Physiological Integrity

1313 questions

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During morning rounds, a licensed practical nurse is providing hygiene and comfort measures for a client who had a right above-the-knee amputation two days ago. The client currently reports moderate phantom limb discomfort. Which actions should the nurse incorporate into the care plan for this shift? Select all that apply.

Select all that apply

Assist the client into a prone position for 20 to 30 minutes several times a day.

Elevate the right residual limb on two stacked pillows while the client is resting in a supine position.

Gently wash the intact skin of the residual limb with mild soap and water, then pat it completely dry.

Instruct the assistive personnel to evaluate the healing progress of the surgical site while assisting with the bed bath.

Assume a newly assessed resting heart rate of 118 bpm with mild hypotension is an expected response to phantom limb discomfort.

Encourage the client to perform active range-of-motion exercises with the unaffected extremities.

Show answer & explanation

Answer: Assist the client into a prone position for 20 to 30 minutes several times a day.; Gently wash the intact skin of the residual limb with mild soap and water, then pat it completely dry.; Encourage the client to perform active range-of-motion exercises with the unaffected extremities.

Answer

The appropriate actions are assisting the client into a prone position periodically, washing and thoroughly drying the residual limb, and encouraging active range-of-motion exercises for the unaffected extremities.

Appropriate basic care for a client 48 hours post-amputation includes implementing prone positioning to stretch hip flexors and prevent contractures, meticulously cleaning and drying the residual limb to maintain skin integrity, and utilizing active range-of-motion exercises to preserve strength in unaffected limbs.

Step-by-Step Solution

Analyze the client's postoperative timeline and current physiological needs.

The client is 48 hours post-amputation, requires basic hygiene, and is experiencing phantom limb discomfort.

Establishing the precise postoperative timeframe (beyond 24 hours) dictates which positioning interventions are safe and which are highly contraindicated.

Identify correct basic care and comfort measures based on the timeline.

Prone positioning prevents contractures, washing prevents infection, and range-of-motion exercises maintain mobility.

These actions fall directly within the safe scope of nursing care and address the highest priority risks for this client.

Identify and exclude contraindicated or unsafe actions from the options.

Elevating the limb on pillows, delegating wound assessments, and dismissing abnormal vital signs are excluded.

These actions promote contractures, violate delegation rules, and risk missing a severe postoperative complication.

Key Concept

Postoperative Basic Care and Complication Prevention Following Amputation

Question 742Question →

A practical nurse (PN) is preparing to administer scheduled morning medications to a client with a history of heart failure. The medication administration record (MAR) includes a prescription for furosemide $40\text{ mg}$ orally. Upon reviewing the client's morning laboratory results, the PN notes a serum potassium level of $2.8\text{ mEq/L}$ . Which of the following is the most appropriate action for the PN to take?

Withhold the furosemide and immediately report the potassium level to the registered nurse (RN).

Administer the furosemide as prescribed and closely monitor the client for signs of muscle weakness.

Perform an independent, comprehensive cardiac assessment before deciding whether to give the medication.

Administer a prescribed intravenous push of potassium chloride to correct the deficit before giving the furosemide.

Show answer & explanation

Answer: Withhold the furosemide and immediately report the potassium level to the registered nurse (RN).

Answer

The correct action is to withhold the furosemide and immediately report the critically low potassium level to the registered nurse (RN).

Furosemide is a loop diuretic that causes the kidneys to excrete excess fluid and electrolytes, prominently potassium. A serum potassium level of

2.8\text{ mEq/L}

indicates significant and dangerous hypokalemia (normal range is

3.5

5.0\text{ mEq/L}

). Administering furosemide would further deplete the client's potassium reserves, placing them at immediate risk for life-threatening cardiac dysrhythmias. Within the practical nurse scope of practice, the mandatory action is to withhold the dose and rapidly communicate this critical laboratory finding to the registered nurse (RN) or healthcare provider so that corrective interventions can be ordered.

Step-by-Step Solution

Identify the medication's mechanism of action.

Furosemide is recognized as a loop diuretic that promotes the renal excretion of potassium.

Understanding the drug's physiological effect is essential to determine its safety based on current lab results.

Evaluate the provided laboratory values against standard physiological ranges.

The client's serum potassium level is

2.8\text{ mEq/L}

, which is critically low compared to the normal range of

3.5

5.0\text{ mEq/L}

Comparing current data to normal parameters reveals that the client is experiencing severe hypokalemia.

Select the appropriate nursing intervention within the PN scope of practice.

The scheduled furosemide dose is withheld, and the abnormal finding is promptly escalated to the supervising RN.

Administering the medication would cause further harm, and it is the PN's responsibility to report critical data to the RN for clinical decision-making.

Key Concept

Pharmacological safety, hypokalemia recognition, and practical nurse scope of practice regarding critical laboratory values.

Question 743Question →

A practical nurse is preparing to administer a scheduled dose of an oral opioid analgesic to a postoperative client. Upon entering the room, the nurse observes that the client is difficult to arouse and has a respiratory rate of 8 breaths per minute. Which action should the nurse take?

