raising the knee gatch and keeping the client completely flat are identified as harmful practices.
These positions compromise circulation and respiratory function, violating basic safety and comfort principles.

Key Concept

Basic Care and Comfort: Skin Integrity and Positioning
Question 577Question →

A client prescribed oral metoprolol for hypertension is resting in bed. Before giving the morning dose, the practical nurse obtains an apical pulse of 48 beats/minute48 \text{ beats/minute}. What is the most appropriate action for the nurse to take?

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Answer: Withhold the scheduled dose and promptly notify the registered nurse.

Answer

The practical nurse should withhold the metoprolol and notify the registered nurse because the client's heart rate is below the safe administration threshold.
Metoprolol is a beta-adrenergic blocking agent that decreases both blood pressure and heart rate. The standard of care requires withholding the medication if the apical pulse is less than 60 beats/minute60 \text{ beats/minute} and reporting the finding to the supervising registered nurse or healthcare provider so they can provide further clinical judgment.

Step-by-Step Solution

1
Evaluate the client's current apical pulse against the expected parameters for the prescribed medication.
The pulse of 48 beats/minute48 \text{ beats/minute} is below the standard 60 beats/minute60 \text{ beats/minute} threshold for administering a beta-blocker.
Metoprolol decreases heart rate; giving it to a bradycardic client can cause severe hemodynamic compromise.
2
Determine the appropriate intervention based on the practical nurse's scope of practice.
The correct action is to withhold the dose and escalate the abnormal finding.
The practical nurse must recognize abnormal vital signs, withhold potentially harmful medications, and report to the supervising registered nurse or provider.

Key Concept

Pre-administration vital sign parameters for beta-blockers and practical nurse scope of practice.
Question 578Question →

A client with a suspected lower respiratory tract infection requires a sputum specimen for culture and sensitivity testing. To minimize the risk of sample contamination with oral flora, which sequence of steps should the practical nurse follow? Arrange the actions in the correct chronological order.

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Answer

The correct sequence begins with oral preparation (rinsing), followed by lung expansion (deep breathing), mobilization of secretions (coughing), collection (expectorating), and finally securing the specimen (sealing and labeling).
Following the chronological order of rinsing the mouth, performing deep breathing, coughing deeply, expectorating into the container, and immediately sealing it ensures the specimen is uncontaminated and accurately reflects the lower respiratory tract environment.

Step-by-Step Solution

1
Instruct the client to rinse the mouth with plain water without swallowing.
Reduces oral flora in the mouth.
Decreases the risk of contaminating the specimen with normal mouth bacteria.
2
Ask the client to take several slow, deep breaths to expand the lungs.
Maximizes lung expansion.
Helps loosen secretions in the lower respiratory tract.
3
Direct the client to perform a deep, forceful cough to mobilize lower airway secretions.
Moves sputum upward.
Ensures the sample is from the lungs, not just saliva from the upper airway.
4
Have the client expectorate the mobilized secretions directly into the sterile container.
Captures the sterile specimen.
Avoids outside contamination by collecting directly into the sterile environment.
5
Secure the lid on the container immediately and apply the client's identification label.
Seals and identifies the sample.
Maintains specimen integrity and ensures correct client identification for laboratory processing.

Key Concept

To ensure diagnostic accuracy and reduce the risk of misdiagnosis due to sample contamination, a sputum specimen must be collected from the lower respiratory tract using a sterile technique and proper client preparation.
Question 579Question →

A practical nurse (PN) is assisting a healthcare provider with a bedside thoracentesis for a client who has a large pleural effusion. To ensure client safety and reduce the risk of procedural complications, in what order should the PN perform the following actions? (Arrange the steps from first to last.)

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: 1) Obtain baseline vital signs and respiratory assessment, 2) Position the client upright and leaning forward, 3) Instruct the client to remain still and not cough, 4) Apply a sterile dressing to the puncture site, and 5) Auscultate bilateral breath sounds.
Safe assistance during a thoracentesis follows a strict logical flow to reduce risk: establishing a clinical baseline, physically preparing the client via positioning, preventing injury during the active procedure by teaching the client not to move, immediately securing the skin breach afterward to prevent air entry, and finally evaluating the client for procedural complications.

Step-by-Step Solution

1
Obtain baseline vital signs and perform a focused respiratory assessment.
Pre-procedure baseline clinical data is established.
Accurate pre-procedure vitals and breath sounds are necessary to recognize subtle physiological changes or respiratory distress later.
2
Position the client sitting upright on the edge of the bed while leaning forward over an overbed table.
The client is secured in the orthopneic position.
This specific position opens the intercostal spaces, giving the provider clear access to the pleural fluid and minimizing the risk of visceral organ injury.
3
Instruct the client to remain completely still and refrain from coughing or talking during needle insertion.
The client understands how to cooperate safely during the invasive portion of the procedure.
Any sudden movement, such as coughing or taking a deep breath, can shift the lung tissue into the path of the needle, risking a traumatic pneumothorax.
4
Apply a sterile dressing to the puncture site once the needle is withdrawn.
The puncture site is immediately sealed and protected.
Immediate application of a sterile dressing prevents environmental contamination and blocks atmospheric air from entering the negative-pressure pleural cavity.
5
Auscultate bilateral breath sounds and monitor for asymmetrical chest expansion.
The client's post-procedure respiratory status is evaluated.
Comparing these findings to the baseline assessment helps the nurse rapidly identify complications, such as a pneumothorax or hemothorax, if breath sounds are diminished on the affected side.

Key Concept

Reduction of Risk Potential: Assisting with Thoracentesis
Question 580Question →

A practical nurse (PN) is assigned to care for a client who has a prescription for a scheduled dose of oral lithium carbonate. Prior to administration, the PN reviews the client's most recent laboratory report, which reveals a serum lithium level of 2.3 mEq/L. Which of the following actions should the PN take in response to this finding?

Show answer & explanation

Answer: Withhold the medication and promptly notify the supervising registered nurse or healthcare provider.

Answer

The correct action is to withhold the medication and promptly notify the supervising registered nurse or healthcare provider.
The therapeutic range for serum lithium is generally 0.6 to 1.2 mEq/L. A level of 2.3 mEq/L indicates severe toxicity. The priority and safest action for the practical nurse is to withhold the dose to prevent further harm and immediately report the critical laboratory value to the supervising registered nurse or healthcare provider for further medical intervention.

Step-by-Step Solution

1
Analyze the client's laboratory results in relation to the prescribed medication.
The serum lithium level of 2.3 mEq/L is identified as being significantly above the normal therapeutic range (0.6 to 1.2 mEq/L).
Safe medication administration requires knowing therapeutic ranges and recognizing laboratory values that indicate drug toxicity.
2
Determine the appropriate nursing intervention based on the practical nursing scope of practice.
The medication must be withheld to prevent further toxicity, and the abnormal finding must be escalated.
A level of 2.3 mEq/L indicates severe lithium toxicity, which is a critical finding that requires immediate medical evaluation and intervention.

Key Concept

Recognizing medication toxicity and escalating critical laboratory values.
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