Physiological Integrity

1313 questions

All types1,313 Multiple choice672 Multiple select289 Numeric68 Ordering284

A practical nurse (PN) is assigned to care for a client who is receiving a continuous intravenous (IV) heparin infusion for a deep vein thrombosis. The primary health care provider prescribes a new order for oral warfarin. Which action regarding medication administration is appropriate for the PN to perform?

Administer the prescribed oral warfarin after matching the client's stated name and date of birth to the medication administration record.

Titrate the continuous IV heparin infusion rate according to the facility's standardized weight-based protocol.

Identify the client by asking them to confirm their room and bed number before dispensing the oral warfarin.

Administer the oral warfarin after noting an international normalized ratio (INR) of 5.5 in the electronic health record without notifying the registered nurse.

Show answer & explanation

Answer: Administer the prescribed oral warfarin after matching the client's stated name and date of birth to the medication administration record.

Answer

The practical nurse should safely administer the oral warfarin by verifying the client's identity using their name and date of birth.

Administering oral medications is within the practical nurse's scope of practice. Using two distinct client identifiers, such as the stated name and date of birth matched to the medication administration record, represents the fundamental standard for safe medication administration.

Step-by-Step Solution

Determine the scope of practice for the practical nurse regarding the prescribed medications.

The PN can administer routine oral medications like warfarin, but titrating high-alert continuous IV infusions like heparin is restricted to the RN.

Adhering to the established scope of practice ensures client safety and legal compliance.

Review the requirements for safe medication administration.

The PN must use two acceptable client identifiers, such as name and date of birth, before administering any drug.

Using proper unique identifiers prevents medication administration errors.

Evaluate the laboratory values related to the medication.

Critically elevated values, such as an INR of 5.5, must be recognized and reported prior to giving a medication that further increases bleeding risk.

Failing to report critical labs and withholding contraindicated medications can lead to severe adverse events like hemorrhage.

Key Concept

Safe Medication Administration and Scope of Practice

Question 922Question →

A resident in an intermediate care facility is recovering from a colonoscopy with multiple polypectomies performed late yesterday afternoon. During the $0600$ rounds, the resident reports feeling "very thirsty and a little dizzy."

Assessment Findings:

Parameter	Current Finding	Baseline
Abdomen	Slightly distended and firm	Soft, non-tender
Blood Pressure	$96/60\text{ mmHg}$	$128/82\text{ mmHg}$
Heart Rate	$112\text{ bpm}$	$74\text{ bpm}$
Respiratory Rate	$22\text{ breaths/min}$	$16\text{ breaths/min}$
Hemoglobin	$10.2\text{ g/dL}$ (at $0500$ )	$14.1\text{ g/dL}$
Hematocrit	$31\%$ (at $0500$ )	$42\%$

Which action is the priority for the practical nurse?

Withhold all oral fluids, position the resident supine with the lower extremities elevated, and immediately alert the charge registered nurse.

Provide a small cup of water for the thirst, assist the resident to a sitting position, and reassess the vital signs in one hour.

Document the laboratory results in the electronic health record, as the hemoglobin level is above the typical transfusion threshold of

7.0\text{ g/dL}

Access the resident's peripheral intravenous line and independently initiate a rapid fluid bolus of normal saline to restore circulatory volume.

Show answer & explanation

Answer: Withhold all oral fluids, position the resident supine with the lower extremities elevated, and immediately alert the charge registered nurse.

Answer

Withhold all oral fluids, position the resident supine with the lower extremities elevated, and immediately alert the charge registered nurse.

The correct action directly addresses the life-threatening complication of postoperative hemorrhage. Thirst, dizziness, a firm abdomen, tachycardia, narrowed pulse pressure, and a nearly

4.0\text{ g/dL}

drop in hemoglobin indicate active internal bleeding and early hypovolemic shock following the polypectomy. The practical nurse must immediately prioritize circulation (positioning), prepare for potential emergency surgery (NPO status), and escalate the critical findings to the registered nurse.

Step-by-Step Solution

Analyze the subjective and objective data in the clinical presentation.

The resident is exhibiting thirst, dizziness, a rigid abdomen, tachycardia, hypotension, and a significant drop in hemoglobin.

Identifying abnormal trends is the first step in recognizing a physiological decline.

Correlate the assessment findings with the recent surgical history.

The recent colonoscopy with polypectomies places the resident at high risk for bowel perforation or postoperative hemorrhage. The data strongly indicates active internal bleeding and early hypovolemic shock.

