Physiological Integrity

1313 questions

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A practical nurse is preparing to administer a scheduled subcutaneous injection of enoxaparin using a prefilled syringe. Arrange the following steps of the procedure in the correct chronological order.

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Answer

The correct chronological sequence is: Verify the client's identity, prepare the site with gloves and alcohol, uncap the needle while retaining the air bubble, pinch the skin to insert the needle, and finally administer the medication and activate the safety device.

Chronological adherence to standard medication administration protocols ensures client safety. Enoxaparin has specific administration requirements, including using the abdomen as the preferred site, retaining the prefilled air bubble, and injecting into a pinched fold of skin to prevent bruising and ensure proper tissue absorption.

Step-by-Step Solution

Verify client identity.

The correct client is identified.

Ensures adherence to the 'right client' principle of medication administration.

Don gloves and cleanse the abdominal site.

The site is properly disinfected.

Maintains asepsis and utilizes the preferred site (the abdomen) for enoxaparin administration.

Remove the needle cap.

The syringe is ready for immediate injection.

The air bubble must not be expelled, as the manufacturer includes it to push all medication into the tissue and prevent tracking.

Pinch a fold of skin and insert the needle.

The needle enters the correct tissue layer.

Pinching elevates the subcutaneous tissue, preventing an accidental and painful intramuscular injection.

Inject the medication and secure the needle.

The dose is fully administered and the sharp is safely contained.

Prevents tracking of the medication and protects the nurse from needlestick injuries.

Key Concept

Safe administration sequence for subcutaneous enoxaparin

Question 642Question →

A client is receiving care for acute pyelonephritis and has been receiving intravenous antibiotics for 24 hours. During morning rounds, the practical nurse finds the client restless and mildly confused. The client's vital signs are: heart rate 118 bpm, blood pressure 94/56 mm Hg, respiratory rate 24 breaths/min, and temperature 99.1°F (37.3°C). The client reports right flank pain rated as 5 on a 0 to 10 scale. Which action should the practical nurse take first?

Report the assessment findings to the supervising registered nurse immediately.

Administer the prescribed PRN oral analgesic for the client's flank pain.

Document the findings and reassess the vital signs in one hour to establish a trend.

Implement fall precautions and dim the room lights to encourage rest.

Show answer & explanation

Answer: Report the assessment findings to the supervising registered nurse immediately.

Answer

The correct action is to report the assessment findings to the supervising registered nurse immediately.

The correct answer prioritizes immediate escalation. Restlessness, new-onset mild confusion, tachycardia, and borderline hypotension in a client with an active infection are early clinical indicators of sepsis and distributive shock. Due to inadequate tissue perfusion, the brain receives less oxygen, causing altered mental status. Within the practical nurse scope of practice, recognizing these signs of acute physiological deterioration requires immediate notification of the registered nurse or provider so that rapid interventions (such as fluid resuscitation) can be initiated.

Step-by-Step Solution

Analyze the vital signs and neurological status.

Heart rate 118 bpm, blood pressure 94/56 mm Hg, respiratory rate 24 breaths/min, restlessness, and mild confusion indicate poor systemic perfusion.

Identifying abnormal clinical data is the first step in recognizing physiological deterioration.

Correlate the findings with the client's current diagnosis.

Acute pyelonephritis is a severe kidney infection that carries a high risk for systemic infection (sepsis).

Understanding the disease process helps anticipate severe complications like distributive shock.

Prioritize needs using the ABC (Airway, Breathing, Circulation) framework.

Circulation is compromised, which is an immediate life-threatening emergency.

Systemic instability takes absolute precedence over localized symptoms such as flank pain.

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

The nurse must immediately notify the registered nurse or provider.

Acute physiological instability requires rapid medical intervention (e.g., fluid resuscitation, pressors) that exceeds the independent scope of the practical nurse.

Key Concept

Recognizing Early Septic Shock and Scope of Practice

Question 643Question →

A practical nurse is providing basic care for a client who is recovering from abdominal surgery and reports feeling nauseous. Which of the following nursing actions should the nurse implement to promote comfort and safety? (Select all that apply.)

Select all that apply

Assist the client into a side-lying position.

Provide a cool, damp cloth for the client to place on their forehead or neck.

Offer the client frequent oral hygiene.

Position the client completely flat in a supine position to encourage deep sleep.

Provide a large glass of warm water for the client to drink immediately.

Show answer & explanation

Answer: Assist the client into a side-lying position.; Provide a cool, damp cloth for the client to place on their forehead or neck.; Offer the client frequent oral hygiene.

Answer

The correct actions include assisting the client into a side-lying position, providing a cool cloth, and offering frequent oral hygiene.

Assisting the client into a side-lying position is a critical safety measure that protects the airway by allowing gravity to drain potential emesis, thereby preventing aspiration. Furthermore, providing a cool, damp cloth and offering frequent oral care are excellent basic care measures that relieve the discomfort of nausea and improve the client's overall well-being.

Step-by-Step Solution

Assess the client's current symptoms and safety risks.

The client is post-operative and experiencing nausea.

Nausea significantly increases the risk of vomiting, which can lead to aspiration if the airway is not protected.

Implement positioning interventions.

