Physiological Integrity

1313 questions

All types1,313 Multiple choice672 Multiple select289 Numeric68 Ordering284

An adult client is receiving care for an acute asthma exacerbation and has a comorbidity of essential hypertension. The medication administration record indicates a new prescription for oral propranolol $40\text{ mg}$ twice daily. The unit's automated medication dispenser supplies $20\text{ mg}$ scored tablets. The client's current assessment reveals audible expiratory wheezing, an $O_2$ saturation of $90\%$ on room air, a heart rate of $98\text{ bpm}$ , and a blood pressure of $138/86\text{ mmHg}$ . Based on this clinical data, what is the most appropriate action for the practical nurse (PN) to take?

Withhold the medication and immediately notify the registered nurse (RN) or healthcare provider.

Administer

0.5

tablets of propranolol to cautiously manage the client's blood pressure.

Administer

2

tablets of propranolol to address the tachycardia, as the heart rate is the highest priority.

Administer

2

tablets of propranolol and independently perform a comprehensive respiratory assessment to monitor for bronchospasm.

Show answer & explanation

Answer: Withhold the medication and immediately notify the registered nurse (RN) or healthcare provider.

Answer

The PN must withhold the propranolol and immediately report the prescription to the RN or healthcare provider due to the risk of severe bronchoconstriction.

Propranolol is a non-selective beta-blocker that inhibits both beta-1 (cardiac) and beta-2 (pulmonary) receptors. Blocking beta-2 receptors leads to bronchoconstriction. In a client already experiencing an acute asthma exacerbation with active wheezing and hypoxia, this medication can trigger a fatal respiratory crisis. The safest and most appropriate action within the PN's scope of practice is to withhold the scheduled dose and immediately notify the RN or healthcare provider to have the prescription changed.

Step-by-Step Solution

Analyze the client's current physiological data.

The client has an acute asthma exacerbation with active airway compromise (wheezing, SpO2 90%).

Establishing the current baseline is required before safely administering any medication.

Identify the pharmacological class and mechanism of the prescribed medication.

Propranolol is identified as a non-selective beta-adrenergic antagonist.

Understanding the drug class reveals its systemic effects, specifically its action on both beta-1 (cardiac) and beta-2 (pulmonary) receptors.

Synthesize the clinical data with the medication mechanism to determine safety.

Blocking beta-2 receptors in the lungs prevents bronchodilation and induces bronchospasm, which is strictly contraindicated in acute asthma.

Administering the medication would directly worsen the client's already compromised airway.

Determine the appropriate intervention within the PN scope of practice.

The PN withholds the dose and escalates the finding to the RN or provider.

The PN is responsible for recognizing critical contraindications, safeguarding the client, and communicating urgent findings to the supervising RN or prescribing provider.

Key Concept

Contraindications of non-selective beta-blockers in respiratory compromise and PN scope of practice in medication safety.

Estimated Time:1m 30s

Question 582Question →

It is time for a client's scheduled transdermal fentanyl patch replacement. To ensure safe medication administration, arrange the following steps in the correct chronological sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence begins with verifying client identity, followed by removing the old patch while wearing gloves, preparing a new site, labeling the new patch, and finally applying it to the skin.

Safe transdermal medication administration requires strict adherence to a specific procedural sequence. Verifying identity ensures the intervention reaches the correct client. Removing the old patch first (while wearing gloves) prevents toxicity and nurse exposure. Preparing the new site promotes proper absorption and prevents skin breakdown. Labeling the patch prior to application prevents client discomfort from writing pressure. Finally, applying firm pressure secures the patch for its duration of use.

Step-by-Step Solution

Verify client identity and perform hand hygiene.

The correct client is confirmed and infection transmission risk is minimized.

This adheres to the basic rights of medication administration and standard safety precautions.

Don clean gloves and remove the old fentanyl patch.

The previous medication source is safely discontinued.

Gloves prevent the nurse from absorbing fentanyl dermally, and removing the old patch prevents accidental overdose.

Cleanse a new, hairless application site and let it dry.

A fresh area of skin is prepared for the new patch.

Rotating sites prevents skin breakdown. A clean, dry surface ensures the new patch will adhere properly and medication will absorb consistently.

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

The patch is clearly marked before it goes on the client's body.

Writing on the patch after application can cause discomfort and may unintentionally push a bolus of medication into the client's tissues.

Remove the protective liner, apply to the skin, and press firmly for 30 seconds.

The new fentanyl patch is securely attached and actively delivering medication.

Firm pressure, especially around the edges, ensures the adhesive matrix bonds tightly to the skin for the entire duration of the order.

Key Concept

Safe Administration of Transdermal Medications

Question 583Question →

A practical nurse is preparing to administer a scheduled dose of subcutaneous enoxaparin to a client who is two days postoperative following a left total knee arthroplasty. While reviewing the client's morning assessment data and electronic health record, which finding requires the nurse to withhold the medication and immediately escalate to the registered nurse?

A decrease in systolic blood pressure from

122 \text{ mm Hg}

108 \text{ mm Hg}

with a resting heart rate of

88 \text{ beats/minute}

An alert indicating that the client's identification barcode wristband was removed during morning hygiene care.