Connecting the symptoms to the risk factors confirms the severity of the complication.

Determine the appropriate practical nurse scope of practice and priority intervention.

The practical nurse must immediately prioritize safety by withholding fluids (NPO status for potential emergency surgery), optimizing perfusion (elevating legs), and escalating to the registered nurse for advanced resuscitation.

Shock is a medical emergency that requires immediate RN and provider intervention beyond independent practical nurse care.

Key Concept

Early Recognition of Hypovolemic Shock and Hemorrhage

Question 923Question →

A practical nurse is preparing to provide a complete bed bath for an adult client who is on strict bed rest. In which order should the nurse wash the following body areas? Arrange the actions from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: Wash the client's eyes and face, then the arms and chest, followed by the legs and feet, and finally the perineal area.

A complete bed bath must follow the fundamental principle of infection control: cleaning from the cleanest area to the least clean area. The eyes and face are the cleanest and are always washed first. The nurse then moves systematically down the body to the arms and chest, followed by the legs and feet. The perineal area is the most contaminated region and must always be washed last to prevent the spread of microorganisms to other body parts.

Step-by-Step Solution

Identify the primary principle of hygiene care and bed baths.

The nurse must always wash from the cleanest area to the least clean area.

This prevents cross-contamination and the spread of microorganisms.

Determine the cleanest area to begin the bath.

The eyes and face are washed first.

Washing the face first prevents transferring bacteria from other body parts to the delicate ocular tissues.

Determine the sequence for the rest of the body.

Care progresses down the body, washing the arms and chest, followed by the legs and feet.

This continues the progression from cleaner areas to less clean areas.

Identify the least clean area to be washed last.

The perineal area is washed at the very end of the procedure.

The perineal area contains the highest concentration of microorganisms.

Key Concept

Basic Hygiene and Bed Bath Sequencing

Question 924Question →

A practical nurse is preparing to administer the morning dose of a prescribed oral antibiotic to a pediatric client. The child weighs $35\text{ lb } 4\text{ oz}$ . The primary health care provider has prescribed cefdinir $14\text{ mg/kg/day}$ PO to be administered in two equally divided doses. The pharmacy dispenses cefdinir oral suspension with a concentration of $125\text{ mg}/5\text{ mL}$ . How many $\text{mL}$ should the nurse administer for the morning dose? (Record the answer to the nearest tenth. Do not include units in your answer.)

Show answer & explanation

Answer: 4.5

Answer

4.5

The correct calculation requires six sequential steps: accurately representing ounces as a decimal of a pound, converting to kilograms, finding the total daily dosage, splitting it into a single dose, computing the volume using the provided concentration, and rounding to the nearest tenth.

Step-by-Step Solution

Convert the client's fractional weight from ounces to pounds.

4\text{ oz} \div 16\text{ oz/lb} = 0.25\text{ lb}

. Total weight is

35.25\text{ lb}

Weight must be in a standard decimal format before converting to kilograms.

Convert the weight from pounds to kilograms.

35.25\text{ lb} \div 2.2\text{ lb/kg} = 16.022...\text{ kg}

, which rounds to

16.0\text{ kg}

The medication dosage is prescribed based on the client's weight in kilograms.

Calculate the total daily medication requirement.

16.0\text{ kg} \times 14\text{ mg/kg/day} = 224\text{ mg/day}

This establishes the maximum therapeutic amount the child should receive over a 24-hour period.

Calculate the individual dose amount.

224\text{ mg/day} \div 2 = 112\text{ mg/dose}

The order specifies administration in two equally divided doses, not as a single bolus.

Determine the liquid volume required for the single dose.

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

This matches the ordered dose to the available physical concentration provided by the pharmacy.

Round the final answer according to instructions.

4.48\text{ mL}

rounds up to

4.5\text{ mL}

Standard medication calculation rules and the stem's instructions require rounding to the nearest tenth for volumes greater than

1\text{ mL}

Key Concept

Multi-step pediatric weight-based dosage calculation requiring unit conversion, fractioned dosing, and liquid concentration computation.

Question 925Question →

A practical nurse is providing care for a client who sustained a T3 spinal cord injury two months ago. The client suddenly reports a severe, pounding headache and exhibits profuse diaphoresis and facial flushing. Arrange the following nursing actions in the correct priority sequence.