The client is placed in a side-lying position.

This position allows any emesis to drain out of the mouth, maintaining a clear airway.

Provide non-pharmacological comfort measures.

A cool cloth and oral hygiene are offered.

These basic care interventions help relieve nausea and promote physical comfort.

Key Concept

Post-operative basic care, comfort measures, and aspiration prevention

Question 644Question →

An older adult client is admitted to the medical-surgical unit after three days of severe vomiting and diarrhea. While collecting data, which of the following findings strongly indicate to the practical nurse that the client is experiencing an acute physiological deterioration requiring immediate escalation of care? Select all that apply.

Select all that apply

Blood pressure decreases from an admission baseline of 138/82 mm Hg to 104/66 mm Hg.

The client becomes suddenly disoriented to time and place during the assessment.

The resting apical heart rate is 114 beats per minute with a thready quality.

The client reports diffuse abdominal cramping rated as a 5 on a 0 to 10 pain scale.

Capillary refill time is brisk and evaluated at less than 2 seconds.

The client experiences a large episode of watery diarrhea during the shift.

Show answer & explanation

Answer: Blood pressure decreases from an admission baseline of 138/82 mm Hg to 104/66 mm Hg.; The client becomes suddenly disoriented to time and place during the assessment.; The resting apical heart rate is 114 beats per minute with a thready quality.

Answer

The correct findings are the decrease in blood pressure, the sudden disorientation, and the tachycardic, thready pulse.

The correct findings represent hallmark early signs of hypovolemic shock due to severe fluid volume deficit. A significant downward trend in blood pressure, compensatory tachycardia with a weak pulse, and sudden altered mental status (indicating decreased cerebral perfusion) are acute, life-threatening changes that require immediate rapid intervention.

Step-by-Step Solution

Analyze the client's admitting diagnosis (severe diarrhea and vomiting) to identify the primary physiological risk.

The client is at extremely high risk for fluid volume deficit progressing to hypovolemic shock.

Prolonged gastrointestinal fluid loss significantly decreases circulating blood volume.

Evaluate each assessment finding to differentiate between expected baseline symptoms and acute, life-threatening complications.

Abdominal cramping and diarrhea are expected. Normal capillary refill is reassuring. The dropping blood pressure, tachycardia, and confusion are unexpected acute changes.

Safe prioritization requires identifying new, unstable, or systemic changes over localized, expected symptoms.

Identify the specific findings that indicate compromised Airway, Breathing, or Circulation (ABCs).

The dropping blood pressure, compensatory tachycardia (114 beats/min), and sudden disorientation indicate poor systemic and cerebral perfusion.

These are early hallmark signs of impending hypovolemic shock requiring immediate escalation to the registered nurse.

Key Concept

Recognizing early signs of hypovolemic shock and acute physiological deterioration.

Question 645Question →

An unresponsive client requires morning oral hygiene. How should the nurse sequence the following interventions? (Arrange the steps from first to last.)

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Answer

The correct sequence is to first turn the client onto their side, then arrange the towel and basin, proceed to swab the oral cavity, and finally apply moisturizer to the lips.

The absolute priority when providing oral care to an unresponsive client is airway management. Positioning the client on their side must always occur first to allow fluids to drain out of the mouth, thereby preventing aspiration. After the airway is secure, preparation of the physical environment with a towel and basin ensures cleanliness. The actual mechanical cleaning of the oral cavity follows. Finally, applying a water-soluble moisturizer provides comfort and preserves skin integrity.

Step-by-Step Solution

Protect the airway

The client is placed in a side-lying position.

An unresponsive client lacks an intact gag reflex. Turning them on their side ensures fluids drain out of the mouth rather than pooling in the back of the throat, which prevents aspiration.

Prepare the immediate area

A towel and emesis basin are placed near the client's face.

This setup catches oral secretions and cleaning solutions, keeping the client's skin and bed linens dry and clean.

Perform oral hygiene

The teeth, gums, and tongue are gently cleansed.

Using a moistened sponge removes plaque, bacteria, and crusts to maintain oral health.

Provide skin protection

Water-soluble moisturizer is applied to the lips.

Moisturizer prevents the lips from drying, cracking, and bleeding, completing the comfort care procedure.

Key Concept

Oral Hygiene for the Unresponsive Client

Question 646Question →

A practical nurse is providing instructions to a female client who needs to collect a midstream clean-catch urine specimen for laboratory analysis. In what order should the nurse instruct the client to perform these actions? Arrange the steps in the correct chronological sequence.

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Answer

The correct sequence for a midstream clean-catch urine collection is: cleanse the perineal area, begin voiding into the toilet, place the container in the active stream, remove the container before stopping urination, and securely apply the lid.

The correct chronological sequence ensures the urine sample is as sterile as possible. Cleansing the area removes surface bacteria. Voiding a small amount flushes the urethra. Collecting the midstream sample captures urine directly from the bladder. Removing the cup before stopping prevents terminal contamination, and securing the lid safely finalizes the aseptic technique.

Step-by-Step Solution

Identify the first necessary action to prevent specimen contamination.

Cleanse the perineal area from front to back with the provided antiseptic wipes.

Removing external bacteria from the meatus is the essential first step before any urination begins.

