Examkin

Physiological Integrity

1313 questions

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Question 821Question →

During morning rounds, a practical nurse observes that a client with a history of chronic obstructive pulmonary disease (COPD) is visibly struggling to breathe while lying flat in bed. The client appears highly anxious and is using accessory muscles for respiration. Which initial action should the nurse take?

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Answer: Assist the client into a high-Fowler's position to maximize lung expansion

Answer

The correct action is to assist the client into a high-Fowler's position to maximize lung expansion.
Sitting a dyspneic client fully upright (high-Fowler's position) is a fundamental, immediate nursing intervention. It utilizes gravity to drop the abdominal organs away from the diaphragm, allowing the lungs to expand more fully with significantly less effort. This directly addresses the priority need of breathing.

Step-by-Step Solution

1
Assess the client's immediate physical need based on the clinical presentation.
The client is experiencing acute respiratory distress while lying flat.
Identifying the primary airway and breathing compromise guides immediate prioritization.
2
Implement a fundamental comfort and positioning measure to alleviate the distress.
The client is moved into an upright, sitting position.
Sitting upright allows gravity to pull the diaphragm downward, facilitating maximum chest expansion and easing respiratory effort.

Key Concept

Client Positioning for Airway Management
Question 822Question →

A practical nurse at a residential care facility is distributing routine medications to residents. Which actions by the nurse indicate compliance with safe pharmacological practices? (Select all that apply.)

Select all that apply

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Answer: Remaining at the bedside until the resident has completely swallowed all oral capsules; Checking the medication label against the electronic administration record three times prior to dispensing; Verifying the resident's identity by asking them to state their name and confirming it with their photo identification

Answer

The correct practices involve remaining with the resident until oral medications are fully swallowed, performing three distinct checks of the medication label, and verifying identity using two approved identifiers such as stated name and photo identification.
Safe pharmacological therapy hinges on strict adherence to medication administration rights. This includes performing three verification checks, utilizing two reliable, patient-specific identifiers, and directly observing the ingestion of oral medications to confirm safe delivery.

Step-by-Step Solution

1
Evaluate the first set of actions against the universal rights of medication administration.
Checking the medication label three times and using two distinct identifiers (like a name and photo ID) are standard safety requirements.
These steps prevent medication errors related to the wrong drug or wrong patient.
2
Assess the practical nurse's scope of practice regarding medication routes.
Administering an IV push cardiac medication is outside the practical nurse's scope.
IV push medications require advanced clinical judgment and immediate physiological monitoring by a registered nurse.
3
Analyze the remaining actions for potential safety risks.
Using a room number for identification and calculating dosages mentally are high-risk behaviors. Staying at the bedside until swallowing is complete is a safe behavior.
Room numbers are not valid identifiers, and mental math invites dosage calculation errors. Observing the swallow ensures medication compliance.

Key Concept

Safe Medication Administration Principles and Scope of Practice
Question 823Question →

A practical nurse (PN) is reviewing the care plan for an older adult client who is admitted with an acute exacerbation of heart failure. Which of the following actions should the PN take to reduce the risk of potential complications? (Select all that apply.)

Select all that apply

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Answer: Report a heart rate of 112 beats per minute and new-onset restlessness to the registered nurse.; Place the call light within the client's reach and instruct them to ask for assistance before standing up.; Notify the registered nurse immediately if the client's blood pressure drops to 86/54 mm Hg.

Answer

The correct actions are to report the elevated heart rate with restlessness, place the call light within reach to prevent falls, and notify the RN of the low blood pressure.
The practical nurse plays a vital role in reducing risk by promptly identifying and escalating early signs of complications. Tachycardia and restlessness can be early indicators of decreased cardiac output or hypoxemia, while a blood pressure of 86/54 mm Hg indicates severe hypotension requiring immediate RN notification. Additionally, implementing fall precautions by keeping the call light within reach minimizes the risk of injury, which is especially important for clients who may experience orthostatic changes from diuretic therapy.

Step-by-Step Solution

1
Analyze the scope of practice for a practical nurse regarding medication administration and task delegation.
The PN must not administer IV push medications, as this requires RN-level assessment.
Accepting tasks outside the PN scope of practice increases the risk of patient harm.
2
Evaluate the clinical findings and laboratory data presented in the scenario.
A heart rate of 112 beats/min with restlessness, a blood pressure of 86/54 mm Hg, and a potassium level of 2.9 mEq/L are all highly abnormal findings.
These findings indicate potential complications such as early shock, hypoxemia, or a high risk for life-threatening dysrhythmias.
3
Determine the appropriate nursing interventions for the abnormal findings.
The PN must immediately escalate the abnormal vital signs and the critical potassium level to the RN or provider.
While the PN collects vital data, rapid escalation is required to ensure timely medical or RN intervention.
4
Assess the routine safety actions described in the options.
The PN must consistently verify two client identifiers before medication administration and implement strict fall precautions.
Skipping identification checks or failing to provide safety instructions directly violates risk reduction protocols.