Drag items to arrange them in the correct order

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Answer

The correct sequence is to first position the client in high Fowler's, then measure the blood pressure, followed by checking the urinary catheter, and finally notifying the registered nurse.

In the event of autonomic dysreflexia, the primary goal is to prevent a catastrophic hypertensive stroke. Elevating the head of the bed immediately lowers blood pressure through orthostasis. Once the client is safe, confirming the hypertension via a blood pressure check guides further care. The nurse then seeks to eliminate the most common cause (bladder distention) by checking the catheter. Finally, escalating to the RN ensures advanced medical intervention if the crisis persists.

Step-by-Step Solution

Place the client in a high Fowler's position.

The client is sitting upright, utilizing gravity to induce orthostatic changes.

This is the most critical and rapid independent action to lower intracranial pressure and blood pressure, reducing the immediate risk of a cerebrovascular accident.

Obtain the client's current blood pressure reading.

The severity of the hypertensive crisis is accurately quantified.

Measuring the blood pressure confirms the suspected autonomic dysreflexia and provides necessary clinical data before proceeding to investigate the trigger.

Inspect the indwelling urinary catheter system for kinks.

A potential noxious stimulus (bladder distention) is identified and resolved.

A full bladder or obstructed catheter is the leading cause of autonomic dysreflexia; removing this stimulus often resolves the crisis.

Notify the supervising registered nurse of the assessment findings.

The RN is made aware of the acute physiological alteration and the interventions performed.

The RN coordinates further pharmacological therapy if conservative nursing measures fail to stabilize the client's blood pressure.

Key Concept

Prioritization of interventions for autonomic dysreflexia in clients with high-level spinal cord injuries.

Estimated Time:2m 0s

Question 926Question →

A practical nurse is assigned to care for a client who is recovering from a recent right-sided mastectomy. Which of the following positioning techniques should the nurse implement to promote comfort and prevent swelling in the affected arm?

Elevate the right arm on a pillow while the client is in a semi-Fowler's position.

Place the client in a right lateral position with a pillow between the knees.

Position the client flat on their back with the right arm resting beside the body.

Assist the client to a sitting position with the right arm dangling at their side.

Show answer & explanation

Answer: Elevate the right arm on a pillow while the client is in a semi-Fowler's position.

Answer

Elevate the right arm on a pillow while the client is in a semi-Fowler's position.

Elevating the affected arm on a pillow while the client is in a semi-Fowler's position uses gravity to promote lymphatic and venous drainage. This basic care measure effectively prevents lymphedema, reduces tissue swelling, and promotes overall comfort for the client following a mastectomy.

Step-by-Step Solution

Identify the client's surgical procedure and the associated risks.

The client had a right-sided mastectomy, which puts them at risk for lymphedema (swelling) in the right arm due to the removal of lymph nodes.

Understanding the procedure is essential for determining the appropriate basic care and comfort interventions.

Determine the optimal basic care intervention that addresses the identified risk.

Elevating the affected arm above the level of the heart promotes venous and lymphatic drainage, preventing swelling and enhancing overall comfort.

Gravity assists in returning fluid to the central circulation when the extremity is properly elevated.

Select the position that best accommodates this intervention without causing additional harm.

A semi-Fowler's position with the right arm supported on a pillow safely achieves the goal without placing pressure on the surgical site.

This position optimizes drainage and avoids direct pressure on the operative side.

Key Concept

Postoperative positioning to prevent lymphedema after a mastectomy

Question 927Question →

The healthcare provider prescribes knee-high graduated compression stockings for a client who is immobile. The practical nurse prepares to apply the stockings at the beginning of the morning shift. Arrange the following actions in the correct chronological sequence.

Drag items to arrange them in the correct order

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Answer

The correct sequence begins with positioning the client supine for 15 minutes, followed by measuring the leg, inverting the stocking down to the heel, slipping it over the foot and heel, and finally pulling it smoothly up the calf.

Applying graduated compression stockings requires ensuring the leg is free of dependent edema before sizing and application. The client must be supine for 15 to 30 minutes to promote venous return. Once edema is minimized, precise measurements of the calf and leg length determine the correct size. To apply the tight garment, the nurse turns it inside out down to the heel, anchors it over the foot and heel, and smoothly pulls the rest over the calf. The nurse must never roll the top edge, as this restricts circulation.

Step-by-Step Solution

Maintain the client in a supine position for at least 15 minutes.

Venous return is promoted and lower extremity edema is reduced.

