Physiological Integrity

1313 questions

All types1,313 Multiple choice672 Multiple select289 Numeric68 Ordering284

While conducting morning rounds, a nurse carries a prescribed dose of oral levothyroxine into a client's room. The client is currently using the bathroom, and dietary staff has just placed a breakfast tray on the bedside table. Which action is the most appropriate for the nurse to perform next?

Leave the medication in a cup on the meal tray so the client can take it immediately upon exiting the bathroom.

Request that the dietary staff member or unlicensed assistive personnel (UAP) observe the client swallowing the pill.

Retain possession of the medication and return to the room when the client is available for proper identification.

Pass the medication cup to the client through the bathroom door to ensure the dose is administered on schedule.

Show answer & explanation

Answer: Retain possession of the medication and return to the room when the client is available for proper identification.

Answer

The most appropriate action is to retain possession of the medication and return to the room when the client is available for proper identification.

The correct action ensures adherence to the core rights of medication administration. A nurse must directly verify the client's identity using two approved identifiers and remain present to physically observe the client swallowing the medication. If the client is temporarily unavailable, the nurse must retain the drug and return later.

Step-by-Step Solution

Evaluate the client's immediate availability to participate in the medication administration process.

The client is in the bathroom and cannot be properly identified or observed.

Safe medication administration requires direct, face-to-face verification of client identity using two identifiers.

Determine the safest course of action regarding the unsecured medication.

The nurse must keep the medication in their possession and return later.

Medications must never be left unattended at the bedside due to the severe risks of loss, accidental ingestion by others, or failure to administer.

Key Concept

Safe Medication Administration Practices

Question 802Question →

A practical nurse (PN) is assigned to care for a $68$ -year-old client with chronic obstructive pulmonary disease (COPD). The PN is reviewing the client's morning data prior to administering the scheduled 0900 medications.

Current Data:
- Vital signs: Blood pressure $138/84\text{ mmHg}$ , Heart rate $118\text{ beats/min}$ , Respiratory rate $22\text{ breaths/min}$ .
- Laboratory results: Serum theophylline level $24\text{ mcg/mL}$ , Fasting blood glucose $165\text{ mg/dL}$ .
- Scheduled 0900 medications: Oral theophylline, oral prednisone, and inhaled albuterol.

Based on the data provided, which of the following actions by the PN demonstrate safe and appropriate pharmacological management? (Select all that apply.)

Select all that apply

Withhold the scheduled oral theophylline and immediately notify the registered nurse (RN) of the laboratory results.

Reinforce education with the client to strictly avoid consuming caffeinated beverages while receiving theophylline therapy.

Proceed with administering the oral prednisone, recognizing that the elevated blood glucose is a known effect of corticosteroid therapy.

Administer the oral theophylline as prescribed because the serum drug level is within the normal therapeutic range.

Accept a delegation from the RN to administer a prescribed intravenous (IV) push beta-blocker to treat the client's tachycardia.

Assume the heart rate of

118\text{ beats/min}

is a baseline finding for COPD and administer all medications without further escalation.

Show answer & explanation

Answer: Withhold the scheduled oral theophylline and immediately notify the registered nurse (RN) of the laboratory results.; Reinforce education with the client to strictly avoid consuming caffeinated beverages while receiving theophylline therapy.; Proceed with administering the oral prednisone, recognizing that the elevated blood glucose is a known effect of corticosteroid therapy.

Answer

The correct actions are to withhold the theophylline and notify the RN, reinforce teaching to avoid caffeine, and proceed with the administration of prednisone.

Theophylline has a narrow therapeutic range of

10

20\text{ mcg/mL}

. The client's level of

24\text{ mcg/mL}

accompanied by tachycardia (

118\text{ beats/min}

) clearly indicates toxicity. The PN must withhold the medication, notify the RN, and reinforce teaching to avoid methylxanthine-containing substances like caffeine, which exacerbate toxicity. Conversely, an elevated blood glucose level is an expected side effect of the corticosteroid prednisone and is not a reason to withhold the dose.

Step-by-Step Solution

Evaluate the client's theophylline laboratory result.

The theophylline level is

24\text{ mcg/mL}

, which exceeds the narrow therapeutic range of

10

20\text{ mcg/mL}

Recognizing a toxic drug level is required to prevent the administration of further doses that could cause fatal arrhythmias or seizures.

Assess the vital signs in relation to the pharmacological therapies.

The client has a heart rate of

118\text{ beats/min}

, which is an active clinical manifestation of theophylline toxicity.

Correlating vital signs with drug levels confirms the presence of toxicity and underscores the urgency of withholding the medication and notifying the RN.

Evaluate the client's blood glucose level in relation to the prescribed prednisone.

The fasting blood glucose is elevated at

165\text{ mg/dL}

, which is an expected, drug-induced effect of corticosteroid therapy.

Understanding expected adverse effects ensures that essential maintenance therapies (like steroids for COPD) are not inappropriately withheld.

Determine appropriate PN actions based on legal boundaries and safety protocols.

The PN must reinforce teaching about interacting substances like caffeine and refuse tasks outside their scope, such as administering IV push medications.

Safe pharmacological management requires strict adherence to the practical nurse's legal scope of practice.

Key Concept

Synthesizing narrow-therapeutic-index drug toxicity, expected medication side effects, and practical nurse scope of practice limitations.

Question 803Question →

A practical nurse is assigned to care for a client who is receiving daily immunosuppressive therapy following a recent kidney transplant. The client has several scheduled interventions and medications for the morning shift. Which actions by the practical nurse demonstrate safe pharmacological practice and adherence to the legal scope of practice? Select all that apply.

Select all that apply

Verifying the client's name and date of birth against the medication administration record before providing oral anti-rejection medications.

Reinforcing the registered nurse's education about the importance of reporting any signs of infection, such as a sore throat or low-grade fever.

Administering a scheduled live-attenuated influenza vaccine to protect the client from seasonal respiratory viruses.

Drawing up and administering an intravenous push dose of a prescribed antiemetic to treat the client's sudden onset of severe nausea.