Determine the next action to further clear potential contaminants.

Begin voiding a small amount of urine directly into the toilet.

The initial stream flushes resident bacteria out of the distal urethra.

Identify when to actually collect the urine sample.

Place the sterile specimen container into the active stream to collect the sample.

The midstream portion of the urine represents the most uncontaminated sample from the bladder.

Determine the action needed to conclude the collection safely.

Remove the specimen container from the urine stream before stopping urination.

Pulling the cup away while the stream is still strong prevents contamination from the skin as the flow dwindles.

Identify the final step to secure the specimen.

Securely apply the lid to the container without touching its inner surface.

Properly sealing the container maintains its internal sterility until it reaches the laboratory.

Key Concept

Specimen Collection protocols to reduce the risk of false-positive laboratory results.

Question 647Question →

A practical nurse is preparing to administer a scheduled dose of oral metoprolol to a client who is alert and watching television. The client's heart rate is $72\text{ beats/min}$ and blood pressure is $118/76\text{ mmHg}$ . Which action must the nurse perform to correctly verify the client's identity before giving the medication?

Ask the client to state their first and last name and date of birth while checking their identification band.

Ask the client, "Are you Mr. Smith?" and wait for the client to verbally agree.

Compare the client's room and bed number to the information on the medication administration record.

Verify the client's identity by checking the name listed on the dry-erase board in the client's room.

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Answer: Ask the client to state their first and last name and date of birth while checking their identification band.

Answer

The nurse must verify the client's identity by asking them to state their first and last name and date of birth while checking their identification band.

The standard of care for medication administration requires nurses to use at least two distinct, acceptable client identifiers before giving any medication. Asking the client to actively state their full name and date of birth, while comparing this information to their physical identification band and the medication administration record, fulfills this critical safety requirement and prevents errors.

Step-by-Step Solution

Review the principles of safe medication administration, specifically the 'Right Client' check.

Identify that at least two distinct, acceptable patient identifiers are required by safety standards.

This ensures the medication is given to the correct individual.

Evaluate the options to determine which represents acceptable identifiers.

Recognize that asking the client to actively state their full name and date of birth, while comparing it to an identification band, meets this requirement.

Active identification prevents errors associated with yes/no questions or unreliable location-based identifiers.

Key Concept

Rights of Medication Administration: Right Client Verification

Question 648Question →

During morning rounds, a client receiving daily oral levothyroxine $150\text{ mcg}$ for primary hypothyroidism reports feeling restless and unusually warm. The practical nurse notes a heart rate of $112\text{ bpm}$ and a blood pressure of $142/88\text{ mmHg}$ . A review of the morning laboratory results reveals a thyroid-stimulating hormone (TSH) level of $0.1\text{ mU/L}$ (normal: $0.4\text{ to }4.0\text{ mU/L}$ ). Which action should the practical nurse take first?

Administer the levothyroxine as prescribed because the low TSH level indicates worsening hypothyroidism.

Verify the client's identity using two identifiers and administer the medication with a prescribed PRN antipyretic.

Withhold the scheduled dose of levothyroxine and report the assessment findings to the registered nurse.

Independently reduce the levothyroxine dose by half to safely manage the client's elevated heart rate.

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Answer: Withhold the scheduled dose of levothyroxine and report the assessment findings to the registered nurse.

Answer

The practical nurse should withhold the scheduled dose of levothyroxine and notify the registered nurse.

The client is exhibiting clinical signs of hyperthyroidism (tachycardia, heat intolerance, restlessness, elevated blood pressure) alongside a suppressed TSH level. These findings indicate levothyroxine toxicity. The safest and most appropriate action within the practical nurse's scope of practice is to withhold the scheduled dose to prevent further physiological harm and immediately escalate the critical findings to the registered nurse or healthcare provider for medical re-evaluation.

Step-by-Step Solution

Analyze the client's physical symptoms and vital signs.

Restlessness, feeling warm, and tachycardia (

112\text{ bpm}

) are identified as classic signs of a hypermetabolic state.

Identifying abnormal assessment findings is the critical first step in evaluating medication safety prior to administration.

Interpret the laboratory results in the context of the medication.

A TSH level of

0.1\text{ mU/L}

is significantly below the normal range, indicating excessive circulating thyroid hormone.

TSH has an inverse relationship with thyroid hormone levels; a suppressed TSH confirms hyperthyroidism or levothyroxine toxicity.

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

The medication must be withheld and the clinical findings immediately escalated to the registered nurse or provider.

Administering the medication would exacerbate the toxicity, and altering the prescribed dose independently is strictly outside the practical nurse's scope.

Key Concept

Recognizing medication toxicity, understanding lab value relationships, and adhering to the practical nurse scope of practice.

Question 649Question →

A practical nurse is preparing to apply a newly prescribed transdermal clonidine patch to a client with hypertension. The client currently has an old patch in place on their right upper chest. In what order should the nurse perform the following actions?

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Answer

The correct sequence is to first don clean gloves and remove the old patch, fold it in half for disposal, cleanse and dry a new application site, apply the new patch with firm pressure, and finally label the patch with the date, time, and initials.