Administer the medication as prescribed to ensure the client's postoperative pain remains controlled.

Withhold the medication and immediately notify the registered nurse.

Obtain an intravenous push opioid antagonist and administer it immediately to reverse the effects.

Administer the medication after identifying the client using the room and bed number on the door.

Show answer & explanation

Answer: Withhold the medication and immediately notify the registered nurse.

Answer

Withhold the medication and immediately notify the registered nurse.

The client is exhibiting signs of severe respiratory depression, as evidenced by a respiratory rate of 8 breaths per minute and difficulty arousing. Opioid analgesics further depress the respiratory center. The safest and most appropriate action within the practical nurse's scope of practice is to withhold the medication and immediately escalate the critical finding to the registered nurse for further assessment.

Step-by-Step Solution

Evaluate the client's vital signs against the medication's expected side effect profile.

The respiratory rate of 8 breaths per minute is identified as severe respiratory depression.

Opioid analgesics suppress the central nervous system, and a respiratory rate below 12 breaths per minute is a critical warning sign that requires intervention.

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

The nurse must withhold the scheduled medication and alert the registered nurse.

Withholding the dose prevents further respiratory compromise, and the registered nurse must promptly assess the client to determine if further medical intervention is needed.

Key Concept

Opioid-induced respiratory depression and the practical nurse's scope of practice.

Estimated Time:45s

Question 744Question →

A practical nurse is providing care for an older adult client who recently returned to the unit following a right total hip arthroplasty. The client appears restless, is newly confused, and is attempting to cross their legs. Which of the following is the most appropriate initial action by the nurse?

Place an abductor pillow between the client's legs and verbally reorient the client.

Apply bilateral soft wrist restraints to prevent the client from disrupting the surgical site.

Document the confusion as an expected age-related change and continue routine observation.

Elevate the head of the bed to a high-Fowler's position to help the client clearly see the surroundings.

Show answer & explanation

Answer: Place an abductor pillow between the client's legs and verbally reorient the client.

Answer

Place an abductor pillow between the client's legs and verbally reorient the client.

After a total hip arthroplasty, it is critical to maintain the client's legs in an abducted position to prevent dislocation of the hip prosthesis. Placing an abductor pillow successfully prevents the client from crossing their legs. Furthermore, verbal reorientation is a standard, non-restrictive nursing intervention that provides comfort and addresses acute confusion safely.

Step-by-Step Solution

Identify the immediate physical risk to the client.

The client is attempting to cross their legs, which places them at high risk for hip dislocation following a total hip arthroplasty.

Post-operative hip precautions require keeping the legs abducted (apart) and avoiding adduction (crossing).

Determine the most appropriate and least restrictive intervention.

Using an abductor pillow physical protects the hip alignment, while verbal reorientation safely addresses the confusion.

Nursing care prioritizes basic comfort, safety, and using the least restrictive interventions before considering restraints.

Key Concept

Postoperative safety and positioning for total hip arthroplasty

Question 745Question →

A practical nurse is preparing to transfer a conscious client from a bed to a wheelchair. Arrange the following nursing actions in the correct sequence from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

First, position and lock the wheelchair. Next, assist the client to sit on the edge of the bed and dangle their legs. Then, apply a transfer belt. After that, brace the client's knees and assist them to stand. Finally, instruct the client to pivot and lower themselves into the wheelchair.

The correct sequence prioritizes foundational client safety. The nurse must first secure the receiving equipment (locking brakes). Next, physiological readiness must be ensured by allowing the client to dangle to prevent orthostatic hypotension. Once ready, applying a safety device (transfer belt) precedes the actual physical movement. Finally, the physical movement is executed using safe body mechanics (bracing and pivoting).

Step-by-Step Solution

Lock the wheelchair brakes on the strong side.

The equipment is stabilized.

Prevents the wheelchair from sliding away, which is a major fall risk.

Have the client sit and dangle their legs.

The client acclimates to an upright position.

Allows cardiovascular adjustment to prevent orthostatic hypotension and potential fainting.

Apply the transfer belt.

A secure grip is established.

Provides a safe way for the nurse to guide and lift the client without pulling on their arms or shoulders.

Assist to stand while bracing knees.

The client stands securely.

Supports the client's lower body and uses proper ergonomic techniques for the nurse.

Pivot and sit in the wheelchair.

The transfer is completed safely.

Reaching back for the armrests gives the client spatial awareness and a controlled descent.

Key Concept

Safe Client Transfer Techniques

Question 746Question →

A practical nurse is positioning a client in bed shortly after a thyroidectomy. Which of the following positions should the nurse use to promote client comfort and reduce the risk of complications?

Semi-Fowler's position with pillows supporting the head and neck

Supine position with a small rolled towel under the shoulders to hyperextend the neck

Flat on the bed in a lateral side-lying position

Trendelenburg position with the head of the bed lowered

Show answer & explanation

Answer: Semi-Fowler's position with pillows supporting the head and neck

Answer

The most appropriate position is the semi-Fowler's position with pillows supporting the head and neck.