A client report of localized, throbbing incisional pain rated as a

5

on a

0

-to-

10

numerical scale.

A complete blood count indicating a platelet level of

42,000 \text{ /mm}^3

(

42 \times 10^9 \text{ /L}

Show answer & explanation

Answer: A complete blood count indicating a platelet level of $42,000 \text{ /mm}^3$ ( $42 \times 10^9 \text{ /L}$ ).

Answer

The correct action is to withhold the medication due to the complete blood count indicating a platelet level of 42,000 /mm³ (42 × 10⁹ /L).

The correct answer identifies a critical laboratory value that directly contraindicates the prescribed medication. Enoxaparin is an anticoagulant. Administering this medication to a client with a platelet count of

42,000 \text{ /mm}^3

(normal is

150,000

400,000 \text{ /mm}^3

) places the client at imminent risk for severe, potentially fatal hemorrhage. The practical nurse must prioritize risk reduction by holding the dose and immediately notifying the registered nurse or healthcare provider.

Step-by-Step Solution

Analyze the prescribed medication and its primary physiological mechanism.

Enoxaparin is a low-molecular-weight heparin used for anticoagulation to prevent deep vein thrombosis.

Understanding the drug's mechanism highlights its primary adverse effect: increased bleeding risk.

Evaluate the clinical significance of each assessment finding.

The platelet count of

42,000 \text{ /mm}^3

is critically low (normal is

150,000

400,000 \text{ /mm}^3

Platelets are essential for blood clotting; severe thrombocytopenia creates an imminent bleeding risk.

Synthesize the findings to prioritize client safety and determine the required nursing action.

Administering an anticoagulant to a severely thrombocytopenic client is directly contraindicated.

The practical nurse must apply principles of risk reduction by holding the dose and immediately notifying the registered nurse.

Key Concept

Correlating critical laboratory values (thrombocytopenia) with pharmacological interventions (anticoagulants) to reduce the risk of severe complications.

Estimated Time:1m 30s

Question 584Question →

A practical nurse (PN) is preparing to administer scheduled morning oral medications to a client on a medical-surgical unit. Which actions must the PN take to ensure safe medication administration? Select all that apply.

Select all that apply

Ask the client to state their full name and date of birth.

Confirm the client's identity by checking the room and bed number.

Administer the medication without scanning the client's barcode if the client is well known to the nurse.

Document the medication administration in the electronic health record immediately after the client takes the medication.

Review the client's allergy band and confirm allergy status verbally prior to administration.

Show answer & explanation

Answer: Ask the client to state their full name and date of birth.; Document the medication administration in the electronic health record immediately after the client takes the medication.; Review the client's allergy band and confirm allergy status verbally prior to administration.

Answer

The correct actions are to ask the client to state their full name and date of birth, document the administration immediately after giving the medication, and review the allergy band while confirming verbally.

Safe medication administration requires strict adherence to safety protocols. Asking the client to state their full name and date of birth utilizes two approved patient identifiers, fulfilling the 'right client' check. Documenting immediately after administration ensures the medical record is accurate and prevents duplicate dosing by other healthcare staff. Checking the allergy band and verbally confirming allergies is a crucial assessment step that prevents adverse allergic reactions.

Step-by-Step Solution

Review the established rights of medication administration.

Identify that the right client, right documentation, and right assessment (including allergies) are critical components of safety.

Adhering to these core principles prevents potentially fatal medication errors.

Evaluate each option against safe medication administration protocols.

Identifying the client with two distinct personal identifiers, documenting immediately after administration, and verifying allergies are safe practices. Using room numbers or bypassing barcode scanning are unsafe practices.

Safety protocols require active verification and strictly prohibit the use of environmental markers (like room numbers) or bypassing automated safety checks.

Key Concept

Rights of Medication Administration and Patient Safety Protocols

Question 585Question →

Following a percutaneous liver biopsy, a client is transferred back to the medical unit. To promote comfort and minimize the risk of internal bleeding, which position should the practical nurse assist the client into?

Left side-lying position with the head of the bed elevated 45 degrees

Right side-lying position with a small towel placed under the puncture site

Supine position with the lower extremities elevated on two pillows

High-Fowler's position with the knees comfortably flexed

Show answer & explanation

Answer: Right side-lying position with a small towel placed under the puncture site

Answer

The client should be assisted into a right side-lying position with a small towel placed under the puncture site to apply direct pressure to the liver.

The liver is a highly vascular organ located in the right upper quadrant of the abdomen. After a percutaneous liver biopsy, the primary complication to prevent is hemorrhage. Assisting the client into a right side-lying position utilizes the client's own body weight to apply direct pressure to the puncture site, promoting hemostasis and minimizing the risk of bleeding.

Step-by-Step Solution

Identify the anatomical location of the organ involved in the procedure.

The liver is located in the right upper quadrant of the abdomen.

Knowing the anatomy determines where pressure needs to be applied post-procedure.

Determine the primary physiological risk following a percutaneous biopsy.

The most significant risk is internal hemorrhage or bleeding from the puncture site.

The liver is a highly vascular organ, making bleeding a primary concern.