If legs are dependent, blood pools and swells the leg, which leads to measuring for an incorrect size and potentially trapping fluid when the stocking is applied.

Measure the circumference of the calf and the length of the lower leg.

The appropriate size of compression stocking is selected.

An incorrectly sized stocking can either provide inadequate compression or act as a dangerous tourniquet, compromising arterial and venous blood flow.

Turn the stocking inside out down to the heel pocket.

The foot portion of the stocking is isolated for initial application.

Compression stockings are highly elastic and tight; this specific inversion technique minimizes friction and struggling during the application process.

Slip the foot portion of the stocking over the toes and align the heel.

The stocking is properly anchored onto the client's foot.

Correct heel placement ensures the gradient pressure is distributed properly according to the manufacturer's therapeutic design.

Smoothly pull the remaining fabric upward over the calf without rolling the top band.

The stocking is completely applied without wrinkles or constricting bands.

Wrinkles or a rolled top edge can constrict blood flow, causing skin breakdown and drastically increasing the risk of deep vein thrombosis.

Key Concept

Application Sequence for Graduated Compression Stockings

Question 928Question →

A practical nurse (PN) is assisting a registered nurse (RN) in caring for a client who reports sudden, severe chest pain. The healthcare provider issues a verbal order for "nitroglycerin 0.4 mg sublingually immediately and morphine sulfate 2 mg IV push." The RN prepares both medications, hands the morphine syringe to the PN, and states, "Give this IV push while I give the nitroglycerin." Which of the following is the most appropriate action by the PN?

Decline to administer the IV morphine and offer to administer the sublingual nitroglycerin instead.

Administer the IV morphine over 2 to 3 minutes while continuously monitoring the client's respiratory status.

Accept the syringe and administer the morphine immediately, bypassing the barcode scan due to the emergency.

Withhold both medications and assess the client's precise pain level on a 0 to 10 scale before proceeding.

Show answer & explanation

Answer: Decline to administer the IV morphine and offer to administer the sublingual nitroglycerin instead.

Answer

The correct action is to decline the administration of the IV push medication and offer to perform a task within the PN scope of practice, such as administering the sublingual medication.

Intravenous (IV) push medication administration is strictly outside the scope of practice for a practical nurse (PN). Even in a life-threatening emergency, the PN must not accept tasks requiring RN-level judgment and skills. However, administering sublingual medications is well within the PN's scope. Declining the out-of-scope task while offering to perform the in-scope task ensures the client receives timely, safe care without violating the Nurse Practice Act.

Step-by-Step Solution

Identify the requested task and route of administration.

The RN is delegating the administration of an IV push medication (morphine sulfate) to the PN.

Understanding the precise nature of the assigned task is required to evaluate if it falls within the legal scope of practice.

Evaluate the delegated task against the PN scope of practice.

IV push medication administration requires RN-level assessment and judgment, and is strictly outside the PN scope of practice.

Patient safety and legal boundaries must be maintained at all times; emergencies do not legally expand a nurse's scope of practice.

Determine the appropriate collaborative action to ensure timely patient care.

The PN must decline the out-of-scope task but can offer to administer the sublingual nitroglycerin, which is an allowable route.

This ensures the client receives prompt, safe care while maintaining professional boundaries and legal safety.

Key Concept

LPN/LVN Scope of Practice in Emergent Medication Administration

Question 929Question →

Following an admission for severe heart failure exacerbation, a client is prescribed scheduled doses of furosemide. Which of the following nursing actions must the practical nurse implement to minimize the client's risk of physiological complications? (Select all that apply.)

Select all that apply

Verify the client's identity by asking them to state their name and date of birth prior to giving the medication

Obtain the client's daily weight using the same scale at the same time each morning

Withhold the diuretic and notify the registered nurse if the client exhibits new-onset resting tachycardia

Administer the furosemide via direct intravenous push to ensure rapid therapeutic diuresis

Delay reporting a morning serum potassium level of 2.8 mEq/L (2.8 mmol/L) until the provider's afternoon rounds

Proceed with the scheduled dose if the client's blood pressure decreases to 88/54 mmHg without further evaluation

Show answer & explanation

Answer: Verify the client's identity by asking them to state their name and date of birth prior to giving the medication; Obtain the client's daily weight using the same scale at the same time each morning; Withhold the diuretic and notify the registered nurse if the client exhibits new-onset resting tachycardia

Answer

The correct actions include verifying the client's identity prior to medication administration, obtaining daily weights using consistent methods, and withholding the medication while notifying the registered nurse if the client exhibits new-onset resting tachycardia.