Key Concept

Reduction of Risk Potential in Heart Failure Management
Question 824Question →

A client is receiving care on the surgical unit on the first postoperative day following a right total hip arthroplasty utilizing a posterior approach. The practical nurse is preparing to perform perineal care and change the soiled bottom bed linens. Which action should the nurse take to safely complete this task?

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Answer: Secure an abduction pillow between the client's legs and gently roll the client onto their left, unoperated side.

Answer

Secure an abduction pillow between the client's legs and gently roll the client onto their left, unoperated side.
Following a total hip arthroplasty utilizing a posterior approach, the client is at a high risk for joint dislocation if the hip is flexed beyond 90 degrees, adducted across the midline, or internally rotated. Securing an abduction pillow between the client's legs before rolling them onto the unoperated (left) side ensures that the legs remain safely abducted and in a neutral anatomical alignment throughout the basic care procedure.

Step-by-Step Solution

1
Identify the surgical procedure and approach.
The client had a right total hip arthroplasty via a posterior approach.
The surgical approach determines the specific movement precautions required to prevent joint dislocation.
2
Recall the contraindications for a posterior approach hip arthroplasty.
Hip flexion greater than 90 degrees, adduction of the leg past the body's midline, and internal rotation are strictly contraindicated.
These specific movements place stress on the posterior joint capsule and can mechanically force the newly implanted femoral head out of the socket.
3
Evaluate the proposed basic care interventions against these surgical precautions.
Rolling the client onto the unoperated side with an abduction pillow in place prevents adduction and internal rotation, ensuring the joint remains completely stable during the bed bath and linen change.
This is the safest clinical method to access the client's posterior and perineal areas for routine hygiene without compromising the integrity of the surgical site.

Key Concept

Postoperative Positioning and Precautions for Total Hip Arthroplasty
Question 825Question →

A practical nurse is preparing to administer an intramuscular (IM) injection of iron dextran using the Z-track method to an adult client with severe anemia. Arrange the following steps in the correct chronological order to ensure safe and effective medication administration.

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Answer

The correct sequence for administering a Z-track intramuscular injection begins with site cleansing, followed by displacing the skin laterally, inserting the needle and injecting the medication, waiting 10 seconds, and finally withdrawing the needle while releasing the skin.
Safe administration using the Z-track method requires strict adherence to sequential steps: proper hygiene and cleansing, lateral skin displacement to shift tissue planes, correct angle of insertion, a mandatory 10-second pause for dispersion, and simultaneous needle withdrawal and skin release to properly seal the track.

Step-by-Step Solution

1
Cleanse the injection site.
The skin is free of surface pathogens.
Reduces the risk of introducing bacteria into the deep muscle tissue during needle insertion.
2
Displace the skin and subcutaneous tissue.
The tissue layers above the muscle are shifted away from their resting alignment.
Creates an angled track that will trap the medication in the muscle once the skin is released.
3
Insert the needle and inject the medication.
The medication is delivered directly into the ventrogluteal muscle.
Iron dextran is highly irritating and can stain subcutaneous tissues, so it must be deposited deep within the muscle.
4
Wait 10 seconds before withdrawing the needle.
The medication begins to absorb and disperse.
Prevents the medication from being forced back up the needle track by muscle pressure.
5
Withdraw the needle and release the skin.
The tissue layers slide back into their natural position.
Breaks the alignment of the needle track through the tissue layers, sealing the medication inside the muscle.

Key Concept

The Z-track method for intramuscular injections prevents highly irritating or staining medications from leaking into the subcutaneous tissue by creating a zigzag path through the tissue layers.
Question 826Question →

A practical nurse is assigned to care for a client who has bacterial conjunctivitis and a history of open-angle glaucoma. The provider has prescribed timolol maleate ophthalmic solution (drops) and erythromycin ophthalmic ointment for the right eye. In which order should the nurse perform the following actions to safely administer these medications? Arrange the steps in the correct chronological sequence.

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Answer

The correct sequence is to first cleanse the eye, then instill the drops, apply nasolacrimal pressure, wait five minutes, apply the ointment, and finally instruct the client to gently close and roll their eyes.
The correct sequence ensures that the eye is properly prepared, the aqueous medication (timolol) is absorbed without causing dangerous systemic side effects, and the lipid-based medication (erythromycin) does not block the absorption of the drops.