Select the nursing intervention that directly mitigates this risk.

Applying direct physical pressure to the puncture site.

Pressure promotes hemostasis (blood clotting) and stops active bleeding.

Choose the client position that naturally achieves this intervention.

Right side-lying position.

Using the client's own body weight against the mattress applies continuous, even pressure to the liver capsule.

Key Concept

Post-procedure positioning to prevent bleeding

Question 586Question →

An individual is recovering on the surgical unit twelve hours after an open cholecystectomy. The morning laboratory report indicates a hemoglobin of 8.2 g/dL (82 g/L). The practical nurse obtains the client's current vital signs, noting a heart rate of 114 beats per minute and a blood pressure of 98/60 mm Hg. Based on these findings, which action is the priority for the practical nurse?

Promptly notify the supervising registered nurse about the client's vital signs and the recent laboratory values

Document the data in the electronic health record, recognizing that a moderate decrease in hemoglobin is typical after abdominal surgery

Wait to reassess the heart rate and blood pressure in one hour, as mild tachycardia can commonly result from post-operative pain

Obtain the prescribed unit of packed red blood cells from the blood bank and independently initiate the transfusion

Show answer & explanation

Answer: Promptly notify the supervising registered nurse about the client's vital signs and the recent laboratory values

Answer

Promptly notify the supervising registered nurse about the client's vital signs and the recent laboratory values.

The client is exhibiting classic signs of hemorrhagic shock, specifically tachycardia and hypotension, combined with a significantly low hemoglobin level. The practical nurse must immediately escalate these life-threatening findings to the registered nurse for prompt intervention, as the client's condition is unstable and requires care beyond the practical nurse scope.

Step-by-Step Solution

Analyze the client's vital signs.

The heart rate of 114 beats per minute (tachycardia) and blood pressure of 98/60 mm Hg (hypotension) are identified as abnormal.

Recognizing deviations from normal vital sign ranges is the first step in identifying postoperative complications.

Evaluate the morning laboratory results in conjunction with the physical assessment data.

The significantly low hemoglobin of 8.2 g/dL aligns with the unstable vital signs.

Correlating laboratory data with clinical signs helps pinpoint the specific complication, which in this case points to acute blood loss.

Synthesize the findings to determine the immediate clinical risk.

The combination of tachycardia, hypotension, and low hemoglobin indicates a high risk for internal postoperative hemorrhage and hypovolemic shock.

Identifying the complication dictates the urgency of the required intervention.

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

The nurse must immediately escalate the situation to the registered nurse or healthcare provider.

Unstable clients requiring complex assessment, fluid resuscitation, and blood product administration must be managed by the registered nurse and provider.

Key Concept

Reduction of Risk Potential: Recognizing and escalating signs of postoperative hemorrhage

Question 587Question →

A client is recovering on a surgical step-down unit 24 hours after undergoing a left total pneumonectomy. The client requests assistance to shift positions for pressure relief and improved comfort. Which positioning action is most appropriate for this client?

Turn the client onto the right side and support the upper extremities with pillows.

Place the client in a strict supine position with the head of the bed completely flat.

Assist the client onto the left side with the head of the bed elevated 30 to 45 degrees.

Position the client prone with a small towel roll placed under the abdomen.

Show answer & explanation

Answer: Assist the client onto the left side with the head of the bed elevated 30 to 45 degrees.

Answer

Assist the client onto the left side with the head of the bed elevated 30 to 45 degrees.

Following a total pneumonectomy, the client should be positioned on the operative side (in this case, the left side) or supine with the head elevated. This specific positioning ensures that the single remaining healthy lung (the right lung) can expand fully without being restricted by the weight of the body. Furthermore, elevating the head of the bed 30 to 45 degrees promotes optimal diaphragmatic excursion and maximizes ventilation.

Step-by-Step Solution

Identify the surgical procedure and the affected side from the clinical scenario.

The client underwent a left total pneumonectomy (complete removal of the left lung).

The specific type and location of thoracic surgery dictate the mandatory postoperative positioning guidelines.

Determine the optimal positioning rules for a total pneumonectomy.

Clients must be positioned on their back (supine with elevation) or on the operative side.

Positioning on the operative side allows the remaining healthy lung to expand without being compressed by the body's weight, and it prevents fluid in the surgical stump from draining into the healthy lung.

Select the option that correctly applies these positioning rules.

The left side is the operative side. Placing the client in a semi-Fowler's position on the left side is correct.

This intervention maximizes respiratory function, promotes comfort, and ensures client safety.

Key Concept

Post-pneumonectomy positioning requires placing the client on the operative side to maximize the expansion of the remaining healthy lung.

Question 588Question →

A pediatric client weighing $35.2$ pounds is prescribed cefdinir $14\text{ mg/kg/day}$ orally, to be administered in two equally divided doses. The medication is supplied as a powder for oral suspension. The bottle instructions state: "Add $38\text{ mL}$ of purified water in two portions to yield $60\text{ mL}$ of suspension with a concentration of $125\text{ mg}/5\text{ mL}$ ." After correctly reconstituting the medication, how many mL should the practical nurse administer for a single dose? Record the answer to the nearest tenth. Do not include units in the answer.