The semi-Fowler's position elevates the head, which utilizes gravity to help decrease surgical edema in the neck and facilitates easier breathing. Supporting the head and neck with pillows maintains neutral alignment, preventing tension on the suture line and reducing pain.

Step-by-Step Solution

Identify the surgical procedure and its anatomical location.

The client had a thyroidectomy, which involves an incision in the anterior neck.

Understanding the surgical site highlights the specific risks, primarily airway compromise from tissue edema and tension on the suture line.

Determine the physiological goal of postoperative positioning for this specific surgery.

The goal is to minimize swelling (edema) in the neck and protect the surgical incision from stretching.

Swelling in the neck can quickly lead to respiratory distress, and stretching the neck can tear the sutures.

Select the position that best achieves these goals.

Semi-Fowler's position uses gravity to reduce swelling, and supporting the head with pillows keeps the neck in a neutral position to avoid tension.

This combination effectively addresses the primary postoperative risks for neck surgery.

Key Concept

Postoperative Care and Positioning

Question 747Question →

A practical nurse is preparing to administer a scheduled oral antibiotic to a client. The barcode on the client's identification band is smudged and cannot be scanned by the medication administration system. The client is alert and oriented. Which action should the nurse take next?

Request a new identification band, verify the client's identity using two identifiers, and then administer the medication.

Ask the client to verbally state their name and bypass the barcode scanning step.

Use a duplicate client barcode label from the medical record to complete the scanning process.

Verify the client's identity using the room number and bed assignment before administration.

Show answer & explanation

Answer: Request a new identification band, verify the client's identity using two identifiers, and then administer the medication.

Answer

The nurse should request a new identification band, verify the client using two identifiers, and then administer the medication.

Safe medication administration requires the nurse to verify the client's identity using two distinct identifiers (such as name and date of birth) and to scan the client's physical identification band. If the band is unreadable, a new one must be obtained and placed on the client prior to administration to ensure strict compliance with medication safety protocols.

Step-by-Step Solution

Identify that the current identification band is unreadable.

The nurse recognizes a barrier to safe medication administration.

A readable barcode is required for the electronic safety check.

Obtain a new identification band for the client.

A functional barcode is made available for scanning.

The system requires a barcode attached directly to the client to verify they are the right person.

Verify the client's identity using two distinct identifiers and scan the new band.

The client's identity is safely and accurately confirmed.

Using two identifiers fulfills the 'right client' requirement of safe medication administration.

Key Concept

Medication Rights Verification

Question 748Question →

A 79-year-old client is admitted to the medical unit with new-onset severe confusion and a temperature of $102.4^\circ\text{F}$ ( $39.1^\circ\text{C}$ ). The client's medication orders include a stat intravenous (IV) push antibiotic and a routine intramuscular influenza vaccine. The registered nurse delegates the administration of both medications to the practical nurse. Which action is most appropriate for the practical nurse to take?

Refuse the delegation for the IV push antibiotic due to scope limitations, and withhold the influenza vaccine because of the acute febrile illness, reporting to the registered nurse.

Administer the routine intramuscular influenza vaccine as ordered for respiratory protection, but request that the registered nurse administer the IV push antibiotic.

Attribute the severe confusion to expected age-related cognitive changes, and proceed to administer the IV push antibiotic slowly to minimize potential adverse effects.

Accept the complete medication delegation to ensure timely treatment of the infection, making certain to inject the IV push antibiotic over the recommended duration.

Show answer & explanation

Answer: Refuse the delegation for the IV push antibiotic due to scope limitations, and withhold the influenza vaccine because of the acute febrile illness, reporting to the registered nurse.

Answer

The practical nurse should decline the IV push medication because it is outside their scope of practice, and withhold the influenza vaccine because the client is currently experiencing a severe acute febrile illness.

The correct action requires the practical nurse to recognize two distinct safety issues. First, the administration of IV push medications generally falls outside the scope of practice for a practical nurse, as it requires advanced assessment and clinical judgment during rapid drug delivery. Second, the client's high fever and sudden confusion indicate an acute, moderate-to-severe illness, which is a recognized clinical precaution for withholding the influenza vaccine until the acute phase resolves.

Step-by-Step Solution

Analyze the delegated IV push antibiotic administration against the practical nurse scope of practice.

Determine that administering medications via IV push involves a level of assessment and clinical judgment reserved for registered nurses.

Ensuring safe and legal delegation is a continuous responsibility of the practical nurse.

Evaluate the client's current clinical presentation regarding the ordered influenza vaccine.

Identify that the client has a high fever of

102.4^\circ\text{F}

(

39.1^\circ\text{C}

) and new-onset confusion.

Moderate to severe acute illness, with or without a fever, is a standard precaution indicating that a vaccine should be deferred until the illness resolves.

Formulate the safest evidence-based response.