The correct actions demonstrate safe clinical judgment within the practical nurse's scope of practice by minimizing risks associated with diuretic therapy. Verifying two patient identifiers prevents medication administration errors. Monitoring daily weights provides essential data to evaluate fluid volume status and prevent complications. Recognizing new-onset resting tachycardia as a potential early compensatory sign of hypovolemia correctly prompts the nurse to withhold the medication and escalate the finding to the registered nurse.

Step-by-Step Solution

Analyze the client's clinical scenario and prescribed treatment.

The client has heart failure and is receiving furosemide, a loop diuretic that reduces fluid volume but can cause electrolyte loss and hypovolemia.

Understanding the medication's mechanism of action highlights the risk for hypovolemia, electrolyte imbalances (like hypokalemia), and physiological instability.

Evaluate each nursing action against the practical nurse scope of practice and safety standards.

The nurse must verify patient identifiers, measure daily weights accurately, and escalate early signs of hypovolemia such as tachycardia. The nurse must avoid giving IV push medications, ignoring critical laboratory values, or disregarding hypotensive vital signs.

The primary objective is the reduction of risk potential, which requires strict adherence to scope of practice and prompt recognition of clinical deterioration.

Key Concept

Reduction of Risk Potential (Scope of Practice and Complication Prevention)

Estimated Time:1m 30s

Question 930Question →

During the afternoon shift, an 82-year-old client recovering from a total hip arthroplasty three days ago becomes acutely restless and repeatedly attempts to climb over the bed rails. The client was previously oriented but is now calling out for a deceased spouse. Current vital signs reveal a heart rate of 108 beats/minute, blood pressure of 106/64 mm Hg, and respiratory rate of 24 breaths/minute. Which action should the practical nurse prioritize?

Consult the family members to determine if there is a baseline history of dementia

Document the vital signs as stable and continue with routine postoperative monitoring

Obtain a peripheral pulse oximetry reading to evaluate for potential systemic hypoxia

Reorient the client to the hospital environment and immediately implement strict fall precautions

Show answer & explanation

Answer: Obtain a peripheral pulse oximetry reading to evaluate for potential systemic hypoxia

Answer

The nurse should prioritize obtaining a peripheral pulse oximetry reading to evaluate for potential systemic hypoxia.

Sudden onset of confusion, restlessness, and tachypnea in a postoperative client strongly suggests a physiological complication such as hypoxia, pulmonary embolism, or early shock. The nurse must first prioritize airway and breathing (ABCs) by assessing oxygen saturation before addressing behavioral symptoms.

Step-by-Step Solution

Analyze the clinical presentation and recognize acute changes.

The client exhibits sudden onset confusion, restlessness, slight tachycardia (108 beats/minute), and tachypnea (24 breaths/minute).

Identifying acute deviations from a client's baseline is essential for early recognition of life-threatening complications.

Apply the ABC (Airway, Breathing, Circulation) prioritization framework.

The elevated respiratory rate combined with acute behavioral changes strongly indicates a potential breathing or oxygenation issue.

Physiological needs, especially oxygenation, take precedence over psychosocial or environmental safety needs during acute deterioration.

Determine the most appropriate immediate action within the practical nursing scope.

Measuring oxygen saturation directly and rapidly assesses the client's respiratory status.

Objective data regarding oxygenation is required to confirm hypoxia and guide immediate therapeutic interventions, such as oxygen administration.

Key Concept

Prioritizing ABCs and recognizing hypoxia as a primary cause of acute confusion in older adults.

Question 931Question →

An adult client is prescribed cefazolin $0.75\text{ g}$ intramuscularly for surgical prophylaxis. The medication is supplied as a $1\text{ g}$ vial of dry powder. The manufacturer's instructions state to reconstitute the powder by adding $2.0\text{ mL}$ of sterile water for injection, yielding a total volume of $2.5\text{ mL}$ with a final concentration of $400\text{ mg/mL}$ . How many $\text{mL}$ should be administered to the client? (Record the answer to the nearest tenth. Do not include units in your answer.)

Show answer & explanation

Answer: 1.9

Answer

1.9

To determine the correct volume, the prescribed dose must first be converted to match the available unit:

0.75\text{ g} = 750\text{ mg}

. When a final concentration is provided (

400\text{ mg/mL}

), the diluent amount and total volume become extraneous information. Using the standard formula, divide the desired dose (

750\text{ mg}

) by the available concentration (

400\text{ mg}

) and multiply by the base volume (

1\text{ mL}

), which equals

1.875\text{ mL}

. Rounding to the nearest tenth yields

1.9\text{ mL}

Step-by-Step Solution

Convert the prescribed dose from grams to milligrams.