Show answer & explanation

Answer: 4.5

Answer

4.5

To administer the correct dose, the practical nurse must systematically follow dosage calculation steps. First, the child's weight is converted to kilograms (

35.2 \div 2.2 = 16\text{ kg}

). Then, the total daily dose is calculated by multiplying the weight by the order (

16 \times 14 = 224\text{ mg/day}

). Because the medication is divided into two doses, the single dose is

112\text{ mg}

. Finally, the nurse uses the final reconstituted concentration of

125\text{ mg}/5\text{ mL}

to find the volume:

(112 \div 125) \times 5 = 4.48\text{ mL}

, which rounds to

4.5

. The instructions regarding

38\text{ mL}

and

60\text{ mL}

are necessary for pharmacy preparation but act as distractors during dose calculation.

Step-by-Step Solution

Convert the client's weight from pounds to kilograms.

16\text{ kg}

The prescribed medication dosage is based on kilograms (

14\text{ mg/kg/day}

Calculate the total daily dose in milligrams.

224\text{ mg/day}

Multiply the child's weight in kg (

16\text{ kg}

) by the daily dosage rate (

14\text{ mg/kg/day}

Determine the amount of medication needed for a single dose.

112\text{ mg/dose}

The prescription states the medication is to be administered in two equally divided doses (

224\text{ mg} \div 2

Calculate the volume of liquid needed for one dose.

4.48\text{ mL}

Using the concentration of the reconstituted suspension (

125\text{ mg}

5\text{ mL}

), use dimensional analysis or the desired/have formula:

\frac{112\text{ mg}}{125\text{ mg}} \times 5\text{ mL}

Round the final calculated volume to the nearest tenth.

4.5

The question instructions explicitly require rounding the final answer to the nearest tenth.

Key Concept

Weight-based pediatric dosage calculation and reconstitution

Question 589Question →

During preparation for the morning medication administration, a practical nurse examines the electronic health record of a client prescribed subcutaneous heparin. The chart indicates that the client has a current platelet count of $45,000/\text{mm}^3$ ( $45 \times 10^9/\text{L}$ ). Which of the following is the most appropriate action for the nurse to take?

Proceed with administering the injection and observe the client's skin for petechiae.

Direct the unlicensed assistive personnel to assess the client's body for any signs of active bleeding.

Hold the scheduled dose and immediately inform the registered nurse about the finding.

Document the laboratory value in the electronic health record and administer the medication as ordered.

Show answer & explanation

Answer: Hold the scheduled dose and immediately inform the registered nurse about the finding.

Answer

Hold the scheduled dose and immediately inform the registered nurse about the finding.

The correct answer identifies that a platelet count of

45,000/\text{mm}^3

indicates severe thrombocytopenia (normal is

150,000

400,000/\text{mm}^3

). Because heparin is an anticoagulant, giving this medication to a client who already lacks the platelets needed for blood clotting places them at an imminent risk for severe, spontaneous bleeding. The practical nurse must prioritize client safety by withholding the dose and immediately escalating the finding.

Step-by-Step Solution

Analyze the client's laboratory values against normal reference ranges.

The client's platelet count is

45,000/\text{mm}^3

, which is significantly below the normal range of

150,000

400,000/\text{mm}^3

Identifying abnormal labs is the first step in recognizing potential contraindications for medications.

Correlate the abnormal laboratory finding with the prescribed medication.

Heparin is an anticoagulant that prevents clotting; administering it to a client with severe thrombocytopenia creates an extreme risk for spontaneous hemorrhage.

Understanding the pharmacodynamics of a drug ensures safe administration and reduces risk potential.

Determine the safest nursing action within the practical nurse's scope of practice.

The nurse must withhold the medication to prevent harm and immediately escalate the critical lab value to the registered nurse or healthcare provider.

Protecting the client from harm and escalating critical findings are fundamental responsibilities of the practical nurse.

Key Concept

Reduction of risk potential by evaluating critical laboratory values prior to medication administration.

Question 590Question →

An adult client is resting in a medical-surgical unit on the first postoperative day following a right-sided modified radical mastectomy with axillary lymph node dissection. While assisting the client with morning care, the practical nurse must ensure the affected extremity is positioned correctly to prevent lymphedema. Which of the following is the most appropriate placement for the client's right arm?

Elevated on a pillow so that the hand is positioned higher than the elbow, and the elbow is higher than the heart

Placed flat on the mattress directly alongside the client's torso to maintain joint alignment

Secured firmly across the client's chest using a binder to prevent tension on the surgical incision

Supported in a dependent position slightly below the mattress level to promote arterial perfusion to the fingers

Show answer & explanation

Answer: Elevated on a pillow so that the hand is positioned higher than the elbow, and the elbow is higher than the heart

Answer

Elevate the right arm on a pillow with the hand positioned higher than the elbow, and the elbow higher than the heart.

Following a mastectomy involving axillary lymph node dissection, the natural drainage of lymphatic fluid from the arm is significantly compromised. Elevating the arm on a pillow in a graduated slope (hand higher than elbow, elbow higher than the heart) utilizes gravity to assist the return of lymphatic fluid and venous blood to the central circulation. This prevents fluid from accumulating in the tissues of the arm, thereby reducing the risk of developing painful and debilitating lymphedema.