Refuse the IV push assignment, hold the influenza vaccine, and immediately notify the registered nurse of these decisions.

This protects client safety, prevents medication errors, and keeps the nurse within their legal scope of practice.

Key Concept

Scope of Practice and Immunization Contraindications

Question 749Question →

A client admitted with a severe traumatic brain injury is exhibiting signs of increased intracranial pressure (ICP) and is currently receiving mechanical ventilation. The practical nurse (PN) observes that the client has had a large incontinent liquid bowel movement and requires immediate perineal hygiene and a bed linen change. Which action by the PN demonstrates the most appropriate integration of basic comfort care and physiological safety for this client?

Maintaining the client's head and neck in a neutral, midline alignment while gently logrolling the body to the side.

Lowering the head of the bed completely flat to allow for easier removal of the soiled linens and placement of clean pads.

Elevating the client's lower extremities on pillows to prevent shear forces while pulling the soiled draw sheet.

Performing the hygiene care rapidly and utilizing firm friction during perineal cleansing to stimulate sensory pathways.

Show answer & explanation

Answer: Maintaining the client's head and neck in a neutral, midline alignment while gently logrolling the body to the side.

Answer

Maintaining the client's head and neck in a neutral, midline alignment while gently logrolling the body to the side.

When providing basic hygiene and comfort care to a client with increased intracranial pressure, the nurse must prevent activities that impede cerebral venous return. Maintaining the head and neck in a neutral, midline position prevents kinking or compression of the jugular veins. Logrolling ensures the neck does not twist during turning. Together, these actions allow the nurse to clean the client and change the linens without causing a dangerous spike in intracranial pressure.

Step-by-Step Solution

Analyze the client's primary pathophysiological risk.

The client has increased intracranial pressure (ICP), which can be fatally exacerbated by improper positioning or excessive stimulation.

Identifying the critical physiological constraint determines how basic care must be modified.

Evaluate the impact of neck and body alignment on cerebral hemodynamics.

Neck flexion, extension, or rotation compresses the jugular veins, trapping blood in the cranium and increasing ICP.

The jugular veins are the primary pathway for cerebral venous drainage.

Select the hygiene technique that minimizes physiological stress.

Logrolling keeps the spine, neck, and head aligned as a single unit, preventing cervical twisting while allowing access to the perineum and back.

This method safely accomplishes the basic care requirement without compromising neurological stability.

Key Concept

Modification of basic care and positioning to prevent elevation of intracranial pressure

Question 750Question →

A practical nurse is preparing to administer cefdinir to a pediatric client who weighs $35.2\text{ lb}$ and has acute otitis media. The healthcare provider has prescribed $7\text{ mg/kg}$ orally every $12$ hours. The medication available is cefdinir oral suspension labeled $125\text{ mg}/5\text{ mL}$ . How many $\text{mL}$ should the nurse administer per dose? (Record answer to the nearest tenth. Do not include units in answer.)

Show answer & explanation

Answer: 4.5

Answer

4.5

To determine the correct dose, first convert the weight from pounds to kilograms (

35.2 \div 2.2 = 16\text{ kg}

). Next, calculate the required dose by multiplying the weight by the prescribed amount (

16\text{ kg} \times 7\text{ mg/kg} = 112\text{ mg}

). Then, calculate the liquid volume needed by dividing the desired dose by the available dose and multiplying by the available volume:

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

. Finally, round to the nearest tenth as instructed, which results in

4.5\text{ mL}

Step-by-Step Solution

Convert the client's weight from pounds to kilograms.

35.2\text{ lb} \div 2.2\text{ lb/kg} = 16\text{ kg}

The medication dosage is prescribed based on the client's weight in kilograms, so the weight must be converted first.

Calculate the prescribed dose in milligrams.

16\text{ kg} \times 7\text{ mg/kg} = 112\text{ mg}

This determines the exact amount of medication the client should receive for one dose.

Calculate the required volume in milliliters.

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

Using the standard formula determines how much of the available liquid suspension is needed to deliver the prescribed dose.

Round the calculated volume to the nearest tenth.

4.5\text{ mL}

The question specifies recording the answer to the nearest tenth to ensure accurate measurement.

Key Concept

Weight-based pediatric dosage calculation and liquid medication volume conversion.

Question 751Question →

A licensed practical nurse (LPN) is gathering supplies and reviewing a client's health record prior to administering routine morning medications. Which essential safety practices should the nurse implement? Select all that apply.

Select all that apply

Verify the client's identity using their full name and date of birth.

Confirm that the client does not have any documented medication allergies.

Compare the dispensed medication labels against the medication administration record (MAR).

Administer a medication from an unlabeled container if the pill's appearance is familiar.

Bypass the electronic barcode scanning process if the client is already known to the nurse.

Show answer & explanation

Answer: Verify the client's identity using their full name and date of birth.; Confirm that the client does not have any documented medication allergies.; Compare the dispensed medication labels against the medication administration record (MAR).