Administering the scheduled morning dose of a nephrotoxic immunosuppressant drug despite noting a new, critically elevated serum creatinine level.

Withholding a scheduled oral antihypertensive medication and notifying the registered nurse because the client's systolic blood pressure is 88 mm Hg.

Show answer & explanation

Answer: Verifying the client's name and date of birth against the medication administration record before providing oral anti-rejection medications.; Reinforcing the registered nurse's education about the importance of reporting any signs of infection, such as a sore throat or low-grade fever.; Withholding a scheduled oral antihypertensive medication and notifying the registered nurse because the client's systolic blood pressure is 88 mm Hg.

Answer

The correct actions include verifying the client's identity using two identifiers, reinforcing education regarding infection risks associated with immunosuppression, and withholding antihypertensive medications in the presence of hypotension.

The correct actions align with the practical nurse's legal scope and safe pharmacology principles. Verifying two unique identifiers ensures the right client receives the medication. Reinforcing previously delivered education about infection risks is a designated responsibility of the practical nurse, particularly vital for a client on immunosuppressants. Finally, recognizing a hypotensive state (systolic blood pressure of 88 mm Hg) and withholding an antihypertensive medication prevents dangerous hemodynamic instability, which is a critical safety intervention.

Step-by-Step Solution

Analyze the client scenario and clinical context.

The client is immunocompromised due to anti-rejection medications following a kidney transplant, meaning they are at high risk for infection and organ rejection.

Understanding the client's baseline vulnerabilities guides safe medication choices and education needs.

Evaluate each option against the practical nurse (PN) scope of practice.

Reinforcing teaching and withholding medications based on abnormal vital signs are within the PN scope. Administering IV push medications requires advanced assessment and is outside the standard PN scope.

Scope of practice dictates which pharmacological interventions a practical nurse can safely and legally perform.

Evaluate each option against pharmacological safety rules.

Using two identifiers is a mandatory safety standard. Giving live vaccines to an immunosuppressed client is dangerous. Administering nephrotoxic drugs in the presence of elevated creatinine without consulting a provider risks graft failure.

Medication safety requires checking contraindications (live vaccines) and pertinent laboratory data before administration.

Key Concept

Practical Nurse Scope of Practice and Immunosuppressant Therapy Safety

Question 804Question →

A practical nurse is assisting a client who has a traumatic brain injury with right-sided weakness and moderate dysphagia. The client's dietary order specifies pureed foods and nectar-thick liquids. Which action is the most appropriate for the nurse to implement during the meal?

Position the client upright at 90 degrees, instruct them to tilt the chin downward during swallowing, and place food on the left side of the oral cavity.

Maintain the head of the bed at a 45-degree angle and provide a flexible straw to help the client consume the nectar-thick liquids.

Offer small, alternating sips of unthickened water between bites of pureed food to ensure the throat remains clear of residue.

Delegate the feeding procedure to an unlicensed assistive personnel (UAP) after independently verifying the correct meal tray was delivered.

Show answer & explanation

Answer: Position the client upright at 90 degrees, instruct them to tilt the chin downward during swallowing, and place food on the left side of the oral cavity.

Answer

Position the client upright at 90 degrees, instruct them to tilt the chin downward during swallowing, and place food on the left side of the oral cavity.

The correct answer demonstrates the most comprehensive and safe approach for a client with dysphagia and unilateral weakness. Positioning the client at 90 degrees utilizes gravity to assist swallowing, while the chin-down (chin-tuck) maneuver widens the valleculae and narrows the airway entrance, providing essential protection against aspiration. Placing the food on the left side (the unaffected, strong side) ensures the client can properly sense and manipulate the bolus before swallowing.

Step-by-Step Solution

Analyze the client's physical deficits and dietary orders based on the clinical presentation.

Identifies that right-sided weakness leaves the left side of the mouth as the strong, unaffected side. Notes the strict requirement for pureed foods and nectar-thick liquids.

Understanding the anatomical deficits and dietary constraints is required to plan safe feeding interventions.

Evaluate the physiological risks associated with moderate dysphagia.

Recognizes that the primary risk during oral intake is airway compromise and aspiration pneumonia.

Prioritizing Airway, Breathing, and Circulation (ABCs) guides the selection of interventions that protect the respiratory tract.

Determine the optimal positioning and feeding technique to mitigate aspiration risk.

Concludes that sitting at a 90-degree angle with a chin-tuck maneuver mechanically protects the airway, and utilizing the strong (left) side of the mouth ensures the client can effectively control the food bolus.

Applying evidence-based dysphagia precautions ensures the maintenance of basic care, comfort, and physiological integrity.

Key Concept

Dysphagia Management and Airway Protection

Question 805Question →

A client with mild fluid retention is prescribed furosemide $30\text{ mg}$ by mouth every morning. The client's morning vital signs include a blood pressure of $122/78\text{ mmHg}$ and a heart rate of $76\text{ beats/min}$ , with a recent serum potassium level of $4.1\text{ mEq/L}$ . The pharmacy delivers furosemide oral solution labeled $40\text{ mg}$ per $5\text{ mL}$ . How many milliliters (mL) should the practical nurse administer for the morning dose? Record your answer to the nearest tenth. Do not include units in your answer.

Show answer & explanation

Answer: 3.8

Answer

The practical nurse should administer

3.8\text{ mL}

of the furosemide oral solution.

The correct answer is derived by applying the standard dosage calculation formula

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

. Substituting the given values (

\frac{30\text{ mg}}{40\text{ mg}} \times 5\text{ mL}

) yields

3.75\text{ mL}

. Rounding to the nearest tenth gives

3.8

. The vital signs and potassium level provided (

4.1\text{ mEq/L}

) are within normal limits, confirming it is safe for the practical nurse to proceed with the administration.

Step-by-Step Solution

Identify the prescribed dose and available concentration from the scenario.

Desired =

30\text{ mg}

, Have =

40\text{ mg}

, Quantity =

5\text{ mL}

Accurate extraction of clinical data is required before performing any medication calculation.