Step-by-Step Solution

Identify the surgical procedure and its risks.

The client had a mastectomy with axillary lymph node dissection, which disrupts the normal lymphatic drainage pathways of the right arm.

Understanding the anatomical changes helps anticipate complications such as lymphedema.

Determine the physical principle that aids in fluid management.

Gravity can assist in draining lymphatic and venous fluid from the distal parts of the arm back toward the central circulation.

Proper positioning leverages gravity to compensate for the compromised lymphatic system.

Select the correct positioning strategy.

The arm should be elevated on a pillow in a graduated manner: hand higher than elbow, and elbow higher than the level of the heart.

This specific upward slope creates a clear path for fluid to drain downwards toward the body, preventing pooling and swelling.

Key Concept

Post-mastectomy Lymphedema Prevention and Positioning

Question 591Question →

A client is recovering on the surgical unit the day after undergoing a right posterolateral total hip arthroplasty. The practical nurse is preparing to cleanse the client's back and sacral area. Which action should the nurse take to maintain proper joint alignment and prevent dislocation?

Keep the client's legs close together in adduction while rolling them onto the operative side.

Elevate the head of the bed to a 90-degree angle and have the client lean forward.

Place an abductor pillow between the client's legs and turn them onto the non-operative side.

Ask the client to bend the right knee and push down with the heel to lift the buttocks.

Show answer & explanation

Answer: Place an abductor pillow between the client's legs and turn them onto the non-operative side.

Answer

Place an abductor pillow between the client's legs and turn them onto the non-operative side.

Following a posterolateral total hip arthroplasty, the client is at high risk for hip dislocation if the hip is flexed past 90 degrees, adducted, or internally rotated. Placing an abductor pillow between the legs maintains continuous abduction and proper alignment while safely turning the client onto their non-operative side.

Step-by-Step Solution

Identify the surgical approach and its specific precautions.

The client had a posterolateral total hip arthroplasty, which requires avoiding hip flexion greater than 90 degrees, adduction, and internal rotation.

These specific movements can cause the head of the femur to pop out of the acetabular cup.

Evaluate the safest positioning method for providing back care.

Turning the client safely requires keeping the legs apart to maintain alignment.

An abductor pillow securely maintains the legs in abduction, preventing the operative leg from crossing the body's midline.

Select the correct turning action.

The nurse places the abductor pillow and turns the client to the non-operative side.

This complies with all hip precautions while allowing necessary access to the sacral area.

Key Concept

Postoperative Positioning for Total Hip Arthroplasty

Question 592Question →

An $8$ -year-old pediatric client is prescribed $320\text{ mg}$ of liquid acetaminophen for a mild fever. The clinic's medication supply provides acetaminophen at a concentration of $160\text{ mg}$ per $5\text{ mL}$ . What is the correct volume in milliliters ( $\text{mL}$ ) that the practical nurse should administer?

10\text{ mL}

2\text{ mL}

5\text{ mL}

15\text{ mL}

Show answer & explanation

Answer: $10\text{ mL}$

Answer

The correct answer is

10\text{ mL}

To determine the correct volume, the nurse uses the formula: (Desired / Have)

\times

Volume. Plugging in the clinical values gives (

\frac{320\text{ mg}}{160\text{ mg}}

)

\times

5\text{ mL}

. The ratio of

320

160

simplifies to

2

. Multiplying

2

5\text{ mL}

yields a final answer of

10\text{ mL}

. Administering this exact volume ensures the client receives the prescribed therapeutic dose safely.

Step-by-Step Solution

Identify the desired dose prescribed by the provider.

Desired dose =

320\text{ mg}

This establishes the numerator for the dosage calculation formula.

Identify the available medication concentration (the dose on hand and its volume).

Have =

160\text{ mg}

, Volume =

5\text{ mL}

These values are required to complete the denominator and volume multiplier in the formula.

Set up the calculation using the desired-over-have formula.

\frac{320\text{ mg}}{160\text{ mg}} \times 5\text{ mL}

This formula ensures the dose is properly converted into the correct liquid volume.

Perform the mathematical calculation to find the final volume.

2 \times 5\text{ mL} = 10\text{ mL}

Solving the equation provides the exact milliliter amount to administer to the client.

Key Concept

Liquid Medication Dosage Calculation

Question 593Question →

A 5-year-old child arrives at the outpatient clinic for routine school vaccinations, which includes the live attenuated measles, mumps, and rubella (MMR) vaccine. While gathering the health history, the parent states the child has been taking a high-dose oral corticosteroid for the past two weeks to manage a severe asthma flare-up. What is the most appropriate action for the nurse to take?

Defer the immunization and discuss the child's current medication therapy with the primary healthcare provider.

Give the injection as planned because respiratory conditions do not require pausing vaccination schedules.

Ask the parent why the steroid dose is so high and assure them the vaccine is completely safe.

Calculate a proportionately smaller dose of the vaccine based on the child's most recent weight.

Show answer & explanation

Answer: Defer the immunization and discuss the child's current medication therapy with the primary healthcare provider.