Answer

The correct practices are verifying the client's identity with two distinct identifiers, confirming allergy status, and comparing the medication labels to the medication administration record (MAR).

The correct practices adhere directly to the standard rights of medication administration. Checking two unique identifiers ensures the correct client receives the drug, reviewing allergies prevents adverse reactions, and comparing physical labels against the MAR ensures the correct medication and dose are given.

Step-by-Step Solution

Review the fundamental rights of safe medication administration.

Identify that standard safety protocols require verifying the right client, the right medication, and the client's allergy status.

Adhering strictly to established safety guidelines is necessary to prevent medication errors.

Evaluate each provided option based on established safety protocols.

Select the practices that involve using two client identifiers, checking allergies, and comparing labels directly to the MAR.

These actions actively prevent errors, whereas using unlabeled containers or bypassing scanners introduces severe risk.

Key Concept

Rights of Medication Administration and Client Safety

Question 752Question →

During morning rounds, the nurse evaluates the care plan for a client who is recovering from abdominal surgery and receiving a continuous nasogastric tube feeding. Which of the following basic care interventions should the nurse implement? (Select all that apply)

Select all that apply

Elevate the head of the bed to at least 30 degrees.

Provide oral hygiene with a soft toothbrush or swabs every 2 to 4 hours.

Place the client in a completely flat position while they are sleeping.

Independently increase the feeding pump rate if the client states they are hungry.

Withhold reporting a mild drop in blood pressure if the client appears comfortable.

Assess the skin around the nostril where the tube is secured for any signs of redness.

Show answer & explanation

Answer: Elevate the head of the bed to at least 30 degrees.; Provide oral hygiene with a soft toothbrush or swabs every 2 to 4 hours.; Assess the skin around the nostril where the tube is secured for any signs of redness.

Answer

The correct actions include elevating the head of the bed to at least 30 degrees, providing oral hygiene every 2 to 4 hours, and assessing the skin around the nostril for redness.

Elevating the head of the bed to at least 30 degrees uses gravity to prevent regurgitation and aspiration of the feeding formula. Because clients with nasogastric tubes often breathe through their mouths, providing frequent oral hygiene is essential to prevent drying and cracking of the mucous membranes. Assessing the skin around the nares ensures that the medical device is not causing localized pressure injuries, maintaining overall skin integrity.

Step-by-Step Solution

Identify the primary safety and comfort risks associated with a continuous nasogastric tube feeding.

The main risks are pulmonary aspiration, mucosal dryness, and skin breakdown around the insertion site.

Understanding these specific risks directly guides the selection of appropriate basic care interventions.

Evaluate each care option against safety standards and the practical nursing scope of practice.

Elevating the head of the bed, providing regular oral care, and monitoring skin integrity are safe, within-scope actions. Laying the client flat, altering feeding rates independently, and ignoring borderline vitals are unsafe or out of scope.

Ensuring that interventions promote patient safety and remain within legal boundaries is essential for proper nursing care.

Key Concept

Basic care and comfort for clients with enteral tubes involves preventing aspiration, maintaining skin and mucosal integrity, and practicing within the legal scope.

Estimated Time:1m 30s

Question 753Question →

During morning rounds, a client's laboratory report indicates a serum potassium level of $3.1\text{ mEq/L}$ . The client's vital signs include a blood pressure of $118/76\text{ mmHg}$ and an apical pulse of $56\text{ beats/min}$ . The medication administration record shows a scheduled dose of oral digoxin $0.25\text{ mg}$ . Based on these findings, which of the following actions is most appropriate for the practical nurse to perform?

Proceed with administering the medication after verifying the client's identity using their bed assignment.

Initiate an intravenous push of potassium chloride prior to giving the oral medication.

Withhold the medication and immediately report the clinical findings to the registered nurse.

Administer the medication as prescribed because the serum potassium level is within the expected therapeutic range.

Show answer & explanation

Answer: Withhold the medication and immediately report the clinical findings to the registered nurse.

Answer

Withhold the medication and immediately report the clinical findings to the registered nurse.

The client is exhibiting bradycardia (an apical pulse less than

60\text{ beats/min}

) and hypokalemia (a serum potassium level less than

3.5\text{ mEq/L}

). Both conditions are contraindications or high-risk factors for administering digoxin, as low potassium significantly increases the risk of digoxin toxicity. The appropriate action within the practical nurse scope of practice is to withhold the medication and escalate these critical findings to the registered nurse or healthcare provider.

Step-by-Step Solution

Evaluate the client's vital signs and laboratory values against established normal parameters.

The apical pulse of

56\text{ beats/min}

is below the normal threshold (

60\text{ beats/min}

) for digoxin administration, and the potassium level of

3.1\text{ mEq/L}

indicates hypokalemia.

Safe medication administration requires ensuring that the client's current physiological status does not contraindicate the ordered pharmacological therapy.

Determine the relationship between the abnormal clinical findings and the scheduled medication.

Hypokalemia significantly increases the risk of digoxin toxicity, making the administration of the medication unsafe in the presence of a low heart rate.