Apply the standard dosage calculation formula:

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

\frac{30\text{ mg}}{40\text{ mg}} \times 5\text{ mL} = 3.75\text{ mL}

This formula determines the exact liquid volume needed to deliver the prescribed dose safely.

Round the final answer to the nearest tenth according to the instructions.

3.75\text{ mL}

rounds to

3.8\text{ mL}

Liquid medications measured in small syringes are typically rounded to the nearest tenth for precise administration, adhering to standard rounding rules where the hundredths place is

5

or greater.

Key Concept

Oral liquid dosage calculation using the Desired over Have formula.

Question 806Question →

A practical nurse enters a client's room and observes the client coughing vigorously with enteral nutrition formula visible in their mouth. The client is currently receiving a continuous enteral tube feeding. In which order should the nurse perform the following actions to minimize the risk of aspiration and respiratory complications? Arrange the steps from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The nurse must first stop the enteral feeding pump, turn the client to a side-lying position, suction the oropharynx, obtain vital signs including oxygen saturation, and finally notify the supervising RN.

In any acute clinical emergency, the nurse must follow the principles of priority setting: address the immediate threat to life first. When a client receiving tube feedings begins to aspirate, the nurse must instantly stop the source of the aspiration (the pump). Following the ABCs (Airway, Breathing, Circulation), the nurse then physically protects the airway by turning the client, followed by clearing the airway via suction. Only after the airway is stable should the nurse assess breathing parameters (vital signs/oxygen saturation) and escalate the findings to the RN.

Step-by-Step Solution

Stop the enteral feeding.

Additional formula is prevented from being infused.

The priority in any adverse event is to immediately stop the offending agent to prevent further harm.

Reposition the client to their side.

Gravity assists in draining the mouth.

This physical maneuver immediately protects the airway from the pooling fluid before equipment is gathered.

Suction the oropharynx.

The airway is cleared of residual formula.

Mechanical removal of the formula ensures a patent airway and prevents subsequent aspiration during the next breath.

Assess vital signs and oxygen saturation.

The client's physiological stability is determined.

Objective data must be gathered to determine if the aspiration has caused hypoxemia or respiratory distress.

Notify the RN.

The healthcare team is informed for further medical management.

The RN and healthcare provider need the assessment data to determine if a chest x-ray or changes to the feeding regimen are required.

Key Concept

Immediate airway management and sequence of prioritization during an aspiration event

Estimated Time:1m 15s

Question 807Question →

A practical nurse is preparing a client for a scheduled computed tomography (CT) scan that requires the administration of intravenous contrast dye. The nurse is reviewing the client's electronic health record. Which of the following documented findings indicate an increased risk for complications and require immediate notification to the registered nurse? Select all that apply.

Select all that apply

A serum creatinine level of 2.8 mg/dL

A documented history of anaphylaxis to iodine

Current daily use of prescribed metformin

A serum potassium level of 4.1 mEq/L

A baseline blood pressure of 118/74 mm Hg

Show answer & explanation

Answer: A serum creatinine level of 2.8 mg/dL; A documented history of anaphylaxis to iodine; Current daily use of prescribed metformin

Answer

The findings that require immediate notification to the registered nurse are the elevated serum creatinine level, the documented iodine anaphylaxis, and the current use of metformin.

Intravenous contrast dye is primarily cleared by the kidneys and typically contains iodine. Therefore, renal impairment (evidenced by an elevated creatinine level) and a known iodine allergy are direct risks for nephropathy and anaphylaxis, respectively. Additionally, taking metformin concurrently with contrast dye significantly increases the risk of lactic acidosis, requiring the medication to be temporarily withheld.

Step-by-Step Solution

Analyze the physiological requirements of the scheduled procedure.

CT scans with contrast utilize intravenous iodine-based dye, which is subsequently excreted by the kidneys.

Understanding how the procedure impacts the body helps identify specific physiological risks and contraindications.

Evaluate the client's laboratory values and current medication list.

The elevated serum creatinine level indicates renal impairment, and the use of metformin carries a high risk for lactic acidosis when combined with contrast dye.

The nurse must identify any systemic findings that interfere with the safe excretion of the dye.

Review the client's documented allergy history.

An allergy to iodine is a direct and severe contraindication to the contrast dye used in the scan.

Preventing an anaphylactic reaction is a primary safety responsibility before any diagnostic procedure.

Key Concept

Identifying risk factors and contraindications prior to diagnostic procedures involving intravenous contrast dye.

Question 808Question →

A practical nurse (PN) is preparing to administer morning medications to a client who is receiving continuous enteral nutrition via a nasogastric (NG) tube. The client's medication administration record includes phenytoin oral suspension, an extended-release metoprolol tablet, and a PRN sublingual nitroglycerin tablet for chest pain. Which of the following actions should the PN take? Select all that apply.

Select all that apply

Stop the continuous enteral feeding for 1 to 2 hours before and after administering the phenytoin oral suspension.

Crush the extended-release metoprolol tablet and dissolve it in 30 mL of warm water before administration.

Flush the nasogastric tube with 15 to 30 mL of water before and after administering each medication.

Administer the sublingual nitroglycerin directly into the nasogastric tube if the client experiences acute chest pain.

Delegate the administration of the phenytoin oral suspension to the unlicensed assistive personnel (UAP).

Verify the client's identity using two unique identifiers, such as name and date of birth, prior to medication administration.

Show answer & explanation

Answer: Stop the continuous enteral feeding for 1 to 2 hours before and after administering the phenytoin oral suspension.; Flush the nasogastric tube with 15 to 30 mL of water before and after administering each medication.; Verify the client's identity using two unique identifiers, such as name and date of birth, prior to medication administration.

Answer

The correct actions are: stopping the continuous enteral feeding for 1 to 2 hours before and after administering the phenytoin, flushing the nasogastric tube with 15 to 30 mL of water before and after each medication, and verifying the client's identity using two unique identifiers.