0.75\text{ g} \times 1000\text{ mg/g} = 750\text{ mg}

The available concentration is provided in milligrams, so the prescribed dose must be in the same unit of measurement.

Identify the final medication concentration from the provided instructions.

The final concentration is

400\text{ mg/mL}

Extraneous information such as the diluent volume (

2.0\text{ mL}

) and total reconstituted volume (

2.5\text{ mL}

) should be ignored when the final concentration is explicitly provided.

Calculate the volume to administer.

\frac{750\text{ mg}}{400\text{ mg}} \times 1\text{ mL} = 1.875\text{ mL}

This formula determines the exact liquid volume containing the required dose.

Round the final answer to the nearest tenth.

1.875\text{ mL}

rounds to

1.9\text{ mL}

Standard rounding rules state that if the hundredths digit is 5 or greater, the tenths digit is rounded up.

Key Concept

Medication Reconstitution and Dosage Calculation

Question 932Question →

An adult client with pneumonia is prescribed a diagnostic chest imaging study using intravenous contrast dye. The morning metabolic panel reveals a serum creatinine level of $2.4$ mg/dL. Which action is the priority for the practical nurse to take to reduce the client's risk for potential complications?

Document the result in the medical record and continue routine preparations for the imaging study.

Instruct the client to drink additional oral fluids to flush the kidneys prior to the test.

Immediately communicate the abnormal laboratory finding to the supervising registered nurse.

Contact the laboratory department directly to order a repeat blood draw for confirmation.

Show answer & explanation

Answer: Immediately communicate the abnormal laboratory finding to the supervising registered nurse.

Answer

Immediately communicate the abnormal laboratory finding to the supervising registered nurse.

The serum creatinine level of

2.4

mg/dL is significantly elevated, indicating impaired kidney function. Because intravenous contrast dye is highly nephrotoxic, the practical nurse must immediately alert the registered nurse or healthcare provider to prevent contrast-induced nephropathy.

Step-by-Step Solution

Identify the client's scheduled procedure and current laboratory values.

The client is scheduled for imaging with intravenous contrast and has a serum creatinine of

2.4

mg/dL.

Intravenous contrast dye is nephrotoxic and poses a high risk to clients with pre-existing kidney impairment.

Determine the normal reference range for serum creatinine.

The normal serum creatinine range is typically

0.6

1.2

mg/dL.

Recognizing that

2.4

mg/dL is significantly elevated is necessary for safe clinical reasoning.

Select the priority nursing intervention based on the practical nurse's scope of practice.

The nurse must immediately escalate the finding to the registered nurse or healthcare provider.

The provider may need to cancel the contrast study, order protective hydration protocols, or switch to a non-contrast imaging modality to prevent acute kidney injury.

Key Concept

Identifying critical laboratory values and escalating findings to prevent procedural complications.

Question 933Question →

Following a right femoral cardiac catheterization, a client is admitted to the medical-surgical unit. As part of providing basic comfort and safety, which actions by the practical nurse are appropriate? Select all that apply.

Select all that apply

Keep the head of the bed at an angle of 30 degrees or lower.

Instruct the client to keep the right leg straight and avoid bending it.

Provide a fracture bedpan when the client reports the urge to urinate.

Position a pillow under the client's knees to reduce strain on the lower back.

Raise the head of the bed to a high-Fowler's position while the client eats meals.

Assist the client to stand at the bedside to promote regular voiding.

Show answer & explanation

Answer: Keep the head of the bed at an angle of 30 degrees or lower.; Instruct the client to keep the right leg straight and avoid bending it.; Provide a fracture bedpan when the client reports the urge to urinate.

Answer

The appropriate actions are keeping the head of the bed at or below 30 degrees, keeping the right leg straight, and using a fracture bedpan for elimination.

Following a femoral cardiac catheterization, strict hemostasis is vital. The client must remain on bed rest with the affected leg fully extended. Keeping the head of the bed elevated no more than 30 degrees prevents hip flexion, which could dislodge the clot. When elimination is needed, a fracture bedpan is the appropriate choice because its low profile requires minimal hip elevation, adhering to the strict movement restrictions.