Applying a transdermal patch requires a systematic approach to ensure safety for both the client and the nurse. The nurse must first protect themselves with gloves and remove the old patch to prevent a medication overdose. The old patch is immediately folded and discarded safely. A new site is then cleansed and dried to prevent irritation and ensure adhesion. The new patch is applied with pressure, and finally, it is labeled so the next nurse knows when it was administered.

Step-by-Step Solution

Don clean gloves and remove the old patch.

The client is no longer receiving medication from the previous patch.

Gloves protect the nurse from absorbing the medication. Removing the old patch first prevents delivering a double dose.

Fold the old patch in half with the adhesive sides together and discard it.

The old patch is safely secured.

This prevents anyone else from accidentally coming into contact with residual medication on the patch.

Cleanse a new, hairless application site and allow it to dry completely.

A fresh, clean site is prepared.

Site rotation prevents tissue breakdown. Clean, dry skin is necessary for the adhesive to work properly.

Apply the new patch and hold it firmly in place for 10 to 15 seconds.

The new patch is securely attached.

Applying pressure ensures the edges do not peel up and the medication will be absorbed properly.

Write the date, time, and initials on the outside of the new patch.

The administration is clearly documented.

Proper labeling communicates with the rest of the nursing staff so they know exactly when the patch was placed.

Key Concept

Transdermal Medication Administration

Estimated Time:1m 0s

Question 650Question →

A practical nurse is preparing to perform a routine capillary blood glucose test for a client with diabetes mellitus. In what order should the nurse perform the following actions to obtain an accurate sample and minimize complications? Arrange the steps from first to last.

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Answer

The correct sequence is to first clean the site with alcohol, allow it to dry completely, puncture the side of the finger, wipe away the initial drop of blood, and then apply the second drop to the test strip.

To obtain an accurate capillary blood glucose reading and reduce the risk of potential complications, the practical nurse must follow a strict procedural sequence. First, the site is cleaned to prevent infection. Second, the alcohol must dry completely to prevent it from altering the glucose reading. Third, the puncture is made on the less sensitive side of the finger. Fourth, the first drop of blood is wiped away because it contains tissue fluid that dilutes the sample. Finally, the second drop of pure capillary blood is applied to the test strip for an accurate measurement.

Step-by-Step Solution

Clean the selected puncture site with an alcohol swab.

The skin surface is sanitized.

Reduces the risk of infection by removing surface pathogens before breaking the skin.

Allow the alcohol on the skin to dry completely.

The alcohol evaporates from the puncture site.

Prevents alcohol from mixing with the blood sample, which can cause an inaccurate glucose reading and increase stinging for the client.

Puncture the lateral aspect of the fingertip using a sterile lancet.

A small capillary puncture is created.

The side of the finger has a rich blood supply but fewer nerve endings, minimizing client discomfort.

Wipe away the first drop of blood using a dry, sterile gauze pad.

The initial blood drop is removed.

The first drop contains tissue fluids that can dilute the blood sample and skew the test result.

Apply the second drop of blood directly to the reagent test strip.

The sample is collected on the strip.

The second drop consists of pure capillary blood, providing the most accurate glucose measurement.

Key Concept

Proper technique for capillary blood glucose sampling ensures accurate diagnostic results and minimizes the risk of client harm or discomfort.

Question 651Question →

A practical nurse and an unlicensed assistive personnel (UAP) are preparing to move a postoperative client up in bed using a draw sheet. Arrange the following actions in the correct chronological sequence to ensure client and staff safety.

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Answer

The correct sequence is to first flatten and raise the bed, then protect the client's head with a pillow, have the client cross their arms and bend their knees, grasp the draw sheet closely on both sides, and finally execute the move on a synchronized count.

Moving a client up in bed safely requires strict adherence to body mechanics and safety protocols. Flattening the bed removes gravity as an obstacle. Placing a pillow at the headboard protects the client from head trauma. Having the client fold their arms and bend their knees minimizes friction and allows them to assist with the move. Grasping the draw sheet closely provides the necessary leverage, and moving synchronously on a count ensures smooth, safe repositioning.

Step-by-Step Solution

Position the bed flat and adjust the height.

Gravity resistance is minimized and working posture is optimized.

This establishes a safe starting environment that prevents musculoskeletal injuries.

Place a pillow against the headboard.

The headboard is padded.

This prevents trauma to the client's head if they slide up too quickly.

Instruct the client to cross arms and bend knees.

Friction is reduced and the client is ready to assist.

Keeping limbs compact prevents injury and bending knees provides client leverage.

Grasp the rolled draw sheet tightly.

A secure hold is established on the lifting device.

Holding near the client's body maximizes mechanical advantage.

Shift weight and move on the count of three.

The client is safely repositioned higher in the bed.

Synchronized teamwork ensures a smooth transfer without jerking motions.

Key Concept

Safe client handling, body mechanics, and mobility transfers

Question 652Question →

A client is 6 hours post-operative following a total knee arthroplasty. During a routine assessment, the practical nurse notes that the client has produced only 15 mL of urine via the indwelling catheter over the past hour. The client's current vital signs are blood pressure 100/62 mm Hg, heart rate 108 bpm, and respirations 20 breaths/min. The client reports surgical site pain as 5 on a 0 to 10 scale. Which action should the practical nurse take first?