Understanding drug-laboratory interactions is essential to prevent severe adverse pharmacological events.

Identify the correct nursing intervention within the practical nurse's scope of practice.

The medication must be withheld and the abnormal clinical findings promptly reported to the registered nurse for further medical evaluation.

Practical nurses must escalate critical abnormal findings and withhold potentially harmful medications to ensure client safety.

Key Concept

Pharmacological therapies require the practical nurse to evaluate pertinent laboratory values and vital signs prior to administration, withholding the medication and notifying the registered nurse when findings suggest a heightened risk for adverse effects or toxicity.

Question 754Question →

A practical nurse is preparing to administer prescribed ear drops to an adult client. Arrange the steps of this procedure in the correct chronological order.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: perform hand hygiene and verify identity; position the client on their side; pull the pinna up and back; instill the drops; and instruct the client to remain in position.

The correct sequence ensures medication safety, proper anatomical alignment, and effective drug absorption. Hand hygiene and patient identification are universally the first steps. Positioning the client prepares the treatment area. Because the client is an adult, the pinna must be pulled up and back to straighten the ear canal. Instilling the medication without touching the ear maintains sterility, and having the client remain in position ensures the drops effectively reach their target.

Step-by-Step Solution

Perform hand hygiene and verify the client using two identifiers.

The nurse confirms the right client and maintains infection control.

This is the mandatory foundational safety check for all nursing interventions.

Place the client in a lateral position with the affected ear exposed.

The ear canal is positioned to receive the medication.

Gravity facilitates the flow of the liquid medication into the ear.

Grasp the pinna and pull it up and back.

The adult ear canal is straightened.

Straightening the canal ensures the medication reaches the tympanic membrane rather than resting in the outer curvature of the canal.

Squeeze the dropper to instill the correct number of drops without making physical contact.

Medication is administered safely and cleanly.

Hovering the dropper without touching the skin or ear canal prevents microbial contamination.

Ask the client to remain still for approximately 2 to 3 minutes.

The medication is fully absorbed and dispersed.

It prevents the drops from rolling out of the ear canal prematurely.

Key Concept

Safe and effective administration of otic medications in adult clients

Estimated Time:1m 0s

Question 755Question →

A newly admitted young adult has completed a diagnostic lumbar puncture on the medical unit. To minimize the risk of post-procedure complications, which position should the nurse encourage the client to maintain?

Supine with the head of the bed flat

Semi-Fowler's with the knees slightly bent

Left lateral position with the chin tucked

High-Fowler's position with a pillow behind the head

Show answer & explanation

Answer: Supine with the head of the bed flat

Answer

Supine with the head of the bed flat

Following a lumbar puncture, the client must remain flat in a supine position for a prescribed number of hours. This flat position minimizes hydrostatic pressure on the dural puncture site in the lower back, reducing the risk of cerebrospinal fluid leakage and the subsequent development of a severe spinal headache.

Step-by-Step Solution

Analyze the completed procedure.

The client had a lumbar puncture, which involves a needle entering the subarachnoid space in the lower spine.

Understanding the anatomy of the procedure helps identify potential post-procedure risks.

Identify the primary complication associated with this procedure.

The most common and preventable complication is a post-dural puncture headache caused by cerebrospinal fluid (CSF) leakage.

Nursing interventions for basic care and comfort post-procedure focus on minimizing this specific risk.

Select the position that minimizes pressure on the puncture site.

Remaining flat keeps hydrostatic pressure off the lower spine, reducing the chance of a leak.

Gravity increases pressure on the lower spine if the head is elevated.

Key Concept

Post-lumbar puncture positioning

Question 756Question →

A practical nurse is preparing to administer 10 units of regular insulin and 20 units of NPH insulin mixed in a single syringe to a client with diabetes mellitus. Arrange the following steps in the correct sequence for this procedure.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to roll the NPH vial, inject 20 units of air into the NPH vial, inject 10 units of air into the regular insulin vial, withdraw 10 units of regular insulin, and finally withdraw 20 units of NPH insulin.

When mixing NPH (intermediate-acting) and regular (short-acting) insulins, the standard safety protocol is 'clear before cloudy' for withdrawing the medication to prevent contamination of the fast-acting insulin. However, to prevent a vacuum in the vials, air must first be injected into the cloudy (NPH) vial, followed by injecting air into the clear (regular) vial. The regular insulin is then withdrawn first, and the NPH is withdrawn last to complete the total dose.

Step-by-Step Solution

Roll the NPH insulin vial gently between the palms of the hands.

The cloudy insulin suspension is thoroughly mixed.

Rolling prevents the formation of air bubbles that can occur with shaking, ensuring an accurate dose.

Inject 20 units of air into the NPH insulin vial.

The NPH vial is pressurized.

Injecting air prevents negative pressure. Doing this first (cloudy first for air) prevents contamination of the regular insulin later.

Inject 10 units of air into the regular insulin vial.