Answer

Defer the immunization and discuss the child's current medication therapy with the primary healthcare provider.

The MMR vaccine contains live attenuated viruses. High-dose oral corticosteroids suppress the immune system, making the administration of live vaccines highly dangerous due to the risk of active, uncontrolled infection. The nurse must recognize this critical pharmacological contraindication, withhold the administration, and promptly consult the prescribing healthcare provider.

Step-by-Step Solution

Identify the properties of the prescribed vaccine.

The MMR is recognized as a live attenuated virus vaccine.

Live vaccines carry specific administration risks and require competent immune function.

Evaluate the client's current pharmacological regimen.

The child is currently taking high-dose systemic corticosteroids.

Systemic corticosteroids induce immunosuppression, altering how the body responds to pathogens.

Determine the safest nursing intervention based on pharmacological interactions.

The nurse must pause the procedure and escalate the finding.

Administering a live vaccine to an immunosuppressed client is heavily contraindicated as it can cause a severe active infection.

Key Concept

Live Vaccine Contraindications and Immunosuppressive Therapy

Question 594Question →

An older adult client is resting in bed following a right total hip arthroplasty (posterior approach). The nurse is reviewing the client's care plan regarding mobility and comfort. Which of the following positioning actions is appropriate for this client?

Place an abductor wedge between the client's legs.

Sit the client upright at a 90-degree angle during meals.

Instruct the client to cross their legs at the ankles for comfort.

Place a large rolled blanket directly under the surgical knee.

Show answer & explanation

Answer: Place an abductor wedge between the client's legs.

Answer

The appropriate positioning action is to place an abductor wedge between the client's legs.

Following a posterior total hip arthroplasty, the client's legs must remain abducted to prevent the new prosthetic joint from dislocating. An abductor wedge effectively maintains this safe alignment.

Step-by-Step Solution

Identify the surgical procedure and approach.

The client had a right total hip arthroplasty using a posterior approach.

Different surgical approaches have specific postoperative precautions to prevent complications.

Recall the positioning restrictions for a posterior hip arthroplasty.

Hip flexion greater than 90 degrees, adduction, and internal rotation must be avoided.

These movements can cause the head of the femur to pop out of the acetabulum, leading to dislocation.

Evaluate the given positioning options against these restrictions.

Sitting at 90 degrees causes excessive flexion. Crossing the legs causes adduction. Placing a roll under the knee risks contracture and DVT. Using an abductor wedge maintains proper alignment.

Only the abductor wedge aligns with safe postoperative care for this specific procedure.

Key Concept

Postoperative positioning and joint precautions following a posterior total hip arthroplasty.

Question 595Question →

A practical nurse is preparing to administer an intramuscular (IM) injection using the Z-track method to an adult client. Arrange the following steps for this procedure in the correct chronological order.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first perform hand hygiene and don gloves, then displace the skin laterally, insert the needle at a 90-degree angle, inject the medication slowly, and finally withdraw the needle while releasing the displaced skin.

The Z-track method is designed to prevent medication from leaking into the subcutaneous tissue. To perform this correctly, infection control (hand hygiene and gloves) is always the first step. Next, the nurse displaces the skin to misalign the tissue layers. While holding the skin displaced, the needle is inserted at 90 degrees to reach the muscle, and the medication is injected. Finally, the needle is withdrawn and the skin is released simultaneously to create a zig-zag track that seals the medication in the muscle.

Step-by-Step Solution

Ensure infection control

Hand hygiene is performed and gloves are donned.

To maintain standard precautions and prevent the transmission of microorganisms before touching the client.

Prepare the tissue using the Z-track technique

Skin and subcutaneous tissue are displaced laterally.

This creates a zig-zag path that will prevent the medication from leaking back up the needle track.

Puncture the skin

Needle is inserted at a 90-degree angle.

This angle is required to bypass the subcutaneous layer and deposit the medication directly into the deep muscle.

Administer the medication

Medication is injected slowly and steadily.

Slow administration promotes comfort and allows the muscle fibers to absorb the fluid volume.

Seal the injection track

Needle is withdrawn and the displaced skin is released.

Releasing the tissue seals the track, trapping the medication in the muscle and preventing skin irritation.

Key Concept

Z-track intramuscular injection technique

Question 596Question →

A toddler weighing $33\text{ lbs}$ is diagnosed with acute otitis media. The healthcare provider prescribes cefdinir $14\text{ mg/kg/day}$ orally in two divided doses. The pharmacy dispenses cefdinir oral suspension with a concentration of $125\text{ mg}/5\text{ mL}$ . How many milliliters ( $\text{mL}$ ) should be administered per dose?

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

Show answer & explanation

Answer: 4.2

Answer

4.2

To safely administer this weight-based medication, the practical nurse must first convert the child's weight to kilograms (

33\text{ lbs} \div 2.2\text{ lbs/kg} = 15\text{ kg}

). Next, the total daily dose is calculated by multiplying the weight in kilograms by the prescribed rate (

15\text{ kg} \times 14\text{ mg/kg/day} = 210\text{ mg/day}

). Because the prescription specifies two divided doses, the daily dose is halved to find the single administration amount (

210\text{ mg} \div 2 = 105\text{ mg/dose}

). Finally, the required volume is determined using the dispensed concentration of

125\text{ mg}/5\text{ mL}

. Using the formula

\frac{\text{Desired}}{\text{Have}} \times \text{Quantity}

\frac{105\text{ mg}}{125\text{ mg}} \times 5\text{ mL} = 0.84 \times 5\text{ mL} = 4.2\text{ mL}

Step-by-Step Solution

Convert the client's weight from pounds to kilograms.