Step-by-Step Solution

1
Cleanse the eye from the inner to the outer canthus.
Debris and infectious crusts are safely removed.
Prevents the introduction of bacteria into the eye and tear duct, and avoids cross-contamination to the opposite eye.
2
Administer the timolol drops.
The aqueous medication is delivered to the conjunctival sac.
Aqueous drops cannot penetrate the lipid barrier created by ointments, so they must be administered first.
3
Perform nasolacrimal occlusion.
The tear duct is temporarily blocked.
Prevents systemic absorption of the beta-blocker, reducing the risk of severe side effects like bradycardia and hypotension.
4
Wait 3 to 5 minutes.
The timolol drops are fully absorbed.
Ensures the subsequent ointment does not physically wash the drops out of the conjunctival sac before they take effect.
5
Administer the erythromycin ointment.
Antibiotic ointment is applied.
Ointments are applied last because their thick, lipid-based structure blocks other topical medications from reaching the eye tissue.
6
Instruct the client to gently close their eyes.
Medication is dispersed.
Distributes the ointment evenly without expelling it from the eye via forceful blinking or squeezing.

Key Concept

Administration Sequence for Multiple Ophthalmic Medications
Question 827Question →

A 75-year-old client who sustained a closed right femur fracture 24 hours ago suddenly becomes intensely restless and confused. The practical nurse (PN) notes an apical heart rate of 108 beats per minute and a respiratory rate of 24 breaths per minute. Which immediate actions should the PN take? Select all that apply.

Select all that apply

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Answer: Obtain an immediate, comprehensive set of vital signs including continuous pulse oximetry.; Inspect the client's anterior chest, neck, and axillae for the presence of a petechial rash.; Promptly notify the registered nurse (RN) regarding the acute change in the client's status.

Answer

The correct actions are to obtain a comprehensive set of vital signs with pulse oximetry, inspect the chest and neck for a petechial rash, and promptly notify the RN.
The correct actions focus on immediate ABC (Airway, Breathing, Circulation) assessment, targeted data collection for a specific life-threatening complication of long bone fractures (Fat Embolism Syndrome), and rapid escalation. Restlessness and tachypnea 24 hours after a long bone fracture are classic early signs of hypoxia and fat emboli.

Step-by-Step Solution

1
Analyze the clinical cues provided in the scenario.
The client has restlessness, confusion, tachycardia (108 bpm), and tachypnea (24 breaths/min) exactly 24 hours after a long bone fracture.
These specific findings strongly suggest the onset of Fat Embolism Syndrome (FES) or hypoxia, which requires immediate physiological intervention.
2
Prioritize initial bedside assessment based on the Airway, Breathing, Circulation (ABC) framework.
The PN must immediately assess oxygenation status via continuous pulse oximetry and complete a full set of vital signs.
Restlessness is the earliest sign of hypoxia; obtaining exact perfusion data is critical before any other intervention.
3
Perform targeted, condition-specific data collection.
The PN inspects the client's chest, neck, and axillae for petechiae.
Identifying a petechial rash is a classic hallmark sign that distinguishes Fat Embolism Syndrome from other causes of postoperative hypoxia or delirium.
4
Execute appropriate escalation of care within the practical nursing scope of practice.
The PN immediately reports the acute change in neurological and respiratory status to the supervising RN.
Suspected systemic complications like FES require immediate collaborative management, advanced assessment, and potential transfer to an intensive care setting.

Key Concept

Recognizing and rapidly responding to Fat Embolism Syndrome (FES) and acute hypoxia prioritizing ABCs.
Estimated Time:1m 30s
Question 828Question →

A practical nurse (PN) is caring for a client with a spinal cord injury at the T4 level. The client suddenly reports a severe, pounding headache and blurred vision. The PN measures the client's blood pressure at 218/114 mm Hg and notes profuse diaphoresis above the level of the injury. Arrange the following nursing actions in the priority order the PN should perform them to minimize the risk of a cerebrovascular complication.

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Answer

The correct sequence is to first elevate the head of the bed, then loosen restrictive clothing, followed by assessing the urinary catheter, notifying the RN, and finally documenting the event.
In autonomic dysreflexia (a medical emergency in clients with spinal cord injuries at T6 or above), noxious stimuli below the injury cause an uninhibited sympathetic response, leading to severe hypertension. The absolute first priority is to place the client in a high-Fowler's or sitting position to induce orthostatic hypotension and rapidly lower the blood pressure, reducing the risk of a stroke. Next, the nurse should quickly remove any restrictive clothing that might act as a cutaneous stimulus. The third step is to check for the most common cause of the syndrome: bladder distension (e.g., checking for a kinked catheter). Once initial independent steps are taken, the PN must escalate care by notifying the RN or provider, especially if the blood pressure remains elevated and requires medication. Documentation is always the final step in the sequence.