Notify the registered nurse about the urine output and vital signs.

Administer the prescribed as-needed analgesic for the surgical site pain.

Document the findings and reassess the urinary output in one hour.

Increase the continuous intravenous fluid infusion rate.

Show answer & explanation

Answer: Notify the registered nurse about the urine output and vital signs.

Answer

The priority action is to notify the registered nurse about the urine output and vital signs.

A urine output of less than 30 mL/hr combined with an increasing heart rate and low-normal blood pressure in a post-operative client strongly suggests fluid volume deficit or bleeding. The priority action is to immediately escalate these critical findings to the registered nurse or healthcare provider to reduce the risk of hypovolemic shock.

Step-by-Step Solution

Analyze the clinical data provided in the scenario.

The client has a urine output of 15 mL/hr (normal is greater than 30 mL/hr), an elevated heart rate of 108 bpm, and a low-normal blood pressure of 100/62 mm Hg.

Identifying abnormal clinical findings is the first step in risk reduction and early complication management.

Determine the potential complication based on the findings.

The combination of oliguria, tachycardia, and a dropping or borderline blood pressure in a post-operative client indicates a high risk for hypovolemia, hemorrhage, or impending shock.

Recognizing patterns of clinical deterioration guides proper prioritization.

Select the priority nursing action based on the practical nurse's scope of practice.

The most appropriate immediate action is to alert the registered nurse or healthcare provider.

The practical nurse must rapidly escalate signs of clinical instability to ensure the client receives prompt medical intervention.

Key Concept

Reduction of Risk Potential: Early Recognition of Post-Operative Complications

Question 653Question →

A practical nurse is caring for a 78-year-old client who is 12 hours post-operative following abdominal surgery. The client suddenly becomes restless, confused, and has a resting heart rate of 114 beats per minute. Which action should the practical nurse take first?

Measure the client's oxygen saturation and report the findings to the registered nurse.

Ask the client about their current pain level and prepare to administer prescribed analgesics.

Reorient the client to the room and document the new confusion as a standard age-related change.

Continue to monitor the client routinely, as mild tachycardia is an expected finding after surgery.

Show answer & explanation

Answer: Measure the client's oxygen saturation and report the findings to the registered nurse.

Answer

Measure the client's oxygen saturation and report the findings to the registered nurse.

Sudden restlessness, confusion, and tachycardia are classic early indicators of hypoxia, hemorrhage, or shock in a post-operative client. The priority action is to assess the client's respiratory status (ABCs) and immediately notify the registered nurse so that prompt medical intervention can be initiated.

Step-by-Step Solution

Analyze the client's new symptoms: sudden restlessness, confusion, and tachycardia in a post-operative older adult.

These findings point to an acute physiological change.

Identifying changes from the baseline is the first step in clinical reasoning.

Correlate the symptoms with potential post-operative complications.

Restlessness, confusion, and an elevated heart rate are classic early signs of hypoxia or impending shock.

The brain is highly sensitive to decreased oxygen and perfusion, often manifesting as altered mental status before blood pressure significantly drops.

Apply the Airway, Breathing, and Circulation (ABC) prioritization framework.

Assessing oxygenation status directly addresses the highest-priority threat to the client's life.

ABC issues always take precedence over comfort measures or routine monitoring.

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

The nurse must gather focused data (oxygen saturation) and immediately escalate the acute change to the registered nurse.

Acute physiological decompensation requires rapid intervention and RN/provider collaboration.

Key Concept

Early recognition of hypoxia and shock (ABCs)

Estimated Time:1m 0s

Question 654Question →

An individual is receiving ongoing rehabilitative care one week after a unilateral below-the-knee amputation for severe peripheral arterial disease. The care plan focuses on promoting optimal healing, preparing the residual limb for future prosthetic fitting, and maintaining overall well-being. Which of the following actions are appropriate for the practical nurse to include in the client's daily care? Select all that apply.

Select all that apply

Assist the client into a prone position with the hips completely flat for 20 to 30 minutes several times daily.

Wrap the residual limb with an elastic compression bandage using a figure-eight technique, proceeding from distal to proximal.

Encourage the client to actively push the residual limb downward against the bed mattress while resting in a supine position.

Maintain continuous elevation of the residual limb on two firm pillows to prevent swelling and promote comfort.

Accept delegation from the registered nurse to administer an intravenous push analgesic prior to performing painful dressing changes.

Provide the standard high-protein meal tray to support tissue healing without confirming the client's cultural or religious dietary needs.

Show answer & explanation

Answer: Assist the client into a prone position with the hips completely flat for 20 to 30 minutes several times daily.; Wrap the residual limb with an elastic compression bandage using a figure-eight technique, proceeding from distal to proximal.; Encourage the client to actively push the residual limb downward against the bed mattress while resting in a supine position.

Answer

The correct interventions are assisting the client into a prone position, wrapping the residual limb with a figure-eight technique, and encouraging the client to actively push the limb against the mattress.