The regular insulin vial is pressurized.

Prevents negative pressure in the regular insulin vial. The needle is left in place to immediately draw the medication.

Invert the regular insulin vial and withdraw 10 units of insulin.

The clear insulin is drawn into the syringe.

Drawing clear insulin first ('clear before cloudy') prevents contaminating the short-acting insulin with the longer-acting NPH insulin.

Insert the needle into the NPH insulin vial and withdraw 20 units of insulin.

The final combined dose of 30 units is achieved.

The cloudy insulin is drawn last. The nurse must carefully draw exactly 20 units, as it cannot be pushed back into the vial if overdrawn.

Key Concept

Safe administration and preparation of mixed insulins

Question 757Question →

A practical nurse (PN) is caring for a client who underwent a right total hip arthroplasty (posterior approach) 24 hours ago. The client is receiving continuous enteral feeding via a gastrostomy tube and reports significant sacral discomfort from lying supine. The PN determines that the client needs to be repositioned to relieve pressure. Which sequence of actions is the most appropriate for the PN to implement?

Pause the enteral feeding, lower the head of the bed to a flat position, ensure the abductor pillow is secured, logroll the client onto the left side, and then elevate the head of the bed to 30 degrees before resuming the feeding.

Lower the head of the bed to a flat position to maintain spinal alignment, logroll the client onto the left side with the abductor pillow in place, and leave the continuous feeding running to ensure adequate caloric intake.

Maintain the head of the bed at a 30-degree angle to prevent aspiration, temporarily remove the abductor pillow to facilitate easier movement, and assist the client to turn onto the left side.

Elevate the head of the bed to a 90-degree angle to shift the client's body weight from the sacrum to the ischial tuberosities while maintaining optimal aspiration precautions during the feeding.

Show answer & explanation

Answer: Pause the enteral feeding, lower the head of the bed to a flat position, ensure the abductor pillow is secured, logroll the client onto the left side, and then elevate the head of the bed to 30 degrees before resuming the feeding.

Answer

The sequence where the nurse pauses the enteral feeding, lowers the bed flat, keeps the abductor pillow secured, logrolls the client to the left side, and elevates the bed to 30 degrees before resuming the feed.

This sequence safely addresses both the client's aspiration risk and postoperative hip precautions. When turning a client to relieve sacral pressure, the bed should be lowered to a flat position to maintain proper body alignment and prevent shearing. Because the client is receiving continuous enteral feeding, the pump must be paused before lowering the head of the bed to prevent regurgitation and aspiration. The abductor pillow must remain securely in place to prevent adduction of the operated leg, which could cause a posterior dislocation. Once the client is safely logrolled to the unoperated side, the head of the bed must be elevated back to at least 30 degrees before the feeding is resumed.

Step-by-Step Solution

Identify the client's concurrent positioning risks.

The client has a severe aspiration risk from the enteral feeding and a high dislocation risk from the recent posterior approach total hip arthroplasty.

Recognizing overlapping precautions is essential for planning safe basic care.

Determine the physical requirements for a safe turn.

Turning the client requires flattening the bed to maintain proper spinal alignment and reduce shearing forces.

Turning a client with the head of the bed elevated creates poor body mechanics and increases skin friction.

Address the aspiration risk prior to movement.

The continuous enteral feeding must be temporarily paused before lowering the head of the bed.

Laying a client flat while formula is actively infusing into the stomach can lead to immediate regurgitation and aspiration into the lungs.

Execute the turn while maintaining musculoskeletal precautions.

The abductor pillow is left in place, and the client is logrolled onto the unoperated (left) side.

The abductor pillow prevents the operated leg from crossing the midline (adduction), which is the primary cause of dislocation in posterior hip replacements.

Restore aspiration precautions and comfort.

The head of the bed is elevated back to at least 30 degrees, and the feeding is resumed.

Formula can only be safely administered when the upper body is adequately elevated to allow gravity to assist digestion.

Key Concept

Prioritization of basic care interventions involving concurrent aspiration precautions and postoperative mobility restrictions.

Question 758Question →

While caring for a client who has been resting in a bedside chair, the practical nurse receives a prescription to apply knee-high anti-embolism stockings. In what order should the nurse perform the following actions to safely and effectively apply the stockings? Arrange the steps from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first assess the skin and pulses, elevate the legs, invert the stocking to the heel, align the foot and heel, and finally pull the stocking up smoothly.

Applying anti-embolism stockings correctly requires a sequence that prioritizes assessment, preparation, and proper technique. First, the practical nurse must collect baseline data by observing the skin and checking pedal pulses to identify any contraindications. Next, because the client has been sitting in a chair, the nurse must assist the client into a supine position and elevate their legs for 15 to 30 minutes. This critical step reduces dependent edema and prevents trapping venous blood in the lower extremities. Once prepared, the nurse inverts the stocking inside out down to the heel, which facilitates sliding it over the foot. The foot is positioned into the stocking with careful attention to aligning the heel in the pocket to prevent pressure points. Finally, the remaining portion of the stocking is pulled up the calf, and all wrinkles or rolls are smoothed out to prevent a tourniquet effect that could impede venous return and damage the skin.