The correct actions ensure medication efficacy and client safety. Enteral nutritional formulas bind to phenytoin, significantly decreasing its absorption; therefore, the feeding must be paused 1 to 2 hours before and after administration. Flushing the nasogastric tube with 15 to 30 mL of water before and after each medication maintains tube patency and ensures the full dose reaches the stomach. Verifying the client using two unique identifiers is a mandatory safety standard prior to any medication administration.

Step-by-Step Solution

Analyze the prescribed medications and the client's current administration route.

The client has a nasogastric tube with continuous feeding. Medications ordered are phenytoin suspension, extended-release metoprolol, and sublingual nitroglycerin.

Identifying the route and specific medication formulations is the first step in ensuring safe administration practices.

Evaluate the interaction between phenytoin and continuous enteral nutrition.

The enteral feeding must be stopped 1 to 2 hours before and after administering the phenytoin.

Nutritional formulas bind strongly to phenytoin in the gastrointestinal tract, severely reducing its absorption and therapeutic effect.

Assess the formulation of the remaining medications against NG tube protocols.

The extended-release metoprolol cannot be crushed, and the sublingual nitroglycerin must be given under the tongue, not via the NG tube.

Crushing extended-release medications causes toxic dose dumping. Sublingual medications require mucosal absorption to bypass liver metabolism.

Apply general medication safety and PN scope of practice principles.

The tube must be flushed properly, the client's identity must be verified using two identifiers, and administration cannot be delegated to a UAP.

These are fundamental nursing standards for safety, infection control, and legal delegation.

Key Concept

Safe Medication Administration via Enteral Tubes

Question 809Question →

A practical nurse (PN) is contributing to the care of a client who is 4 hours postoperative following a total thyroidectomy. Which interventions should the PN implement to reduce the client's risk for postoperative complications? (Select all that apply.)

Select all that apply

Keep an emergency tracheostomy tray and functioning suction equipment readily available at the bedside.

Assess the surgical dressing and the back of the client's neck for dependent pooling of blood.

Monitor for the presence of a positive Trousseau's sign or Chvostek's sign during routine data collection.

Maintain the client in a flat, supine position to minimize tension on the cervical suture line.

Administer the prescribed intravenous push (IVP) morphine sulfate to manage severe incisional pain.

Escalate to the registered nurse immediately if the client's serum total calcium level is reported as 9.4 mg/dL (2.35 mmol/L).

Show answer & explanation

Answer: Keep an emergency tracheostomy tray and functioning suction equipment readily available at the bedside.; Assess the surgical dressing and the back of the client's neck for dependent pooling of blood.; Monitor for the presence of a positive Trousseau's sign or Chvostek's sign during routine data collection.

Answer

The correct interventions are to keep an emergency tracheostomy tray and suction equipment at the bedside, assess the back of the neck for dependent bleeding, and monitor for Trousseau's or Chvostek's signs.

The correct actions directly address the three most critical complications of a thyroidectomy. Maintaining airway equipment at the bedside prepares the care team for acute respiratory distress caused by swelling, hematoma, or laryngeal nerve damage. Checking the back of the neck ensures dependent hemorrhage is not missed, as blood often drains posteriorly via gravity. Monitoring for Trousseau's or Chvostek's signs allows for early clinical detection of hypocalcemia, which frequently occurs if the parathyroid glands were disturbed or removed during surgery.

Step-by-Step Solution

Analyze the specific risks associated with a total thyroidectomy.

The primary life-threatening risks include airway compromise (from edema or hematoma), hemorrhage, and hypocalcemia (due to inadvertent damage to the parathyroid glands).

Identifying the target complications directs the nurse toward the correct preventative and monitoring interventions.

Evaluate the preventive interventions that directly mitigate these risks.

Emergency airway equipment prepares for respiratory distress, checking the posterior neck detects hidden hemorrhage, and assessing for tetany (Trousseau's/Chvostek's) identifies early hypocalcemia.

These actions are evidence-based, within the PN scope of practice, and directly address the identified high-risk complications.

Differentiate expected care and scope boundaries from the incorrect options.

Placing the client flat is dangerous (increases edema). IV push analgesics are outside the standard PN scope. A calcium level of 9.4 mg/dL is a normal finding, not a crisis.

Eliminating incorrect actions requires combining knowledge of safe positioning, legal scope of practice, and normal laboratory thresholds.

Key Concept

Postoperative Thyroidectomy Complications and Scope of Practice

Question 810Question →

A practical nurse (PN) is monitoring a client who is 4 hours post-percutaneous coronary intervention (PCI) via the right femoral artery approach. Which of the following assessment findings should the PN identify as an impending complication requiring immediate escalation to the registered nurse (RN)? Select all that apply.

Select all that apply

The client reports a new onset of constant, deep lower back pain.

The client's resting heart rate gradually increased from 76 to 112 beats per minute over the past two hours.

The client exhibits new-onset paresthesia and numbness in the right toes.

The cardiac monitor displays occasional premature ventricular contractions (PVCs) at a rate of two per hour.

A morning serum magnesium laboratory result of 1.9 mEq/L.

The assistive personnel (AP) reports the client voided 150 mL of clear, yellow urine over the past three hours.

Show answer & explanation

Answer: The client reports a new onset of constant, deep lower back pain.; The client's resting heart rate gradually increased from 76 to 112 beats per minute over the past two hours.; The client exhibits new-onset paresthesia and numbness in the right toes.

Answer

The findings that require immediate escalation are the new onset of deep lower back pain, the gradually increasing heart rate, and the new-onset paresthesia in the toes.

Following a femoral PCI, clients are at high risk for retroperitoneal hemorrhage (indicated by flank or lower back pain), hypovolemic shock (indicated by a steadily increasing heart rate), and distal arterial occlusion (indicated by neurovascular changes like paresthesia). These findings require immediate escalation to prevent life-threatening deterioration or limb loss.

Step-by-Step Solution

Analyze the client's clinical context and risk factors.