Step-by-Step Solution

1
Elevate the head of the bed to a high-Fowler's or sitting position.
Takes advantage of orthostatic hypotension to lower the blood pressure.
The client is experiencing autonomic dysreflexia, a life-threatening hypertensive crisis. The most immediate risk is a cerebrovascular accident (stroke), so mechanically lowering the blood pressure via gravity is the absolute highest priority.
2
Loosen any tight clothing, restrictive binders, or anti-embolism stockings.
Removes immediate cutaneous stimuli.
Any painful or restrictive stimulus below the level of the spinal cord injury can trigger or worsen the sympathetic nervous system surge.
3
Assess the urinary catheter tubing for kinks or dependent loops.
Identifies and potentially resolves the most common noxious stimulus.
A distended bladder is the leading cause of autonomic dysreflexia. Unkinking a catheter can immediately relieve the distension and resolve the crisis.
4
Notify the registered nurse (RN) or healthcare provider.
Escalates the clinical situation for further medical management.
If removing immediate stimuli does not lower the blood pressure, the RN or provider must be involved to administer short-acting antihypertensive medications or perform advanced assessments.
5
Document the clinical findings, interventions performed, and client response.
Maintains an accurate legal and medical record.
Documentation is always performed after life-saving interventions and escalation of care have been completed.

Key Concept

Prioritization in Autonomic Dysreflexia: Position, Stimulus Removal, Escalation
Question 829Question →

A practical nurse is preparing to apply knee-high anti-embolism stockings for a client who has been sitting in a chair for the past hour. In what order should the nurse perform the following actions? (Arrange the steps from first to last.)

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Answer

The correct sequence is to first elevate the client's legs, invert the stocking down to the heel pocket, fit the stocking over the toes, align the heel pocket on the client's heel, and finally smooth the remaining fabric up the calf.
Applying anti-embolism stockings requires a specific sequence to be both effective and safe. Because the client has been sitting, gravity has caused venous pooling; elevating the legs first allows this fluid to drain. Inverting the stocking facilitates a smooth application starting from the toes. Anchoring the heel in the pocket ensures proper placement, and finishing with a wrinkle-free fit over the calf maintains an even, distal-to-proximal pressure gradient without restricting circulation.

Step-by-Step Solution

1
Assist the client to a supine position and elevate the legs for 15 to 30 minutes.
Dependent fluid drains from the lower extremities.
Applying stockings while blood is pooled in the lower legs traps the fluid, defeating the purpose of the compression.
2
Reach inside the stocking and turn it inside out down to the heel pocket.
The stocking is prepared for application.
This technique minimizes friction and prevents overstretching the fabric during application.
3
Slip the foot of the stocking over the client's toes and instep.
The distal end of the stocking is anchored.
Starting at the toes ensures the graduated compression is applied properly from distal to proximal.
4
Stretch the fabric and align the heel pocket correctly over the client's heel.
The heel is properly seated in the reinforced pocket.
Misaligned heels can cause the fabric to bunch, leading to pressure injuries and impaired blood flow.
5
Unroll the remaining fabric evenly up the calf and smooth out any wrinkles.
The stocking fits snugly and evenly across the leg.
Wrinkles or a rolled top edge can act as a tourniquet, dangerously restricting venous return and causing ischemia.

Key Concept

Proper application of anti-embolism stockings to promote venous return and prevent complications.
Question 830Question →

A client with end-stage renal disease arrives at the outpatient care center stating they have missed their last two scheduled hemodialysis treatments. The practical nurse performs a focused data collection. Which findings indicate acute physiological decompensation and require immediate escalation to the registered nurse? (Select all that apply.)

Select all that apply

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Answer: Crackles auscultated halfway up the posterior lung fields; Irregular heart rate of 114 beats per minute with frequent ectopic beats; New-onset generalized muscle weakness and paresthesia

Answer

The findings that require immediate escalation are lung crackles, an irregular tachycardic heart rate, and new-onset muscle weakness.
A client who has missed hemodialysis is at extreme risk for life-threatening fluid overload and hyperkalemia. Lung crackles indicate fluid backing up into the alveoli (pulmonary edema), which compromises breathing. An irregular, rapid heart rate suggests cardiac dysrhythmias, a dangerous complication of elevated serum potassium (circulation). New-onset muscle weakness and paresthesia are also classic neuromuscular signs of severe hyperkalemia that precede cardiac arrest. All three of these findings reflect acute physiological decompensation requiring immediate emergency intervention.

Step-by-Step Solution

1
Identify the client's condition and associated physiological risks.
The client has end-stage renal disease and missed hemodialysis, placing them at severe risk for life-threatening fluid retention and electrolyte imbalances, particularly hyperkalemia.
Understanding the pathophysiology of missed dialysis guides the nurse to anticipate specific acute complications.
2
Evaluate each assessment finding using the Airway, Breathing, Circulation (ABC) prioritization framework.
Lung crackles compromise breathing; an irregular heart rate compromises circulation; muscle weakness indicates imminent cardiac compromise from hyperkalemia.
The ABC framework is the standard for prioritizing physiological emergencies over chronic or stable symptoms.
3
Differentiate between acute, life-threatening symptoms and expected, chronic manifestations of the disease.
Pruritus, baseline hypertension, and chronic anemia are expected findings, whereas pulmonary edema and hyperkalemia symptoms indicate acute decompensation.
Escalation must be reserved for acute changes that threaten the client's immediate stability.

