Physiological Integrity

A client who underwent a lumbar laminectomy the previous day requires morning care. To ensure safety and comfort, which actions should the practical nurse incorporate into the care plan? Select all that apply.

A practical nurse (PN) is observing a client who is receiving continuous enteral tube feedings. The client suddenly begins coughing forcefully and appears dyspneic. Arrange the following nursing actions in the priority order the PN should perform them.

A 45-year-old client on a medical unit is prescribed antibiotic ear drops for an acute outer ear infection. Which of the following techniques should the practical nurse use when administering this medication?

During morning rounds, a client is scheduled to receive a daily dose of levothyroxine $75\text{ mcg}$ PO. The practical nurse accesses the automated dispensing cabinet and retrieves a scored tablet labeled $0.15\text{ mg}$. Upon seeing the prepared medication, the client remarks, 'I always take a pink pill for my thyroid, but this one is white. Is there a mistake?' Which action should the practical nurse take next?

A practical nurse (PN) is evaluating a client two hours after a percutaneous liver biopsy. Which assessment finding requires immediate notification to the registered nurse (RN)?

An older adult client is recovering on the surgical unit $12$ hours after a transurethral resection of the prostate (TURP) with ongoing continuous bladder irrigation (CBI). While performing a focused assessment, the practical nurse (PN) notes several clinical changes. Which of the following findings represent emergent complications that must be immediately reported to the registered nurse (RN)? Select all that apply.

A practical nurse is monitoring a client who underwent a percutaneous liver biopsy 3 hours ago. The client's current vital signs are blood pressure 102/64 mm Hg, pulse 98 beats/minute, and respirations 20 breaths/minute. Two hours ago, the blood pressure was 126/78 mm Hg and the pulse was 72 beats/minute. The client now reports a new onset of dull right shoulder pain. Which action should the nurse take first?

During bedside handoff in a surgical step-down unit, a practical nurse reviews the clinical data of a young adult client who underwent a laparoscopic splenectomy earlier in the day. The client is drowsy but rouses to verbal stimuli. The flow sheet indicates that over the past three hours, the client's heart rate has climbed from 82 to 118 beats per minute, and blood pressure has narrowed from 120/78 to 106/82 mmHg. The client reports new, mild left shoulder pain and slight abdominal fullness. Based on these clinical findings, which action is the priority for the practical nurse to implement?

A practical nurse is assigned to care for a client who receives continuous medical nutrition via a percutaneous endoscopic gastrostomy (PEG) tube. The client recently underwent a complex lumbar laminectomy that was complicated by a dural tear. The surgeon has prescribed strict bed rest in a completely flat (0-degree) supine position to prevent a cerebrospinal fluid leak. Which action should the practical nurse implement to safely manage this client's basic care needs?

An older adult client with a history of heart failure suddenly becomes highly restless, confused, and demonstrates a respiratory rate of 30 breaths per minute. Which intervention should be prioritized immediately?

A practical nurse is providing care for a client who has just returned to the unit following a percutaneous liver biopsy. The nurse is preparing to assist the client into a resting position. Which position is most appropriate to promote client safety and prevent bleeding complications?

An older adult client is $24\text{ hours}$ postoperative following an open cholecystectomy. The client is prescribed scheduled subcutaneous dalteparin for venous thromboembolism prophylaxis. Morning laboratory results reveal a hemoglobin decrease from $14.1\text{ g/dL}$ ($141\text{ g/L}$) to $10.2\text{ g/dL}$ ($102\text{ g/L}$). During morning rounds, the client appears restless. The automated vital signs are: temperature $98.6^\circ\text{F}$ ($37.0^\circ\text{C}$), heart rate $116\text{ beats/min}$, respiratory rate $22\text{ breaths/min}$, and blood pressure $98/62\text{ mmHg}$. The registered nurse (RN) directs the practical nurse to administer the scheduled dalteparin. Which action should the practical nurse take?

A practical nurse is caring for a client with heart failure who receives enteral nutrition and medications via a percutaneous endoscopic gastrostomy (PEG) tube. The client's current weight is $73\text{ kg}$. The health care provider prescribes a maintenance dose of digoxin oral solution at $6\text{ mcg/kg}$ daily. The pharmacy dispenses digoxin liquid with a concentration of $0.05\text{ mg/mL}$. Prior to administration, the nurse notes a regular apical pulse of $68\text{ beats/min}$ and a serum potassium level of $4.3\text{ mEq/L}$. How many milliliters will the nurse administer? Record answer to the nearest tenth. Do not include units in answer.

A practical nurse is managing care for multiple clients on an acute medical-surgical unit. Which of the following independent or collaborative actions by the practical nurse demonstrate the correct application of risk reduction principles? Select all that apply.

A practical nurse is caring for a client who has a T4 spinal cord injury. The client suddenly reports a severe, pounding headache. The nurse notes profuse diaphoresis above the level of the injury and measures a blood pressure of 210/110 mm Hg. In which order should the nurse perform the following actions? (Arrange the items in the correct sequence, starting with the most immediate priority).

An 80-year-old client with a history of mild cognitive impairment and chronic bronchitis is admitted for a suspected urinary tract infection. Upon entering the room, the practical nurse observes the client is highly restless, picking at the bedsheets, and speaking incoherently. Current vital signs are: temperature 99.1°F (37.3°C), heart rate 112 beats/min, respiratory rate 26 breaths/min, blood pressure 102/60 mm Hg, and oxygen saturation 89% on room air. Which action should the practical nurse take first?

A client is receiving continuous nasogastric (NG) suctioning for a small bowel obstruction. While reviewing the morning electronic health record, the practical nurse (PN) notes a serum potassium level of $2.8 \text{ mEq/L}$ ($2.8 \text{ mmol/L}$) and a current apical pulse of $105 \text{ beats/min}$. Which action should the PN take first?

A practical nurse (PN) is preparing to administer a scheduled oral antihypertensive medication. The barcode scanner on the medication cart is temporarily broken. Which action is the most appropriate for the PN to take before administering the medication?

A practical nurse (PN) is caring for a client who is $18$ hours postoperative following a partial bowel resection. The client is scheduled to receive a routine dose of oral furosemide for a history of heart failure. The client's admission baseline blood pressure was $142/86\text{ mmHg}$. The current vital signs are blood pressure $98/64\text{ mmHg}$, heart rate $108\text{ beats per minute}$, and respiratory rate $20\text{ breaths per minute}$. The morning comprehensive metabolic panel indicates a serum potassium level of $2.8\text{ mEq/L}$ ($2.8\text{ mmol/L}$). Which action should the PN take?

An uncircumcised adult client requires assistance with personal hygiene while on strict bed rest. In what sequence should the practical nurse execute the steps for male perineal care? Arrange the actions from first to last.