Step-by-Step Solution

Identify the primary physiological risk associated with a femoral cardiac catheterization.

The main risk is hemorrhage or hematoma formation at the femoral artery puncture site in the groin.

Arterial access points are under high pressure and require strict hemostasis protocols post-procedure.

Determine the positioning constraints required to protect the insertion site.

The affected hip must remain straight (unflexed). Therefore, the head of the bed must remain low (≤30 degrees), and the right leg must be kept fully extended.

Flexion of the hip joint places physical stress on the femoral artery, increasing the likelihood of disrupting the newly formed clot.

Select basic care interventions that align with these strict mobility constraints.

Using a fracture pan is necessary because it minimizes the need to lift the hips. Interventions like ambulation, sitting completely upright, and placing pillows under the knees all cause dangerous hip flexion and must be avoided.

Basic nursing care (such as assisting with elimination or eating) must be adapted to the physical limitations of the prescribed bed rest and limb immobilization.

Key Concept

Post-procedure basic care for femoral arterial access requires strict bed rest, maintaining the affected extremity in a straight position, and avoiding hip flexion to prevent severe hemorrhage.

Question 934Question →

After undergoing a right-sided mastectomy with axillary lymph node dissection, a client is admitted to the surgical recovery unit. The healthcare provider prescribes basic interventions to prevent lymphedema in the affected extremity. Which positioning strategy is correct for the client's right arm?

Elevated on a pillow above the level of the heart

Placed flat on the mattress directly beside the torso

Immobilized tightly across the chest in a standard medical sling

Positioned in a dependent manner below the level of the mattress

Show answer & explanation

Answer: Elevated on a pillow above the level of the heart

Answer

The right arm should be elevated on a pillow above the level of the heart.

Following a mastectomy with lymph node dissection, elevating the affected arm on a pillow above the level of the heart is a fundamental comfort and basic care measure. This position uses gravity to promote continuous lymphatic and venous drainage, thereby preventing or reducing the onset of lymphedema.

Step-by-Step Solution

Identify the surgical procedure and its associated risks.

The client had a mastectomy with axillary lymph node dissection, which disrupts normal lymphatic drainage and places the client at high risk for lymphedema.

Understanding the physiological impact of the surgery dictates the required basic care interventions.

Determine the basic care principles for preventing edema in an extremity.

Raising the extremity above the level of the heart is required.

Elevation uses gravity to facilitate the return of venous blood and lymphatic fluid back toward the central circulation.

Key Concept

Postoperative Positioning for Lymphedema Prevention

Question 935Question →

A practical nurse is collecting data on an adult client who is receiving intravenous fluid resuscitation for severe hypovolemia caused by acute gastrointestinal bleeding. Which of the following clinical findings indicate that the client is experiencing a positive therapeutic response to the fluid therapy? Select all that apply.

Select all that apply

Heart rate decreases from 128 to 92 beats per minute.

Urine output is documented as 50 mL per hour.

The client is alert, awake, and oriented to person, place, and time.

Capillary refill time remains at 5 seconds.

Respiratory rate increases to 28 breaths per minute with new bilateral crackles.

Blood pressure reading is 86/52 mm Hg.

Show answer & explanation

Answer: Heart rate decreases from 128 to 92 beats per minute.; Urine output is documented as 50 mL per hour.; The client is alert, awake, and oriented to person, place, and time.

Answer

The findings that indicate a positive response to fluid resuscitation are a decrease in heart rate to 92 beats per minute, a urine output of 50 mL per hour, and an alert and oriented mental status.

A positive therapeutic response to fluid resuscitation in a hypovolemic client is evidenced by signs of restored intravascular volume and adequate organ perfusion. A heart rate returning toward a normal baseline (from 128 to 92 beats per minute) indicates the heart is no longer compensating for low fluid volume. A urine output of 50 mL per hour demonstrates that the kidneys are receiving adequate blood flow (normal is greater than 30 mL/hr). An alert and oriented mental status indicates that the brain is being properly perfused.

Step-by-Step Solution

Analyze the client's current clinical condition and the goal of the prescribed treatment.

The client is experiencing severe hypovolemia; the goal of intravenous fluid resuscitation is to restore intravascular volume and improve systemic tissue perfusion.

Understanding the pathophysiology of hypovolemic shock establishes the baseline needed to evaluate if interventions are working.

Evaluate each clinical finding to determine if it reflects improved perfusion or an ongoing/worsening complication.