Key Concept

Physiological Adaptation
Question 831Question →

A practical nurse is assessing a client who is recovering from a total knee arthroplasty performed earlier in the day. Over the past few hours, the client's heart rate has steadily increased from 82 to 118 beats per minute, and their blood pressure has dropped from 124/76 mm Hg to 94/56 mm Hg. The client states, "I just feel really tired." Which of the following is the most appropriate immediate action for the nurse to take?

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Answer: Report the vital sign changes to the registered nurse or healthcare provider.

Answer

Report the vital sign changes to the registered nurse or healthcare provider.
The correct action is to immediately notify the registered nurse or healthcare provider. A rising heart rate combined with a falling blood pressure in a postoperative client strongly suggests internal bleeding or hypovolemic shock. Because practical nurses work under the direction of an RN or provider, escalating critical changes in condition is the essential next step to reduce the risk of a severe complication.

Step-by-Step Solution

1
Analyze the client's vital sign trends and current symptoms.
The heart rate has increased significantly while the blood pressure has decreased.
Identifying these specific trends helps recognize the early physiological signs of hypovolemia or shock.
2
Determine the priority intervention based on the practical nurse's scope of practice.
The nurse must escalate the findings to a higher level of care provider.
Signs of impending shock require immediate medical evaluation and interventions that may exceed the independent scope of a practical nurse.

Key Concept

Recognition and Escalation of Early Shock
Question 832Question →

A client who underwent a left posterior total hip arthroplasty 24 hours ago is currently receiving continuous enteral nutrition via a nasogastric tube. The client experiences an episode of bowel incontinence and requires immediate perineal care alongside a full bed linen change. Which specific sequence of actions represents the safest method for the practical nurse to complete this care?

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Answer: Stop the enteral feeding pump, lower the bed to a flat position, secure an abduction wedge between the client's legs, and roll them onto their right side.

Answer

The safest method is to first pause the enteral feeding, lower the head of the bed flat, secure an abduction wedge between the legs, and turn the client onto their unaffected (right) side.
This sequence comprehensively addresses multiple conflicting physiological safety requirements. First, pausing the feeding allows the bed to be safely lowered without risking pulmonary aspiration. Second, lowering the bed to a flat position prevents shearing forces on the sacrum and prevents dangerous hip flexion during the turn. Finally, securing an abduction wedge and rolling the client onto their unaffected right side maintains strict posterior hip precautions, preventing joint dislocation and avoiding direct pressure on the fresh surgical incision.

Step-by-Step Solution

1
Pause the continuous enteral feeding pump.
The flow of gastric nutrition is temporarily halted.
The client must be laid flat for safe turning, and stopping the feed prevents aspiration of stomach contents into the lungs while supine.
2
Lower the head of the bed to a completely flat position.
The client's spine and hips are aligned horizontally.
Turning a client while the head of the bed is elevated causes significant skin shearing forces and forces the hip into dangerous flexion beyond 90 degrees.
3
Place and secure a firm abduction wedge between the client's legs.
The lower extremities are locked in slight abduction.
This prevents the operative leg from crossing the midline (adduction), which is a primary cause of hip dislocation following a posterior approach arthroplasty.
4
Logroll the client onto their right side.
The client is safely positioned laterally to allow access to the perineum and back.
The right side is the unaffected side. Rolling onto the non-operative side prevents compression, compromised circulation, and pain at the fresh surgical site.

Key Concept

Integrating safe positioning protocols for post-operative posterior total hip arthroplasty with aspiration precautions for enteral feeding during basic hygiene care.
Question 833Question →

A practical nurse is initiating a 24-hour urine collection to evaluate a client's renal function. To ensure the accuracy of the diagnostic test and prevent measurement errors, arrange the following nursing actions in the correct chronological sequence.

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Answer

The correct sequence is to first have the client void and discard the urine, then document this exact time as the start time, collect all subsequent urine on ice for the next 24 hours, instruct the client to void exactly 24 hours later, and finally add this last specimen to the container before sending it to the laboratory.
A 24-hour urine collection requires precise timing to accurately measure renal function or hormone levels. The client must begin the test with an empty bladder, meaning the very first void is always discarded. The time of this discarded void becomes the official start time. All subsequent urine must be collected and properly stored (usually on ice or refrigerated) to prevent chemical degradation of the specimen. Exactly 24 hours after the start time, the client must void one final time to complete the collection. This final void is added to the container, which is then immediately dispatched to the laboratory.