15\text{ kg}

Weight-based medication prescribing requires the client's weight to be accurately calculated in kilograms (

33\text{ lbs} \div 2.2 = 15\text{ kg}

Calculate the total daily dose of the medication.

210\text{ mg/day}

The prescription is ordered based on the total amount needed for a full 24-hour period (

15\text{ kg} \times 14\text{ mg/kg/day}

Determine the amount of medication required for a single dose.

105\text{ mg/dose}

The total daily dose must be divided into two equal doses as prescribed (

210\text{ mg} \div 2

Calculate the liquid volume to administer per dose using the available concentration.

4.2\text{ mL}

Using the formula (Desired / Have)

\times

Quantity: (

\frac{105\text{ mg}}{125\text{ mg}}) \times 5\text{ mL} = 4.2\text{ mL}

Key Concept

Weight-Based Pediatric Dosage Calculation

Question 597Question →

A practical nurse (PN) receives the shift report and begins medication administration for a group of assigned clients. Which of the following actions demonstrate adherence to safe pharmacological principles and the practical nurse scope of practice? (Select all that apply.)

Select all that apply

Asking the client to state their full name and date of birth while verifying their identification band before giving an oral antihypertensive.

Proceeding to administer subcutaneous enoxaparin to a client who has a morning platelet count of

38,000/\text{mm}^3

without alerting the registered nurse.

Accepting a delegated task from the registered nurse to administer an intravenous (IV) push dose of furosemide to a client with fluid volume overload.

Withholding a scheduled dose of oral potassium chloride for a client whose laboratory report shows a serum potassium level of

6.2\text{ mEq/L}

and notifying the charge nurse.

Documenting the administration of an oral analgesic in the electronic health record immediately after observing the client swallow the medication.

Bypassing a broken barcode scanner and identifying a sleeping client by confirming the room number matches the medication record before giving oral levothyroxine.

Show answer & explanation

Answer: Asking the client to state their full name and date of birth while verifying their identification band before giving an oral antihypertensive.; Withholding a scheduled dose of oral potassium chloride for a client whose laboratory report shows a serum potassium level of $6.2\text{ mEq/L}$ and notifying the charge nurse.; Documenting the administration of an oral analgesic in the electronic health record immediately after observing the client swallow the medication.

Answer

The correct actions include verifying two unique client identifiers (name and date of birth), withholding potassium for a hyperkalemic client (

6.2\text{ mEq/L}

) while notifying the charge nurse, and documenting medication administration immediately after it is swallowed.

The correct actions align with the fundamental rights of medication safety and the boundaries of the practical nurse's scope of practice. Using two valid identifiers (name, date of birth) guarantees the right client receives the medication. Withholding potassium in the presence of an elevated serum level (

6.2\text{ mEq/L}

) and immediately notifying the charge nurse demonstrates appropriate clinical vigilance and escalation. Finally, documenting medications immediately after administration prevents accidental double-dosing by other staff.

Step-by-Step Solution

Evaluate the principles of medication safety and client identification.

Safe practice requires the use of two unique identifiers (e.g., name and date of birth) and immediate documentation after administration.

These steps are foundational to the 'rights' of medication administration to prevent wrong-client errors and duplicate dosing.

Analyze the clinical data and laboratory values presented in the scenarios.

A potassium level of

6.2\text{ mEq/L}

(hyperkalemia) and a platelet count of

38,000/\text{mm}^3

(severe thrombocytopenia) are critical laboratory abnormalities.

Administering potassium to a hyperkalemic client or an anticoagulant to a severely thrombocytopenic client can precipitate life-threatening complications.

Apply the practical nurse (PN) scope of practice to the scenarios.

The PN correctly withholds contraindicated medications and reports critical findings, but must refuse to administer medications via the intravenous (IV) push route.

IV push administration requires complex assessment and rapid clinical judgment that belongs within the registered nurse's scope of practice.

Key Concept

Safe Medication Administration and Scope of Practice

Question 598Question →

The practical nurse (PN) is collecting vital signs on a client who is 4 hours postoperative following abdominal surgery. Which finding requires the PN to notify the registered nurse (RN) immediately?

Blood pressure of 88/56 mm Hg and a heart rate of 118 beats per minute

The client reporting incisional pain of 6 on a 0 to 10 numerical scale

A tympanic temperature of 37.4°C (99.3°F)

A postoperative hemoglobin level of 13.5 g/dL (135 g/L)

Show answer & explanation

Answer: Blood pressure of 88/56 mm Hg and a heart rate of 118 beats per minute

Answer

The correct answer is the finding of a blood pressure of 88/56 mm Hg and a heart rate of 118 beats per minute.