The client is 4 hours post-PCI via the right femoral artery, placing them at high risk for vascular complications such as retroperitoneal bleeding, arterial occlusion, and hemorrhagic shock.

Identifying the procedure and access site directs the focus of the risk assessment.

Evaluate each finding for signs of bleeding or shock.

Deep lower back pain indicates retroperitoneal bleeding. A gradual heart rate increase to 112 beats per minute is an early compensatory mechanism for volume loss.

Internal bleeding may not be externally visible at the insertion site and must be detected through vital sign trends and referred pain.

Evaluate findings for signs of neurovascular compromise.

New-onset paresthesia and numbness in the right toes indicate impaired distal blood flow.

Arterial thrombosis or hematoma compression at the femoral site can obstruct blood flow to the lower extremity, presenting as one or more of the '6 Ps'.

Differentiate expected or benign findings from true emergencies.

A magnesium level of 1.9 mEq/L, rare PVCs, and a urine output of 50 mL/hr are all within expected or safe limits and do not require immediate escalation.

Recognizing normal parameters prevents unnecessary escalation and focuses nursing care on genuine priorities.

Key Concept

Recognizing early complications following a percutaneous coronary intervention (PCI) via a femoral approach.

Question 811Question →

A $6\text{-year-old}$ client weighing $55\text{ lb}$ is admitted to the pediatric unit with a soft tissue infection. The client's vital signs are temperature $100.8^\circ\text{F}$ ( $38.2^\circ\text{C}$ ), heart rate $110\text{ beats/min}$ , and blood pressure $98/64\text{ mm Hg}$ . The client has no known drug allergies. The healthcare provider prescribes oral cephalexin $25\text{ mg/kg/day}$ divided into two equal doses every $12\text{ hours}$ . The medication available is cephalexin oral suspension $250\text{ mg}/5\text{ mL}$ . How many $\text{mL}$ should the practical nurse administer per dose? (Record answer to the nearest tenth. Do not include units in answer.)

Show answer & explanation

Answer: 6.3

Answer

6.3

To safely administer this medication, the nurse must accurately compute a multi-step calculation. First, convert the child's weight to kilograms (

55\text{ lb} \div 2.2 = 25\text{ kg}

). Next, determine the total daily dose by multiplying the weight by the prescribed rate (

25\text{ kg} \times 25\text{ mg/kg} = 625\text{ mg/day}

). Because the medication is divided into two equal doses given every

12\text{ hours}

, divide the daily dose by 2 (

625\text{ mg} \div 2 = 312.5\text{ mg/dose}

). Using dimensional analysis or the ratio-proportion method with the available concentration of

250\text{ mg}

5\text{ mL}

, the volume is calculated:

(312.5\text{ mg} \div 250\text{ mg}) \times 5\text{ mL} = 6.25\text{ mL}

. Following the instruction to record the answer to the nearest tenth,

6.25

rounds up to

6.3

Step-by-Step Solution

Convert weight from pounds to kilograms.

25\text{ kg}

Pediatric weight-based dosages are calculated using metric weight.

Calculate the total daily dose prescribed.

625\text{ mg/day}

The prescription is for

25\text{ mg/kg/day}

Calculate the individual dose amount.

312.5\text{ mg/dose}

The daily dose is divided into two equal doses given every 12 hours.

Calculate the volume needed per dose.

6.25\text{ mL}

The medication concentration is

250\text{ mg}

per

5\text{ mL}

Round the final volume to the nearest tenth.

6.3

Standard rounding rules dictate that a hundredths digit of 5 rounds the tenths digit up.

Key Concept

Pediatric Weight-Based Dosage Calculation

Question 812Question →

A client who underwent a right above-the-knee amputation 36 hours ago is receiving care on the surgical unit. Which actions should the practical nurse include in the client's care plan to promote comfort, maintain skin integrity, and prevent complications? Select all that apply.

Select all that apply

Position the client in a prone position for 20 to 30 minutes three to four times a day.

Elevate the right residual limb on pillows continuously while the client is resting in bed.

Wash the residual limb with mild soap and warm water, gently patting it completely dry.

Encourage the client to sit in a bedside chair for at least 4 hours at a time to increase endurance.

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

Serve the facility's standard postoperative meal without verifying the client's cultural dietary preferences.

Show answer & explanation

Answer: Position the client in a prone position for 20 to 30 minutes three to four times a day.; Wash the residual limb with mild soap and warm water, gently patting it completely dry.; Encourage the client to perform active range-of-motion exercises with the unaffected extremities.

Answer

The correct actions are positioning the client prone for 20 to 30 minutes several times daily, washing the residual limb gently with mild soap and water, and encouraging active range-of-motion exercises for the unaffected extremities.

After the first 24 hours following an amputation, prone positioning for short intervals is crucial to prevent hip flexion contractures. Proper hygiene, such as washing with mild soap and patting the skin dry, maintains skin integrity. Active range-of-motion exercises for the unaffected limbs prevent muscle deconditioning and promote overall physical mobility.

Step-by-Step Solution

Identify the client's surgical procedure (above-the-knee amputation) and the timeframe (36 hours postoperative).

The client is past the initial 24-hour acute swelling phase and is at high risk for hip flexion contractures.

Care priorities shift from purely managing acute postoperative swelling to preventing long-term mobility complications.

Evaluate positioning interventions to prevent contractures.

Prone positioning is identified as beneficial, while elevating the limb on pillows or prolonged sitting is contraindicated.

After 24 hours, keeping the hip flexed (via pillows or sitting) causes the muscles to shorten, whereas prone positioning stretches them out.

Evaluate basic hygiene and skin care interventions.

Washing the residual limb with mild soap and patting it dry is selected as a correct action.

Proper hygiene maintains skin integrity without causing mechanical irritation to the surgical site.

Evaluate mobility interventions for the rest of the body.

Active range-of-motion exercises for unaffected limbs are selected as a correct action.

Strengthening the unaffected limbs prevents deconditioning and is critical for the client's future ability to perform transfers and use assistive devices.

Evaluate nutritional and holistic comfort interventions.