Step-by-Step Solution

1
Initiate the test with an empty bladder.
The client voids, and the urine is discarded.
This ensures that urine produced prior to the 24-hour period is not included in the total volume, preventing falsely elevated diagnostic results.
2
Document the start time.
The exact time of the initial discarded void is recorded in the client's health record.
Provides the definitive starting mark for the 24-hour collection period.
3
Collect and preserve all subsequent urine.
Every void over the next 24 hours is transferred to a cooled collection jug.
Cooling prevents the degradation of urinary components and inhibits bacterial growth, which could skew laboratory values.
4
Obtain the final void.
The client voids exactly 24 hours after the start time.
Captures the urine produced at the very end of the 24-hour window to complete the collection.
5
Complete and transport the collection.
The final void is added to the container and immediately sent to the laboratory.
Finalizes the total volume for accurate laboratory analysis and ensures prompt processing.

Key Concept

Diagnostic Test Preparation and Specimen Collection Protocols
Question 834Question →

A client in an acute care setting requires various pharmacological treatments during the morning shift. Which action by the practical nurse demonstrates safe administration within their established scope of practice?

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Answer: Requesting the client to state their full name and date of birth while cross-checking the identification band prior to providing an oral antihypertensive.

Answer

Requesting the client to state their full name and date of birth while cross-checking the identification band prior to providing an oral antihypertensive.
The correct answer emphasizes the fundamental safety practice of verifying two distinct client identifiers (such as full name and date of birth) against the identification band before administering any medication. This ensures the right client receives the right medication and is fully within the practical nurse's scope of practice.

Step-by-Step Solution

1
Evaluate the IV push administration option.
Administering IV push medications, especially initial doses, falls outside the standard scope of practice for a practical nurse.
IV push medications require advanced, continuous assessment and have rapid systemic effects.
2
Analyze the dosage calculation option.
A prescription of 15 mg15\text{ mg} from a concentration of 5 mg/mL5\text{ mg/mL} requires administering 3 mL3\text{ mL} (15÷5=315 \div 5 = 3). Administering 15 mL15\text{ mL} results in a massive 75 mg75\text{ mg} overdose.
The nurse must calculate volume based on concentration, not match the milligram number to milliliters.
3
Analyze the immunization option.
Live-attenuated vaccines must be withheld for clients receiving high-dose systemic corticosteroids.
Immunosuppressed clients are at a high risk for developing an active infection from a live-attenuated vaccine.
4
Evaluate the patient identification option.
Checking two unique identifiers (name and date of birth) against the wristband is a mandatory safety standard.
This is a fundamental and in-scope nursing action that prevents medication errors.

Key Concept

Safe medication administration principles and LPN/LVN scope of practice
Question 835Question →

A practical nurse is providing basic care for a client who is on strict bed rest following a right femoral cardiac catheterization. Which of the following actions should the nurse include in the client's care? Select all that apply.

Select all that apply

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Answer: Keep the client's right leg straight and minimize movement of the extremity.; Provide a bedpan or urinal to assist the client with elimination needs.; Encourage the client to drink plenty of oral fluids, if not contraindicated.

Answer

The correct actions are keeping the right leg straight, providing a bedpan or urinal, and encouraging oral fluid intake.
Appropriate care involves keeping the affected leg straight to prevent bleeding, providing a bedpan since the client is on strict bed rest, and encouraging fluids to clear the procedural contrast dye.

Step-by-Step Solution

1
Analyze the client's situation and primary safety needs.
The client is on strict bed rest post-femoral cardiac catheterization, which poses a high risk for bleeding at the puncture site.
Understanding the procedural risks guides the selection of safe basic care interventions.
2
Evaluate each care intervention against post-procedure protocols and basic care standards.
Keeping the leg straight, assisting with the bedpan, and encouraging fluids are safe and supportive. High-Fowler's position, delegating assessments, and delaying reports of unstable vital signs compromise safety.
Nursing care must prevent complications while meeting the client's basic hydration and elimination needs.

Key Concept

Basic care following a femoral cardiac catheterization requires maintaining the affected extremity straight, meeting elimination needs on bed rest, and promoting hydration, while adhering to safe positioning and delegation.
Question 836Question →

A client is transferred to the surgical unit following a right modified radical mastectomy that included an axillary lymph node dissection. When implementing basic care and comfort measures, which action should the practical nurse take regarding the client's right arm?

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Answer: Elevate the arm on pillows so it rests consistently above the level of the client's heart.

Answer

The practical nurse should elevate the client's right arm on pillows so it rests consistently above the level of the heart.
Elevating the affected arm above the level of the heart promotes venous and lymphatic return through gravity. This basic care intervention is essential for preventing fluid accumulation (lymphedema) and promoting comfort after the removal of axillary lymph nodes.