Appropriate basic care for a client with a recent lower extremity amputation involves interventions that prepare the limb for a prosthesis and prevent complications. Assisting the client to a prone position for 20 to 30 minutes multiple times a day stretches the flexor muscles and prevents hip flexion contractures. Wrapping the residual limb with a figure-eight technique from distal to proximal reduces edema and properly shapes the limb for a future prosthesis, while avoiding the restricted blood flow associated with circular wrapping. Encouraging the client to push the limb down against the mattress strengthens the necessary muscles and further prevents contracture formation.

Step-by-Step Solution

Evaluate the positioning, mobility, and healing needs for a client recovering from a lower extremity amputation.

Identified that preventing hip flexion contractures and correctly shaping the residual limb are primary priorities for basic care and comfort during the rehabilitative phase.

Contractures can permanently prevent the successful fitting and use of a prosthetic limb, undermining the entire rehabilitation process.

Analyze each proposed intervention against evidence-based basic care standards and the practical nursing scope of practice.

Selected prone positioning, figure-eight wrapping, and active muscle pushing as correct actions. Rejected continuous pillow elevation, intravenous push administration, and bypassing cultural dietary assessments as unsafe or inappropriate.

Safe nursing practice requires strict adherence to physiological principles (avoiding contractures), legal boundaries (refusing out-of-scope tasks), and psychosocial integrity (respecting cultural diets).

Key Concept

Basic care and comfort following an amputation focuses on contracture prevention, proper limb shaping, and holistic, safe care within the practical nurse's legal scope.

Question 655Question →

A practical nurse (PN) is collecting data on a client who is 2 hours postoperative following an abdominal surgery. The client's vital signs are: heart rate 112 beats/minute, blood pressure 98/62 mm Hg, respiratory rate 18 breaths/minute, and oxygen saturation 97% on room air. The client reports incisional pain of 6 on a 0 to 10 scale and states, 'I feel a little dizzy when I try to sit up.' Which of the following is the priority action for the PN?

Notify the registered nurse (RN) immediately regarding the client's vital signs and dizziness.

Administer the prescribed as-needed (PRN) analgesic to manage the client's postoperative pain.

Document the findings as expected early postoperative changes and continue routine monitoring.

Elevate the head of the bed to a high-Fowler's position to assist with the client's dizziness.

Show answer & explanation

Answer: Notify the registered nurse (RN) immediately regarding the client's vital signs and dizziness.

Answer

Notify the registered nurse (RN) immediately regarding the client's vital signs and dizziness.

The client is exhibiting tachycardia, borderline hypotension, and dizziness, which are classic early signs of hypovolemia or hemorrhage following surgery. Within the practical nurse scope of practice, recognizing acute decompensation requires immediate escalation. The priority is to notify the RN so that a comprehensive assessment can be performed and emergency interventions can be initiated promptly.

Step-by-Step Solution

Analyze the collected data for abnormalities.

The client has tachycardia (112 beats/min), borderline hypotension (98/62 mm Hg), and orthostatic symptoms (dizziness when sitting up).

Identifying abnormal vital signs is the first step in recognizing clinical deterioration.

Correlate the abnormal findings with the clinical context.

In a 2-hour postoperative client, these findings are early indicators of hypovolemia, hemorrhage, or impending shock.

Understanding the significance of the data allows for proper prioritization of care.

Determine the most appropriate action within the PN scope of practice.

The PN must immediately escalate these critical findings to the RN.

The RN needs to perform a comprehensive assessment and coordinate potentially life-saving interventions (such as fluid resuscitation) with the healthcare provider.

Key Concept

Recognition of Early Shock and Scope of Practice

Question 656Question →

A client who is comatose due to a traumatic brain injury requires routine oral hygiene. Arrange the steps the practical nurse should take to safely provide mouth care in the correct sequence.

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Answer

The correct sequence prioritizes airway safety by first positioning the client laterally, followed by preparing the equipment, safely accessing the oral cavity, performing the cleaning, and finally removing the fluids with suction.

The sequencing of oral care for an unconscious client is strictly dictated by airway safety. Positioning the client laterally is always the first priority to prevent aspiration. Only after the airway is protected from gravity-induced pooling should the nurse prepare the linens, open the mouth safely with an instrument, perform the hygiene, and finally suction out the debris.

Step-by-Step Solution

Establish a safe position for the unconscious client.

The client is placed in a lateral (side-lying) position with the head turned to the side.

Because the client cannot swallow or expectorate, this position allows fluids to drain out of the mouth, preventing pulmonary aspiration.

Prepare the immediate area.

A towel and emesis basin are placed under the client's chin and cheek.

This protects the bed linens and provides a direct path for fluids to drain into the basin.

Open the oral cavity safely.

A padded tongue blade is inserted between the upper and lower back teeth.

This ensures safe access to the oral cavity without risking injury to the nurse's fingers if the client experiences an involuntary bite reflex.

Perform oral hygiene.

The oral cavity is thoroughly cleaned with a moistened sponge swab or soft-bristled toothbrush.

Cleaning removes plaque, bacteria, and crusts, preventing infection and maintaining the integrity of the mucous membranes.

Remove excess fluids.

The mouth is suctioned using a Yankauer or standard suction catheter.

Suctioning eliminates pooling fluids and loosened secretions, completing the cleaning process while continuing to protect the airway.