Ignoring cultural dietary preferences is identified as incorrect.

Providing adequate and culturally appropriate nutrition is a fundamental aspect of basic care.

Key Concept

Basic care, comfort, and proper positioning to prevent complications following an above-the-knee amputation.

Question 813Question →

During a shift on a medical-surgical unit, a provider prescribes 'Regular insulin 8 units intravenous (IV) push immediately' for a client experiencing severe hyperglycemia. The available medication vial is labeled 'Regular insulin 100 units/mL'. What is the most appropriate action for the practical nurse to take?

Decline the task and notify the registered nurse that administering IV push medications exceeds the practical nurse scope of practice.

Prepare 8 units of the medication and administer it directly into the client's continuous IV infusion port.

Calculate the required volume as 0.8 mL of regular insulin and prepare it for immediate intravenous administration.

Give the 8 units of regular insulin via the subcutaneous route to provide a legally permitted method of delivery.

Show answer & explanation

Answer: Decline the task and notify the registered nurse that administering IV push medications exceeds the practical nurse scope of practice.

Answer

The practical nurse should decline the task and notify the registered nurse that administering IV push medications exceeds their scope of practice.

The correct action is to decline the task and hand it over to the registered nurse. According to standard national nursing regulations, administering medications via the intravenous (IV) push route is strictly outside the scope of practice for a practical nurse (PN/LVN). This rule is especially critical for high-alert medications like insulin, which can cause rapid, life-threatening changes in the client's condition. The PN must recognize this limitation to maintain client safety and legal compliance.

Step-by-Step Solution

Analyze the prescribed medication and the requested route of administration.

The provider has ordered 8 units of regular insulin to be given via intravenous (IV) push.

Identifying the specific medication and route is the first step in ensuring safe medication administration.

Evaluate the requested task against the legal scope of practice for a practical nurse (PN/LVN).

Administration of IV push medications is restricted to registered nurses (RNs) and providers.

National nursing standards prohibit practical nurses from administering IV push medications due to the rapid onset of action and the advanced clinical judgment required.

Determine the safest and most legally compliant action.

The nurse must safely decline the order and immediately escalate the task to the registered nurse.

Protecting the client from unsafe practices and adhering to licensure limitations is the primary responsibility of the nurse.

Key Concept

Practical Nurse Scope of Practice regarding Intravenous Medications

Question 814Question →

A semi-conscious client who underwent a supratentorial craniotomy two days ago receives continuous enteral nutrition via a nasogastric tube. The nurse is preparing to perform a complete bed bath, linen change, and repositioning to maintain skin integrity. Which of the following actions represents the safest approach for providing this care?

Pausing the continuous enteral feeding infusion prior to lowering the head of the bed to turn the client

Positioning the client in a completely flat, supine posture to facilitate a rapid and efficient linen change

Accepting a directive to administer a prescribed intravenous push sedative to relax the client during the procedure

Applying soft bilateral wrist restraints immediately to prevent the client from displacing the nasogastric tube

Show answer & explanation

Answer: Pausing the continuous enteral feeding infusion prior to lowering the head of the bed to turn the client

Answer

The safest action is to pause the continuous enteral feeding infusion before lowering the head of the bed.

When a client is receiving continuous enteral nutrition, the head of the bed must remain elevated to at least 30 degrees to prevent regurgitation and aspiration. Because a complete linen change and repositioning require temporarily lowering the head of the bed to safely turn the client side-to-side, the nurse must first pause the feeding infusion. Furthermore, for a client who is recovering from a supratentorial craniotomy, keeping the head elevated promotes venous drainage and prevents increased intracranial pressure. Pausing the feeding before executing any flat positioning is the most critical physiological safety measure.

Step-by-Step Solution

Identify the client's specific risk factors based on the clinical scenario.

The client is semi-conscious, recovering from a craniotomy, and receiving continuous enteral nutrition.

These factors place the client at high risk for aspiration and increased intracranial pressure if positioned incorrectly.

Evaluate the physical requirements of the planned basic care procedure.

A complete bed bath and linen change typically require lowering the head of the bed to safely turn and roll the client.

Performing physical turns and linen changes is difficult and often unsafe for the nurse's body mechanics when the bed remains highly elevated.

Synthesize the physiological risks with the procedural requirements to determine the priority safety action.

Because the head of the bed must be lowered, the continuous feeding pump must be temporarily stopped.

Lowering the head of the bed while a tube feeding is actively infusing removes gravity's protective effect, dramatically increasing the risk of regurgitation and pulmonary aspiration.

Key Concept

Aspiration Prevention and Safe Positioning

Question 815Question →

A client with a documented history of severe asthma is receiving care on a medical-surgical unit. The practical nurse is preparing to administer scheduled morning medications, which includes a new prescription for oral propranolol to manage a familial tremor. During the pre-administration assessment, the client's vital signs are: blood pressure 132/84 mm Hg, heart rate 86 beats/min, and respiratory rate 18 breaths/min. The nurse notes faint expiratory wheezes upon auscultation. What is the most appropriate action for the practical nurse to take?

Withhold the propranolol and immediately notify the registered nurse of the assessment findings.

Administer the medication after verifying the client's identification band and scanning the barcode.

Provide a prescribed as-needed albuterol treatment to clear the wheezes before giving the propranolol.

Request that the registered nurse administer the medication via intravenous push to avoid systemic respiratory absorption.

Show answer & explanation

Answer: Withhold the propranolol and immediately notify the registered nurse of the assessment findings.

Answer

The correct action is to withhold the medication and immediately notify the registered nurse of the client's respiratory status.

Propranolol is a non-selective beta-blocker, meaning it blocks both beta-1 (cardiac) and beta-2 (pulmonary) receptors. The blockade of beta-2 receptors leads directly to bronchoconstriction. In a client with a history of severe asthma who is already exhibiting wheezes, administering this medication can precipitate a severe, potentially life-threatening asthma attack. Safe pharmacological practice requires the practical nurse to withhold the contraindicated medication and escalate the finding to the registered nurse for intervention.