Step-by-Step Solution

Palpate pedal pulses and observe the skin of the lower extremities for any lesions.

Baseline circulatory and skin integrity data is collected.

Data collection must occur before the intervention to ensure there are no contraindications, such as severe arterial disease or open wounds, to applying compression.

Assist the client into a supine position and elevate the legs for 15 to 30 minutes.

Venous pooling in the lower extremities is reduced.

Because the client was sitting, elevating the legs promotes venous return and reduces dependent edema, ensuring the stockings will not trap pooled blood.

Invert the anti-embolism stocking inside out down to the heel.

The stocking is prepared for application.

Turning the stocking inside out makes it much easier to smoothly slide the foot portion over the client's toes and ankle without excessive friction.

Position the client's foot into the stocking and align the heel in the heel pocket.

The foot and heel are properly secured in the garment.

Proper alignment of the heel ensures the graduated compression is distributed correctly across the foot and ankle, preventing pressure injuries.

Pull the stocking up over the calf and smooth out any wrinkles or rolls.

The stocking provides uniform compression along the leg.

Wrinkles or rolled edges act as a tourniquet, which can impede blood flow, cause discomfort, and lead to skin breakdown.

Key Concept

Proper application of anti-embolism stockings to promote venous return and prevent complications.

Estimated Time:1m 30s

Question 759Question →

A practical nurse is assisting a postoperative client who is still drowsy from anesthesia. The client suddenly experiences nausea and begins to actively vomit. To prevent aspiration and protect the airway, which position should the nurse immediately assist the client into?

Side-lying (lateral) position

Flat on the back (supine) position

Head lower than the feet (Trendelenburg) position

Lying on the stomach (prone) position

Show answer & explanation

Answer: Side-lying (lateral) position

Answer

The side-lying (lateral) position is the safest and most effective choice.

The side-lying (lateral) position is the standard of care for a semiconscious or vomiting client. It utilizes gravity to allow vomit and oral secretions to drain safely from the mouth, preventing the fluid from entering the lungs.

Step-by-Step Solution

Assess the client's immediate physical risk.

The client is drowsy and actively vomiting, which creates a high risk for aspiration.

Recognizing aspiration risk dictates the priority of care.

Determine the best position to use gravity for airway clearance.

The side-lying position is selected.

Turning the client on their side allows fluids to naturally drain out of the mouth instead of into the airway.

Key Concept

Airway Protection and Postoperative Positioning

Question 760Question →

An older adult client with a history of dysphagia and seizures receives scheduled medications via a percutaneous endoscopic gastrostomy (PEG) tube. The healthcare provider prescribes valproic acid syrup at a dosage of $15\text{ mg/kg/day}$ divided into two equal doses. The client's current weight is $143\text{ lb}$ . The pharmacy supplies valproic acid syrup with a concentration of $250\text{ mg}/5\text{ mL}$ .

How many $\text{mL}$ should the practical nurse administer for one single dose? (Record the answer to the nearest tenth. Do not include units in your answer.)

Show answer & explanation

Answer: 9.8

Answer

9.8

The correct calculation requires sequential mathematical steps: converting weight to kilograms (

143 \div 2.2 = 65\text{ kg}

), determining the total daily dose (

65 \times 15 = 975\text{ mg}

), dividing by two for a single dose (

975 \div 2 = 487.5\text{ mg}

), calculating the required liquid volume (

487.5 \times \frac{5}{250} = 9.75\text{ mL}

), and correctly rounding

9.75

to the nearest tenth to yield

9.8

Step-by-Step Solution

Convert the client's weight from pounds (lb) to kilograms (kg).

143\text{ lb} \div 2.2\text{ lb/kg} = 65\text{ kg}

Weight-based medication dosages require the client's weight to be in kilograms.

Calculate the total daily dose in milligrams (mg).

65\text{ kg} \times 15\text{ mg/kg/day} = 975\text{ mg/day}

The prescription specifies

15\text{ mg}

per kilogram for the entire 24-hour period.

Calculate the amount for a single dose.

975\text{ mg/day} \div 2\text{ doses} = 487.5\text{ mg/dose}

The total daily amount must be divided into two equal doses as prescribed.

Calculate the volume (mL) to administer based on the pharmacy concentration.

\frac{487.5\text{ mg}}{250\text{ mg}} \times 5\text{ mL} = 1.95 \times 5\text{ mL} = 9.75\text{ mL}

Dimensional analysis is used to convert the ordered dose in milligrams to the deliverable volume in milliliters.

Round the final answer to the nearest tenth.

9.75\text{ mL} \rightarrow 9.8\text{ mL}

The question explicitly asks to record the answer to the nearest tenth. Because the hundredths digit is 5, round up.

Key Concept

Weight-based dosage calculation, unit conversion, and liquid medication administration via enteral tube.

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