Step-by-Step Solution

1
Analyze the surgical procedure and its physiological impact on the client.
A mastectomy with axillary lymph node removal disrupts normal lymphatic drainage pathways, creating a high risk for lymphedema in the affected extremity.
Understanding the physiological risk factors dictates the necessary basic care and comfort interventions.
2
Evaluate each nursing action for safety, scope of practice, and therapeutic benefit.
Elevating the arm uses gravity to assist fluid drainage. The other options introduce significant risks: lying on the arm increases swelling, restraints are an unethical first response to protect drains, and delegating initial post-op joint exercises is unsafe.
Basic care must prioritize non-invasive, safe physiological adaptation while adhering to legal delegation guidelines.
3
Select the action that best promotes fluid return and client comfort.
Supporting the affected arm on pillows above heart level is identified as the correct evidence-based intervention.
This specific positioning directly mitigates the risk of edema and enhances post-procedure comfort without compromising circulation.

Key Concept

Basic care and comfort positioning to prevent lymphedema following axillary lymph node dissection.
Estimated Time:1m 15s
Question 837Question →

A practical nurse is preparing 0900 medications for a client with stage 4 chronic kidney disease. The electronic health record indicates the client is prescribed oral carvedilol, lisinopril, and calcium acetate. Morning laboratory results reveal a serum potassium level of 6.2 mEq/L6.2\text{ mEq/L} and a serum calcium level of 8.1 mg/dL8.1\text{ mg/dL}. The client's vital signs are blood pressure 142/88 mm Hg142/88\text{ mm Hg}, heart rate 64 bpm64\text{ bpm}, and respiratory rate 18/min18/\text{min}. Which action is most appropriate for the practical nurse to take?

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Answer: Withhold the lisinopril and promptly notify the registered nurse of the laboratory findings.

Answer

The practical nurse should withhold the lisinopril and immediately notify the registered nurse of the hyperkalemia.
The client has a critically elevated serum potassium level of 6.2 mEq/L6.2\text{ mEq/L} (normal is 3.53.5 to 5.0 mEq/L5.0\text{ mEq/L}). Lisinopril is an ACE inhibitor, a class of drugs known to cause potassium retention. Administering this medication would further dangerously elevate the client's potassium, increasing the risk of fatal cardiac dysrhythmias. The practical nurse's priority within their scope of practice is to withhold the medication and immediately report the critical finding to the registered nurse.

Step-by-Step Solution

1
Analyze the morning laboratory results against normal reference ranges.
The potassium level is 6.2 mEq/L6.2\text{ mEq/L} (critically high) and the calcium level is 8.1 mg/dL8.1\text{ mg/dL} (mildly low).
Identifying abnormal laboratory values is a mandatory safety check before administering pharmacological therapies.
2
Evaluate the prescribed medications for contraindications based on the laboratory findings.
Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor, which retains potassium and is highly contraindicated with a potassium level of 6.2 mEq/L6.2\text{ mEq/L}.
Administering a potassium-sparing medication to a hyperkalemic client can lead to lethal cardiac dysrhythmias.
3
Determine the most appropriate intervention within the practical nurse scope of practice.
The nurse must withhold the contraindicated medication (lisinopril) and immediately escalate the critical lab value to the supervising registered nurse.
The practical nurse cannot independently alter medical orders or administer intravenous push medications, but has a duty to withhold harmful medications and report critical findings.

Key Concept

Recognizing pharmacological contraindications (ACE inhibitors exacerbating hyperkalemia) and adhering to the practical nurse scope of practice when managing critical laboratory values.
Question 838Question →

During a morning medication pass on a medical-surgical unit, a client with heart failure is scheduled to receive oral digoxin 0.25 mg0.25\text{ mg} and oral furosemide 40 mg40\text{ mg}. The client reports experiencing new-onset nausea and states, 'I have not had any appetite since yesterday.' The morning laboratory report indicates a serum potassium level of 2.9 mEq/L2.9\text{ mEq/L}, and the current apical pulse is 62 beats per minute. Which action should the practical nurse take?

Show answer & explanation

Answer: Withhold both the digoxin and furosemide, and immediately notify the registered nurse of the client's symptoms and laboratory value.

Answer

The correct action is to withhold both medications and immediately report the findings to the registered nurse.
The client is exhibiting early signs of digoxin toxicity (nausea, anorexia) combined with a critically low potassium level of 2.9 mEq/L2.9\text{ mEq/L}. Hypokalemia sensitizes the myocardium to digoxin, significantly increasing the risk of life-threatening dysrhythmias. Furthermore, furosemide is a potassium-wasting diuretic that would worsen the hypokalemia. The appropriate action within the practical nurse's scope is to withhold both medications and immediately notify the registered nurse so the healthcare provider can be alerted.

Step-by-Step Solution

1
Evaluate the morning laboratory results and vital signs.
The potassium level is critically low at 2.9 mEq/L2.9\text{ mEq/L} (normal is 3.53.5 to 5.0 mEq/L5.0\text{ mEq/L}), and the apical pulse is 62 beats per minute.
Identifying abnormal baseline data is the first step in pre-administration safety checks.
2
Analyze the client's reported symptoms.
The client is experiencing new-onset nausea and a complete loss of appetite.
Gastrointestinal symptoms are often the earliest clinical indicators of digoxin toxicity.
3
Correlate the prescribed medications with the clinical findings.
Furosemide depletes potassium, and hypokalemia directly increases the risk of digoxin toxicity. Administering either drug would cause further harm.
Understanding pharmacokinetic interactions is essential for safe medication administration.
4
Determine the appropriate nursing intervention within the practical nurse scope of practice.
The medications must be withheld and the registered nurse immediately notified.
The practical nurse must hold medications that pose an immediate risk and report critical findings to the supervising nurse for medical escalation.

Key Concept

Recognizing Digoxin Toxicity and Hypokalemia within the Practical Nurse Scope of Practice
Question 839Question →

Following a total knee arthroplasty, an older adult client's baseline preoperative vital signs were a blood pressure of 132/78132/78 mm Hg and a resting heart rate of 7070 beats per minute. Four hours postoperatively, the practical nurse assesses the client and notes a blood pressure of 102/60102/60 mm Hg, a heart rate of 114114 beats per minute, and a respiratory rate of 2222 breaths per minute. The surgical dressing has a moderate amount of sanguineous drainage. Which action should the nurse take next?

Show answer & explanation

Answer: Notify the supervising registered nurse immediately regarding the changes in vital signs.

Answer

Notify the supervising registered nurse immediately regarding the changes in vital signs.
The correct action is to notify the registered nurse immediately. The client is exhibiting classic early signs of hypovolemic shock—specifically tachycardia and a drop in blood pressure compared to their baseline—along with active bleeding indicated by the sanguineous drainage. These findings require immediate escalation to ensure patient safety and to initiate rapid medical intervention.

Step-by-Step Solution

1
Compare the client's current postoperative vital signs to the preoperative baseline.
The client's blood pressure has decreased significantly (from 132/78132/78 to 102/60102/60 mm Hg), and the heart rate has increased (from 7070 to 114114 beats per minute).
Identifying deviations from the baseline is critical for recognizing early postoperative complications.
2
Analyze the significance of the vital sign trends alongside the physical assessment.
The combination of tachycardia, hypotension, and sanguineous drainage strongly suggests early hypovolemic shock or active bleeding.
Early recognition of shock mechanisms allows for prompt, life-saving interventions before the condition becomes irreversible.
3
Determine the most appropriate and safe nursing action within the practical nurse's scope of practice.
The practical nurse must immediately escalate these critical findings to the registered nurse.
The registered nurse is responsible for performing advanced assessments, contacting the healthcare provider, and initiating complex interventions for shock.

Key Concept

Reduction of Risk Potential: Early Recognition of Shock
Question 840Question →

A practical nurse is providing care for a client who recently returned to the unit following an esophagogastroduodenoscopy (EGD) with moderate sedation. Which of the following nursing actions should the nurse take to reduce the risk of potential complications? (Select all that apply)

Select all that apply

Show answer & explanation

Answer: Verify the return of the client's gag reflex prior to offering any oral fluids or medications.; Monitor the client's respiratory rate and oxygen saturation closely.; Assess the client for sudden, severe abdominal pain or a rigid abdomen.

Answer

The nurse must verify the return of the gag reflex, monitor respiratory status, and assess for signs of perforation such as severe abdominal pain.
After an EGD, the client's throat is numb from local anesthetics, and they have received moderate sedation. Checking the gag reflex prevents aspiration, while monitoring respirations ensures the sedation is not dangerously depressing the central nervous system. Assessing for a rigid abdomen or severe pain is critical to quickly identify a gastrointestinal perforation.

Step-by-Step Solution

1
Identify the procedure and its associated risks.
An EGD involves sedation and instrumentation of the upper gastrointestinal tract, creating risks for aspiration, respiratory depression, and perforation.
Understanding procedure-specific risks is necessary to plan appropriate preventative care.
2
Evaluate each action against safety standards and the practical nurse's scope of practice.
Checking the gag reflex, monitoring respirations, and assessing for pain directly reduce post-procedure risks. Delegating initial assessments, dismissing borderline vital signs, and delaying critical lab reporting are unsafe practices.
Risk reduction requires proactive monitoring and prompt escalation of abnormal findings.

Key Concept

Post-Procedure Risk Reduction
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