Step-by-Step Solution

Identify the pharmacological classification of the prescribed medication.

Propranolol is recognized as a non-selective beta-adrenergic antagonist (beta-blocker).

Understanding the drug class is essential to anticipate its systemic physiological effects on both the heart and lungs.

Analyze the client's medical history and current physical assessment findings.

The client has a history of severe asthma and is currently exhibiting faint expiratory wheezes.

Identifying pre-existing respiratory compromise is a critical pre-administration safety check.

Correlate the medication's mechanism of action with the client's respiratory condition.

Non-selective beta-blockers cause bronchoconstriction by blocking beta-2 receptors in the lungs, which is contraindicated for asthmatic clients.

This synthesis determines if the medication is safe to administer or if it will cause an adverse event.

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

The medication must be withheld and the findings escalated to the RN and the prescribing provider.

Practical nurses are responsible for recognizing severe contraindications and withholding harmful medications to prevent client injury.

Key Concept

Non-selective beta-blockers (like propranolol) are strictly contraindicated in clients with asthma due to the high risk of severe bronchoconstriction; the practical nurse must recognize this, withhold the drug, and report it.

Question 816Question →

While caring for a client who had an open appendectomy 4 hours ago, the practical nurse reviews the client's postoperative status. The client's preoperative heart rate was 76/min and blood pressure was 118/74 mm Hg. Which current finding is the most critical to report to the registered nurse?

Heart rate of 108/min and blood pressure of 100/62 mm Hg

Client report of throbbing pain at the surgical site

Oral temperature of 37.7°C (99.9°F)

Absence of bowel sounds in the lower quadrants

Show answer & explanation

Answer: Heart rate of 108/min and blood pressure of 100/62 mm Hg

Answer

The most critical finding to report is a heart rate of 108/min and blood pressure of 100/62 mm Hg.

The correct answer identifies a trend of tachycardia (heart rate 108/min) and mild hypotension (blood pressure 100/62 mm Hg). In a postoperative client, these are classic early compensatory signs of hypovolemic shock, often caused by internal bleeding. The practical nurse must recognize this risk potential and report it immediately to the registered nurse to prevent further deterioration.

Step-by-Step Solution

Analyze the client's surgical timeline and baseline vital signs.

The client is 4 hours post-open appendectomy with a baseline heart rate of 76/min and blood pressure of 118/74 mm Hg.

Establishing the baseline allows the nurse to identify significant deviations that indicate postoperative complications.

Evaluate each assessment finding against expected postoperative norms.

Pain, mild temperature elevation, and absent bowel sounds are expected 4 hours postoperatively. The elevated heart rate and decreased blood pressure are not expected.

Differentiating between benign, expected findings and signs of deterioration is a key practical nursing responsibility.

Identify the physiological implication of the abnormal vital signs.

Tachycardia combined with mild hypotension indicates early compensatory hypovolemic shock, likely due to postoperative hemorrhage.

Early recognition of shock allows for prompt intervention before the client becomes hemodynamically unstable.

Key Concept

Early recognition of postoperative hypovolemic shock

Question 817Question →

An older adult client is receiving daily oral warfarin for atrial fibrillation management. The electronic health record displays a morning International Normalized Ratio (INR) of 5.2. When the practical nurse enters the room, the client complains of a new, severe headache and asks for their prescribed as-needed acetaminophen. Which action is the priority for the practical nurse?

Withhold all medications and immediately alert the registered nurse about the client's symptoms and laboratory values.

Provide the prescribed acetaminophen for pain relief and monitor the client closely for visible signs of bleeding.

Conduct a comprehensive neurological assessment to determine the cause of the headache before proceeding.

Withhold the scheduled warfarin dose and document the abnormal laboratory result in the client's chart.

Show answer & explanation

Answer: Withhold all medications and immediately alert the registered nurse about the client's symptoms and laboratory values.

Answer

Withhold all medications and immediately alert the registered nurse about the client's symptoms and laboratory values.

An INR of 5.2 is dangerously elevated above the standard therapeutic range of 2.0 to 3.0 for atrial fibrillation. A new, severe headache in a client with supratherapeutic anticoagulation strongly indicates a possible intracranial hemorrhage. The priority is physiological safety; therefore, the practical nurse must withhold all medications and immediately escalate these critical findings to the registered nurse for comprehensive evaluation.

Step-by-Step Solution

Evaluate the laboratory results against normal therapeutic ranges.

An INR of 5.2 is identified as critically supratherapeutic (normal therapeutic range for atrial fibrillation is 2.0 to 3.0).

High INR values indicate an extreme risk for spontaneous hemorrhage.

Correlate the client's new symptom with the critical laboratory value.

The new, severe headache is recognized as a hallmark sign of a potential life-threatening intracranial hemorrhage.

Identifying complications of pharmacological therapies is essential for client safety.

Determine the appropriate intervention based on practical nursing scope of practice.

The decision is made to withhold all medications (which could mask symptoms or worsen bleeding) and escalate the emergent finding.

Acute, life-threatening changes require immediate registered nurse or provider assessment.

Key Concept

Recognizing critical medication adverse effects, prioritizing physiological safety, and adhering to the practical nurse scope of practice during a potential emergency.

Question 818Question →

A practical nurse is providing care for a client who is 72 hours post-operative following a right above-the-knee amputation. The client reports a dull, aching discomfort in the right hip and requests that the head of the bed be raised to 60 degrees with a thick pillow placed under the residual limb. Which action is most appropriate for the nurse to take?

Provide the requested pillow and raise the head of the bed to promote venous return and relieve the reported hip discomfort.

Raise the head of the bed to 60 degrees, but explain that the residual limb must remain flat on the mattress to prevent swelling.

Acknowledge the discomfort, keep the bed flat, and assist the client into a prone position to stretch the hip flexor muscles.

Ask the client why they want to elevate the limb when they were previously instructed about the importance of proper joint alignment.