A low blood pressure (hypotension) combined with a fast heart rate (tachycardia) in a postoperative client are classic early signs of hypovolemic shock or internal hemorrhage. This indicates compromised circulation, which is a life-threatening emergency that must be immediately reported to the RN.

Step-by-Step Solution

Identify the client's clinical context.

The client is 4 hours postoperative.

Surgical clients are at high risk for complications such as hemorrhage in the immediate postoperative period.

Analyze each assessment finding for severity and priority.

The low blood pressure and tachycardia indicate circulatory compromise.

According to the ABCs (Airway, Breathing, Circulation) framework, circulatory issues are life-threatening and take highest priority.

Determine the appropriate PN nursing action.

The PN must report the vital signs indicating shock to the RN.

Signs of physiological instability must be immediately escalated to the RN for further assessment and intervention.

Key Concept

Early recognition of hypovolemic shock and prioritization of circulatory compromise.

Question 599Question →

During morning rounds, a practical nurse (PN) receives the updated coagulation profile for a client with atrial fibrillation. The client has an order for warfarin 5 mg orally each day at 0900. The laboratory report shows an International Normalized Ratio (INR) of 4.6. Which of the following is the priority action for the PN to take?

Withhold the scheduled dose of warfarin and immediately notify the registered nurse.

Administer the scheduled dose of warfarin and monitor the client for signs of bleeding.

Decrease the warfarin dose to 2.5 mg to reduce the risk of spontaneous hemorrhage.

Proceed with medication administration after verifying the client's identity using two identifiers.

Show answer & explanation

Answer: Withhold the scheduled dose of warfarin and immediately notify the registered nurse.

Answer

Withhold the scheduled dose of warfarin and immediately notify the registered nurse.

For a client with atrial fibrillation, the therapeutic INR range is typically 2.0 to 3.0. An INR of 4.6 is significantly elevated, indicating that the client's blood is clotting too slowly and they are at a high risk for spontaneous bleeding. The correct and safe action for the practical nurse is to withhold the scheduled dose of warfarin to prevent further elevation of the INR and to immediately notify the registered nurse or healthcare provider so that the medication regimen can be evaluated and potentially adjusted.

Step-by-Step Solution

Review the client's laboratory results in relation to the prescribed medication.

The INR is 4.6, which is significantly above the standard therapeutic target of 2.0 to 3.0 for atrial fibrillation.

Warfarin dosing is directly dependent on coagulation profiles, specifically the INR, to balance clotting prevention and bleeding risk.

Determine the clinical significance of the abnormal result.

An elevated INR indicates that the client's blood is clotting too slowly, placing them at an imminent risk for bleeding if further anticoagulants are administered.

Identifying the risk of hemorrhage is a critical component of pharmacological safety.

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

The practical nurse must withhold the medication to prevent harm and immediately escalate the critical finding to the registered nurse or healthcare provider.

The PN is responsible for ensuring safe medication administration and reporting significant changes in client condition without altering prescriptions.

Key Concept

The practical nurse must evaluate relevant laboratory values before administering high-alert medications like warfarin, withholding the dose and reporting critical values to ensure client safety.

Estimated Time:1m 0s

Question 600Question →

A 52-year-old client arrives at the nursing unit immediately following an ultrasound-guided right percutaneous liver biopsy. The registered nurse delegates the task of settling the client in bed to the practical nurse. Which positioning action should the practical nurse implement to promote comfort and prevent complications?

Place the client in a left lateral position with the head of the bed flat to minimize dizziness.

Assist the client into a right side-lying position with a rolled towel beneath the puncture area.

Maintain the client in a semi-Fowler's position to relax the abdominal musculature.

Position the client prone with a small pillow placed centrally under the abdomen.

Show answer & explanation

Answer: Assist the client into a right side-lying position with a rolled towel beneath the puncture area.

Answer

Assist the client into a right side-lying position with a rolled towel beneath the puncture area.

Following a percutaneous liver biopsy, the client must be placed in a right side-lying position (the operative side) for at least 2 to 4 hours. Placing a rolled towel or small blanket under the puncture site utilizes the client's own body weight to apply direct pressure to the liver capsule, which helps achieve hemostasis and prevents severe hemorrhage.

Step-by-Step Solution

Identify the anatomical location of the procedure.

The liver is located on the right side of the abdomen, and the biopsy is a right-sided percutaneous puncture.

Knowing the anatomical site is essential for determining post-procedure care.

Recognize the primary post-procedure complication associated with a liver biopsy.

Hemorrhage is the most significant risk because the liver is a highly vascular organ.

Identifying the complication dictates the preventive nursing intervention.

Determine the physical intervention that prevents hemorrhage.

Applying direct, continuous pressure to the puncture site achieves hemostasis.

Pressure promotes blood clotting and minimizes internal and external bleeding.

Select the positioning strategy that applies the necessary pressure.

A right side-lying position with a rolled towel under the site utilizes the client's own body weight to apply pressure.

This specific position safely and effectively maintains continuous pressure on the liver capsule.

Key Concept

Post-Procedure Positioning for Liver Biopsy

Estimated Time:1m 0s

PreviousPage 30 / 66Next

Physiological Integrity

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept