Physiological Integrity

A client is transferred to the clinical unit after undergoing a lumbar puncture. Which resting position should the practical nurse encourage the client to maintain to minimize the risk of a spinal headache?

A practical nurse is preparing to administer a scheduled dose of gabapentin $300\text{ mg}$ PO to a client with neuropathic pain. The medication is supplied as an oral solution with a concentration of $250\text{ mg}/5\text{ mL}$. How many milliliters should the nurse administer? (Record answer as a whole number. Do not include units in answer.)

During afternoon rounds on a rehabilitation unit, a practical nurse observes a client who is 72 hours post-transfemoral amputation of the right leg. The client is resting with the head of the bed elevated to 90 degrees, and the right residual limb is supported on two stacked pillows. The client states, 'My right hip feels extremely tight and stiff.' Which action should the practical nurse implement?

A practical nurse is caring for an adult client who weighs $143\text{ lb}$ and is prescribed cyclosporine oral solution. The prescribed dosage is $8\text{ mg/kg/day}$ divided into two equal doses. The pharmacy dispenses cyclosporine oral solution $100\text{ mg/mL}$. How many mL should the nurse administer for one dose?

Record your answer using one decimal place. Do not include units in your answer.

A practical nurse (PN) is caring for a client being treated for a pulmonary embolism. The client is receiving a continuous intravenous heparin infusion. The health care provider prescribes oral warfarin $5\text{ mg}$ daily to begin today. The client's morning laboratory results show an activated partial thromboplastin time (aPTT) of $115\text{ seconds}$ (control: $30\text{ seconds}$) and an International Normalized Ratio (INR) of $1.1$. The PN assesses the client and notes a blood pressure of $98/62\text{ mm Hg}$ (baseline $136/84\text{ mm Hg}$) and a heart rate of $108\text{ bpm}$ (baseline $74\text{ bpm}$).

Which of the following is the priority action for the practical nurse to take?

A client who is 12 hours postoperative following a lumbar spinal fusion is resting supine in bed. The client suddenly reports severe nausea and begins to actively vomit. Which action should the practical nurse implement first?

An adult client is receiving care on a medical unit shortly after undergoing a percutaneous liver biopsy. Upon entering the room, the practical nurse observes that the client is resting flat on their back and reporting mild soreness in the right upper abdomen. Which of the following positioning actions is the priority for the practical nurse to implement?

A practical nurse (PN) is performing a 2-hour post-procedure assessment on a client who underwent a left-sided thoracentesis with 1,200 mL of pleural fluid removed. The client's medical history includes hypertension managed with daily metoprolol. The client reports a new, persistent dry cough but denies dyspnea. Current vital signs are: heart rate 86 bpm (baseline 64 bpm), blood pressure 104/66 mm Hg (baseline 142/86 mm Hg), and respiratory rate 18 breaths/min. Which action should the PN take first?

A practical nurse is providing morning care for a client who is recovering from a right total hip arthroplasty performed one day ago. Which of the following basic care and comfort measures are appropriate for this client? (Select all that apply)

Upon entering a client's room to administer a prescribed oral analgesic, the practical nurse observes that the client is awake and watching television. Which action must the nurse take to correctly identify this client before giving the medication?

A practical nurse (PN) is preparing to administer morning medications to a client who is 2 days postoperative following a bowel resection. The client is receiving continuous intravenous (IV) fluids.

Current client data:

Which of the following medication administration actions by the PN are appropriate? (Select all that apply.)

An older adult with a history of heart failure received a scheduled dose of an intravenous loop diuretic at $0800$. By $1000$, the urinary catheter drainage bag contains $850\text{ mL}$ of clear yellow urine. The latest laboratory report indicates a serum potassium level of $3.1\text{ mEq/L}$ ($3.1\text{ mmol/L}$). Current vital signs include a blood pressure of $102/58\text{ mm Hg}$, a heart rate of $110\text{ beats per minute}$, and respirations of $18\text{ per minute}$. Based on these findings, which action should the practical nurse take first?

A practical nurse is assisting with the monitoring of a client who recently underwent a bedside thoracentesis to remove pleural fluid. Which of the following post-procedure assessment findings require immediate escalation to the registered nurse? (Select all that apply)

An older adult client is receiving care for a history of peptic ulcer disease. The client suddenly appears pale and anxious. The practical nurse measures the client's vital signs and notes a heart rate of 124 beats per minute and a blood pressure of 96/52 mm Hg. Which of the following actions is the priority for the nurse?

A practical nurse and an unlicensed assistive personnel (UAP) are preparing to reposition a client who is 24 hours postoperative following a right total hip arthroplasty (posterior approach). Arrange the following actions in the correct sequence to safely turn the client onto their left side.

A practical nurse is preparing to administer a large-volume cleansing enema to an adult client who is experiencing constipation. Arrange the following actions in the correct sequence. (Place the first action at the top and the final action at the bottom.)

An adult client is resting in bed after undergoing a right modified radical mastectomy with axillary lymph node dissection. How should the nurse position the client's right arm to promote optimal comfort and reduce swelling?

During a central venous access device tubing change, the catheter accidentally disconnects. The client immediately exhibits severe dyspnea, cyanosis, and tachycardia. In what order must the nurse perform the following emergency actions to mitigate the risk of a fatal air embolism?

A practical nurse (PN) is caring for an adult client who is receiving continuous enteral nutrition via a nasogastric (NG) tube. The client is scheduled to receive $300\text{ mg}$ of phenytoin. The pharmacy dispenses phenytoin oral suspension $125\text{ mg}/5\text{ mL}$. The client's morning laboratory results show a serum phenytoin level of $26\text{ mcg/mL}$. During the morning assessment, the client exhibits involuntary, rapid eye movements and a noticeably unsteady gait when transferring to the chair. Which of the following actions should the PN take? Select all that apply.

A client who is unresponsive following a traumatic brain injury is receiving continuous enteral feedings via a gastrostomy tube. The health care provider prescribes scheduled liquid oral phenytoin for seizure prophylaxis. The practical nurse is preparing to administer the medication. Which action should the nurse take?