Show answer & explanation

Answer: Acknowledge the discomfort, keep the bed flat, and assist the client into a prone position to stretch the hip flexor muscles.

Answer

The most appropriate action is to acknowledge the discomfort, maintain a flat bed position, and assist the client into a prone position to stretch the hip flexor muscles.

Following an above-the-knee amputation, the residual limb should not be elevated on a pillow after the first 24 hours due to the high risk of developing a hip flexion contracture. Furthermore, raising the head of the bed flexes the hip joint significantly. The prone position is the optimal nursing intervention, as it fully extends the hip joint, stretches the flexor muscles, prevents contractures, and alleviates aching caused by prolonged flexion.

Step-by-Step Solution

Analyze the client's postoperative timeline and positioning request.

The client is 72 hours post-operative from an above-the-knee amputation (AKA) and is requesting both limb elevation and a high-Fowler's position.

Identifying the time since surgery is critical, as positioning guidelines change significantly after the first 24 hours to prevent complications.

Evaluate the physiological impact of the requested positions on the residual limb and hip joint.

Both elevating the limb on a pillow and raising the head of the bed to 60 degrees will cause prolonged flexion of the hip joint.

Continuous hip flexion after an AKA leads to shortening of the flexor muscles, resulting in a permanent hip flexion contracture that impairs future prosthesis use.

Select the most appropriate nursing intervention within the practical nurse's scope of practice.

The nurse must gently deny the unsafe request, explain the rationale to reinforce teaching, and assist the client into a prone position.

The prone position fully extends the hip joint, counteracting the flexed positions typical of sitting or resting in bed, and safely addresses the aching discomfort caused by muscle tension.

Key Concept

Prevention of hip flexion contractures following an above-the-knee amputation

Question 819Question →

A registered nurse (RN) is caring for a client who was recently admitted with severe sepsis. The RN is busy initiating an emergency blood transfusion for another client and asks the practical nurse (PN) to assist with the septic client's medication administration. Which pharmacological task is most appropriate for the PN to accept?

Administering a scheduled oral dose of acetaminophen for an elevated temperature

Administering the initial dose of an intravenous (IV) broad-spectrum antibiotic

Titrating a continuous IV infusion of norepinephrine based on blood pressure trends

Assessing the client's therapeutic response shortly after an IV push analgesic was given

Show answer & explanation

Answer: Administering a scheduled oral dose of acetaminophen for an elevated temperature

Answer

Administering a scheduled oral dose of acetaminophen for an elevated temperature

The administration of standard, scheduled oral medications is a fundamental skill well within the practical nurse scope of practice. Even when a client is acutely ill, giving a basic oral antipyretic does not require the advanced clinical judgment or immediate physiological assessment that intravenous therapies demand.

Step-by-Step Solution

Analyze the client's condition and the tasks being delegated by the registered nurse.

The client has severe sepsis, but the tasks involve different routes and levels of clinical judgment.

Delegation must match the legal scope of practice for a practical nurse, regardless of how busy the unit is.

Evaluate each pharmacological task against the standard practical nurse (PN) scope of practice.

IV push medications, initial IV antibiotic doses, vasoactive titrations, and primary evaluations are identified as out of scope.

These tasks require advanced nursing assessment, clinical judgment, and interpretation of unstable physiological changes.

Identify the task that involves routine administration without the need for advanced initial assessment.

Providing a scheduled oral antipyretic is identified as a safe, within-scope task.

Oral medication administration is a core competency for practical nurses.

Key Concept

LPN/LVN Scope of Practice in Pharmacological Therapies

Estimated Time:45s

Question 820Question →

A practical nurse is assigned to care for a client with a history of heart failure. The client is scheduled to receive oral furosemide and oral digoxin at this time. Upon reviewing the morning laboratory report, the nurse notes a serum potassium level of 2.9 mEq/L (2.9 mmol/L). The client's most recent apical pulse is 62 beats per minute. Based on these findings, which of the following is the most appropriate next action for the practical nurse?

Withhold both the furosemide and the digoxin, and immediately notify the registered nurse.

Administer the digoxin because the apical pulse is greater than 60 beats per minute, but withhold the furosemide.

Administer both medications as prescribed and encourage the client to consume a potassium-rich breakfast.

Withhold the medications and independently perform a comprehensive cardiovascular assessment before notifying the provider.

Show answer & explanation

Answer: Withhold both the furosemide and the digoxin, and immediately notify the registered nurse.

Answer

The most appropriate action is to withhold both the furosemide and the digoxin, and immediately notify the registered nurse.

A serum potassium level of 2.9 mEq/L (2.9 mmol/L) is critically low (the normal range is 3.5 to 5.0 mEq/L). Furosemide is a potassium-wasting loop diuretic that would further deplete the client's potassium levels. Additionally, hypokalemia significantly increases the client's risk for life-threatening digoxin toxicity, even when the apical pulse is within the standard administration parameter of being greater than 60 beats per minute. To reduce the potential for severe cardiovascular complications, the practical nurse must withhold both medications and immediately escalate these findings to the registered nurse.

Step-by-Step Solution

Analyze the laboratory data provided in the scenario.

The client has a serum potassium level of 2.9 mEq/L (2.9 mmol/L).

Normal serum potassium is 3.5 to 5.0 mEq/L. A value of 2.9 mEq/L indicates severe hypokalemia, a critical laboratory finding.

Evaluate the scheduled medications against the client's current physiological status.

Furosemide wastes potassium and will worsen the hypokalemia. Digoxin toxicity is strongly potentiated by low potassium levels.

Understanding the pharmacodynamics of these medications helps identify immediate risks to client safety.

Determine the necessary nursing intervention within the practical nurse scope of practice.

Both medications must be withheld, and the registered nurse must be notified immediately.

Escalating critical lab values that impact high-risk medications is a vital component of risk reduction and falls within the practical nurse's mandatory reporting duties.

Key Concept

Reduction of risk potential regarding medication administration requires correlating critical laboratory values (such as hypokalemia) with high-risk medications (such as furosemide and digoxin) and escalating findings appropriately.

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