Physiological Integrity

Following an abdominal hysterectomy, a client is transferred to the surgical unit. During the initial data collection, the practical nurse notes a heart rate of 114 beats/min and a blood pressure of 94/58 mm Hg. The client states, 'I feel a little nauseous and my incision hurts.' Which action should the nurse take first?

A practical nurse (PN) is collecting data on a client admitted with a severe exacerbation of ulcerative colitis. The client has had several large, bloody bowel movements over the past four hours. The client's current vital signs are: heart rate 112 beats/min, blood pressure 106/68 mm Hg, and respiratory rate 22 breaths/min. The client's admission vital signs were: heart rate 78 beats/min, blood pressure 134/82 mm Hg, and respiratory rate 16 breaths/min. The client appears restless and reports abdominal cramping. Which action should the PN take first?

A practical nurse (PN) provides care for a 75-year-old resident in a skilled nursing facility who is receiving oral antibiotics for a lower urinary tract infection. During the afternoon shift, the PN discovers the resident is unusually restless, picking at their clothing, and breathing at a rate of 26 breaths/min. Which actions should the PN prioritize? Select all that apply.

An older adult client is resting in the surgical unit following a left cataract extraction. The client reports mild postoperative discomfort and asks to be repositioned in bed. Which positioning strategy should the licensed practical nurse implement?

Four hours after a percutaneous liver biopsy, an assigned client reports the new onset of right shoulder pain. The client's baseline vital signs were a blood pressure of $134/82 \text{ mm Hg}$ and a heart rate of $76 \text{ beats/min}$. The licensed practical nurse (LPN/LVN) assesses current vital signs, noting a blood pressure of $108/72 \text{ mm Hg}$ and a heart rate of $114 \text{ beats/min}$. Which action must the nurse take first?

While monitoring an older adult client who is being treated with a continuous intravenous heparin infusion for a pulmonary embolism, a practical nurse (PN) reviews the trend of the client's vital signs. Over the past four hours, the client's heart rate has climbed from $78\text{ bpm}$ to $112\text{ bpm}$, and the blood pressure has trended downward from $134/82\text{ mmHg}$ to $104/68\text{ mmHg}$. The client currently reports feeling faint. What is the priority action for the PN?

A practical nurse is preparing to provide oral hygiene for a client who is unresponsive following a severe traumatic brain injury. In what order should the nurse perform the following actions? (Arrange the steps from first to last.)

A practical nurse enters the room of a client receiving intravenous fluids via a central venous catheter. The nurse observes that the intravenous tubing has become disconnected from the catheter hub. The client is suddenly grasping their chest, gasping for air, and appears cyanotic. In which order should the nurse perform the following emergency actions to mitigate the risk of a fatal complication? Arrange the steps from first (highest priority) to last.

A practical nurse is caring for a client who is 4 hours postoperative following an open cholecystectomy. The registered nurse (RN) is managing the client's continuous intravenous (IV) fluids and delegates the administration of scheduled oral metoprolol, oral oxycodone, and a PRN dose of IV push ondansetron to the practical nurse. The client's current vital signs are blood pressure 86/52 mmHg, heart rate 118 bpm, and respiratory rate 16 breaths/min. The client reports a pain level of 7 on a 0 to 10 scale. Which action should the practical nurse take first?

A practical nurse is providing postoperative care for a client who recently returned to the unit following a right-sided cataract extraction. Which basic care and positioning interventions should the nurse implement to prevent complications? Select all that apply.

The nursing care team is managing the daily needs of a client who is non-ambulatory and receiving continuous enteral feedings via a gastrostomy tube following a recent abdominal surgery. When implementing basic hygiene and comfort measures, which actions are appropriate for the practical nurse (PN) to perform? Select all that apply.

A practical nurse (PN) is reviewing the morning clinical data for a client who is $2$ days postoperative following a total hip arthroplasty. The client is scheduled to receive subcutaneous enoxaparin, oral celecoxib, and oral pantoprazole.

Morning clinical data:
- Blood pressure: $96/58\text{ mmHg}$
- Heart rate: $112\text{ beats/min}$
- Hemoglobin: $10.4\text{ g/dL}$
- Platelet count: $85,000/\text{mm}^3$

Which action should the PN take FIRST?

A practical nurse (PN) is assigned to a client in a neurological rehabilitation unit. The client has a new prescription for phenytoin $5\text{ mg/kg/day}$ by mouth, to be given in two equally divided doses. The client's current weight is $176\text{ lb}$. The facility pharmacy provides phenytoin oral suspension at a concentration of $125\text{ mg}/5\text{ mL}$. Which of the following actions represents safe nursing practice by the PN?

An LPN/LVN is caring for a client with chronic pain who has a new prescription for a fentanyl transdermal patch. The client currently has an older patch in place on their right upper chest. Arrange the following actions in the correct chronological order to safely administer this medication.

A client who is experiencing a productive cough has a prescription for guaifenesin $400\text{ mg}$ by mouth every $4\text{ hours}$. The facility pharmacy dispenses guaifenesin liquid with a labeled concentration of $200\text{ mg}$ per $10\text{ mL}$. How many milliliters $(\text{mL})$ should the nurse administer for a single dose?

While evaluating a client who returned from the post-anesthesia care unit 4 hours ago following a subtotal thyroidectomy, a practical nurse notes that the client appears increasingly restless. The client states, "My neck feels a little tight." The current vital signs reveal a heart rate of 116 beats/minute, a blood pressure of 96/58 mm Hg, and a respiratory rate of 22 breaths/minute. Which action is the priority for the practical nurse?

A practical nurse is reinforcing discharge instructions for a client who underwent a left cataract extraction earlier in the day. Which instruction regarding resting positions should the nurse provide to promote comfort and prevent complications?

A practical nurse (PN) is preparing to administer a scheduled dose of oral amoxicillin to a 3-year-old toddler weighing $15\text{ kg}$ who was admitted with a severe respiratory infection. Which of the following actions demonstrate safe pharmacological practice by the PN? Select all that apply.

An older adult client is resting in a surgical recovery unit two hours after a right-sided cataract extraction with intraocular lens implantation. The client requests assistance with morning hygiene, getting dressed, and finding a comfortable resting position. Which basic care actions should the nurse implement? Select all that apply.

A practical nurse (PN) is caring for an older adult client who has a history of heart failure, asthma, and gastroesophageal reflux disease. The PN is reviewing the medication administration record. Which actions by the PN demonstrate safe pharmacological practice? (Select all that apply.)