Key Concept

Oral Care for the Unconscious Client (Aspiration Prevention)

Question 657Question →

A primary health care provider prescribes a deep intramuscular injection of iron dextran for an adult client with severe anemia. To prevent superficial tissue irritation and skin staining, the practical nurse must utilize the Z-track technique. Arrange the following procedural steps for preparing and administering this medication in the correct chronological order.

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Show answer & explanation

Answer

The correct sequence is: draw the medication and replace the needle, displace the skin laterally, insert the needle at 90 degrees, inject slowly, wait 10 seconds, and finally withdraw the needle while releasing the skin.

The Z-track method is meticulously designed to seal highly irritating or staining medications (such as iron dextran) deep within the muscle tissue. The process begins with drawing up the medication and strictly changing the needle to ensure no residue is on the needle shaft. Next, the skin is pulled laterally to displace the tissue layers. The needle is then inserted at a 90-degree angle, and the medication is injected slowly. The nurse must wait 10 seconds before withdrawing the needle to allow the fluid to disperse and prevent backflow. Finally, withdrawing the needle and immediately releasing the skin creates a staggered track, effectively trapping the medication in the muscle layer and preventing superficial damage.

Step-by-Step Solution

Draw up the medication and change the needle.

A sterile needle without irritating medication residue on the outside is attached to the syringe.

Prevents tracking of the highly irritating or staining medication through superficial tissues during insertion.

Displace the skin and subcutaneous tissue laterally.

The superficial tissue layers are misaligned with the deeper muscle layers.

Creates the mechanical foundation required for the Z-track seal.

Insert the needle at 90 degrees and inject slowly.

Medication is deposited deep into the ventrogluteal muscle.

Ensures proper depth, prevents subcutaneous pooling, and minimizes tissue trauma.

Wait 10 seconds before needle withdrawal.

The medication begins to disperse into the surrounding muscle.

Prevents immediate backflow of the fluid into the needle track.

Withdraw the needle and simultaneously release the skin.

The tissue layers slide back into their natural alignment.

The staggered needle track is closed, physically sealing the medication deep within the muscle layer.

Key Concept

Safe Administration of Intramuscular Medications utilizing the Z-Track Method

Question 658Question →

A practical nurse (PN) is assessing a client who is $12$ hours postoperative following an open reduction and internal fixation (ORIF) of the right femur. Which of the following findings indicate a potential life-threatening complication that requires IMMEDIATE escalation to the registered nurse (RN)? (Select all that apply.)

Select all that apply

Hemoglobin level of

7.8 \text{ g/dL}

(

78 \text{ g/L}

) and hematocrit of

24\%

Heart rate of

112 \text{ beats/minute}

with a blood pressure of

96/60 \text{ mm Hg}

New-onset petechiae scattered across the anterior chest and axillae

White blood cell (WBC) count of

9,500/\text{mm}^3

(

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

)

Serosanguineous drainage measuring

25 \text{ mL}

in the closed-suction device over the last

4

hours

Client requests an as-needed (PRN) analgesic for localized incisional pain rated as

6

on a

0

10

scale

Show answer & explanation

Answer: Hemoglobin level of $7.8 \text{ g/dL}$ ( $78 \text{ g/L}$ ) and hematocrit of $24\%$ ; Heart rate of $112 \text{ beats/minute}$ with a blood pressure of $96/60 \text{ mm Hg}$ ; New-onset petechiae scattered across the anterior chest and axillae

Answer

The findings that require immediate escalation are the critically low hemoglobin/hematocrit, the tachycardia with borderline hypotension, and the petechial rash on the chest.

Clients with long bone fractures are at high risk for hemorrhage and fat embolism syndrome. A critical drop in hemoglobin, tachycardia combined with borderline hypotension, and a new-onset petechial rash on the chest are hallmark signs of these life-threatening complications. These physiological changes indicate a deteriorating state that falls outside the practical nurse's independent scope and mandates immediate escalation to the registered nurse.

Step-by-Step Solution

Evaluate the surgical context and inherent risks

The client had an ORIF of the femur

Long bone fractures and orthopedic surgeries carry high physiological risks for severe hemorrhage and fat embolism syndrome (FES).

Analyze laboratory and vital signs for indications of shock

Identified that a hemoglobin of

7.8 \text{ g/dL}

and vitals of

112 \text{ bpm}

with

96/60 \text{ mm Hg}

are abnormal

These specific values represent acute blood loss and early hypovolemic shock, requiring immediate RN intervention.

Assess physical findings for FES

Identified petechiae on the anterior chest and axillae

This is a classic, life-threatening clinical indicator of FES that occurs when fat droplets enter the circulation, requiring emergency escalation.

Differentiate expected postoperative findings from emergencies

Excluded the WBC of

9,500/\text{mm}^3

, the

25 \text{ mL}

of drainage, and the pain level of

6/10

These findings are within normal postoperative limits or fall within the independent scope of the practical nurse to manage, preventing unnecessary escalation.

Key Concept

Recognition and escalation of life-threatening postoperative orthopedic complications (hemorrhage, hypovolemic shock, and fat embolism syndrome).

Question 659Question →

An adult client in an inpatient psychiatric unit receives scheduled clozapine for treatment-resistant schizophrenia. During the morning medication pass, the practical nurse observes that the client has a new-onset temperature of $101.4^\circ\text{F}$ ( $38.6^\circ\text{C}$ ), severe pharyngitis, and marked lethargy. The morning laboratory report indicates a white blood cell (WBC) count of $1,800/\text{mm}^3$ ( $1.8 \times 10^9/\text{L}$ ). Based on these findings, which action should the practical nurse take first?

Withhold the scheduled dose of the medication and immediately report the clinical findings and laboratory results to the registered nurse.

Administer the scheduled medication and document the abnormal laboratory values in the client's electronic health record.

Perform a comprehensive, independent physical assessment to determine if the medication should be permanently discontinued.

Administer an as-needed analgesic to relieve the throat pain and ensure the client rests comfortably in bed.

Show answer & explanation

Answer: Withhold the scheduled dose of the medication and immediately report the clinical findings and laboratory results to the registered nurse.

Answer

The correct action is to withhold the scheduled dose of the medication and immediately escalate the clinical findings to the supervising registered nurse.

Clozapine is an atypical antipsychotic associated with a significant risk of agranulocytosis, a potentially fatal drop in white blood cells. A WBC count of

1,800/\text{mm}^3

(

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

), combined with signs of infection such as fever and pharyngitis, strongly indicates this adverse effect. The safest and most appropriate action within the practical nurse scope of practice is to withhold the offending agent and immediately escalate the critical findings to the registered nurse for urgent medical intervention.

Step-by-Step Solution

Analyze the client's presenting symptoms and laboratory results.

The client has a fever, pharyngitis, and a critically low WBC count of

1,800/\text{mm}^3

(normal is typically

4,500

11,000/\text{mm}^3

Identifying abnormal clinical and laboratory findings is the foundational step in safe medication administration.

Correlate the assessment findings with the prescribed pharmacological therapy.

Clozapine carries a severe risk for agranulocytosis, a dangerous depletion of white blood cells that compromises the immune system.

Connecting the drug to its potential life-threatening adverse effect determines the required clinical intervention.

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

The nurse must withhold the drug to prevent further harm and immediately report the findings to the registered nurse.

Administering the medication would worsen the life-threatening condition, and independent medical or complex assessment decisions fall outside the practical nursing scope.

Key Concept

Pharmacological Therapies

Question 660Question →

During a busy shift on a medical-surgical unit, a practical nurse is prioritizing client care and safety. Which of the following actions by the practical nurse demonstrate the correct application of risk reduction principles? Select all that apply.

Select all that apply

Withholding a scheduled dose of oral furosemide for a client whose morning serum potassium level is 2.8 mEq/L and alerting the registered nurse.

Declining a delegated task to administer an intravenous push (IVP) dose of morphine to a client experiencing severe postoperative pain.

Documenting a one-hour postoperative client's rising heart rate of 114 beats/min and blood pressure of 90/58 mmHg as expected surgical anxiety without further escalation.

Bypassing the electronic barcode scanning system and relying solely on the client's room number to verify identity before administering routine antibiotics.

Leaving a laboratory report showing a serum calcium level of 6.4 mg/dL (1.60 mmol/L) on the chart for the provider to review during afternoon rounds.

Accepting a delegated assignment to independently monitor and titrate a continuous intravenous heparin infusion for a client with a pulmonary embolism.

Show answer & explanation

Answer: Withholding a scheduled dose of oral furosemide for a client whose morning serum potassium level is 2.8 mEq/L and alerting the registered nurse.; Declining a delegated task to administer an intravenous push (IVP) dose of morphine to a client experiencing severe postoperative pain.

Answer

The correct actions are withholding the furosemide due to critical hypokalemia and declining to administer the intravenous push (IVP) morphine.

The correct actions demonstrate a clear understanding of risk reduction. Hypokalemia increases the risk of severe dysrhythmias, so withholding a loop diuretic and notifying the registered nurse is essential. Furthermore, refusing to perform tasks outside the practical nurse scope of practice, such as administering IV push medications, protects the client from potential harm and medication errors.

Step-by-Step Solution

Evaluate each action for adherence to safety protocols, critical value escalation, and practical nursing scope of practice.

Identified that handling medications appropriately and recognizing scope limitations are key components of risk reduction.

Risk reduction requires proactive identification of potential harm.

Analyze the action regarding furosemide administration.

A potassium level of 2.8 mEq/L is critically low. Withholding a potassium-depleting diuretic prevents further life-threatening hypokalemia.

Nurses must verify that current laboratory values support the safe administration of scheduled medications.

Analyze the action regarding the intravenous push (IVP) medication.

Declining the IVP administration is appropriate because it falls outside the legal and educational scope of the practical nurse.

Practicing within legal boundaries prevents client injury and professional liability.

Identify why the remaining actions fail to reduce risk.

The other actions involve ignoring early signs of shock, skipping vital medication identity checks, delaying the report of critical lab values, and accepting assignments beyond the PN scope.

Each of these distractors represents a direct violation of clinical safety and risk potential reduction.

Key Concept

Risk reduction requires the practical nurse to operate strictly within their defined scope of practice, properly verify client identity, and promptly escalate abnormal physiological findings and critical laboratory values.

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