A decreasing heart rate, adequate urine output (> 30 mL/hr), and normal mental status show improved perfusion. Prolonged capillary refill, hypotension, and tachypnea with crackles show ongoing shock or fluid overload.

Systematic evaluation of assessment data ensures accurate differentiation between expected therapeutic benefits and adverse responses.

Key Concept

Evaluation of Fluid Resuscitation and Tissue Perfusion

Question 936Question →

A practical nurse (PN) is preparing to collect an anaerobic wound culture from a client with a deep, foul-smelling stage 4 pressure injury. To ensure a viable specimen and reduce the risk of a false laboratory result, in what chronological order should the PN perform the following actions? (Arrange the steps from first to last.)

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to cleanse the wound, swab the deep tissue, insert the swab into the tube, crush the ampule, and label the specimen.

To reduce the risk of inaccurate laboratory results and improper treatment, the practical nurse must first clear away surface contaminants using normal saline. Next, because anaerobic bacteria die in the presence of oxygen, the swab must be taken from deep, tunneling tissue and immediately placed into the designated transport tube. Activating the ampule at the base is critical because it releases an oxygen-scavenging medium that preserves the anaerobes. Finally, the tube must be labeled at the bedside to ensure safe and accurate processing.

Step-by-Step Solution

Cleanse the wound bed thoroughly with sterile normal saline.

Surface exudate and colonizing skin flora are removed.

Reduces the risk of a false laboratory result caused by culturing non-pathogenic surface bacteria.

Rotate the sterile swab deep inside the tunneling tissue of the wound.

Pathogens responsible for the deep infection are collected.

Anaerobic bacteria cannot survive in oxygen-rich environments and must be collected from deep, unexposed tissues.

Insert the swab immediately into the designated anaerobic culture tube.

The specimen is secured in the transport container.

Minimizes the time the anaerobic bacteria are exposed to ambient room oxygen, which is lethal to them.

Crush the ampule at the base of the culture tube to activate the medium.

The transport medium coats the swab.

The chemical medium eliminates remaining oxygen inside the sealed tube, maintaining viability during transport to the laboratory.

Affix the client's identification label to the tube and document the procedure.

The specimen is accurately identified and ready for transport.

Ensures client safety and prevents laboratory processing errors.

Key Concept

Anaerobic Specimen Collection Protocol

Question 937Question →

During the morning shift on a trauma step-down unit, the practical nurse assumes care for a client who sustained a closed pelvic fracture two days prior. The unlicensed assistive personnel reports that the client has suddenly become combative and is trying to get out of bed. Upon evaluation, the nurse notes the client is tachypneic at 28 breaths per minute, has a heart rate of 115 beats per minute, and displays pinpoint reddish-purple spots across the axillary region. Which action must the practical nurse prioritize?

Initiate oxygen therapy, position the client upright, and urgently alert the registered nurse.

Implement fall precautions, dim the room lights, and attempt to reorient the client to the current time and place.

Auscultate bilateral lung fields and assess the client's pupillary responses to light.

Record the findings in the electronic health record and schedule a vital sign reassessment in 15 minutes.

Show answer & explanation

Answer: Initiate oxygen therapy, position the client upright, and urgently alert the registered nurse.

Answer

The correct action is to initiate oxygen therapy, position the client upright, and urgently alert the registered nurse.

The correct answer immediately addresses the physiological threat of hypoxia caused by a suspected fat embolism. Upright positioning and oxygen therapy stabilize the client's respiratory status while the registered nurse is promptly alerted to coordinate advanced, intensive care.

Step-by-Step Solution

Analyze the clinical cues presented in the scenario.

The client has a recent pelvic fracture, sudden combativeness, tachypnea, tachycardia, and axillary petechiae.

Identifying abnormal data points is the first step in recognizing acute physiological deterioration.

Correlate the symptoms with potential complications.

The triad of respiratory distress, neurological compromise, and a petechial rash 48 hours after a pelvic fracture strongly indicates fat embolism syndrome (FES).

FES is a life-threatening systemic complication that requires immediate recognition.

Determine the physiological priority using the ABC (Airway, Breathing, Circulation) framework.

The tachypnea and hypoxia-induced combativeness indicate an immediate threat to breathing and systemic oxygenation.

Prioritization frameworks dictate that acute respiratory compromise must be addressed before secondary assessments or environmental modifications.

Select the intervention that best aligns with the practical nurse's scope of practice.

Applying oxygen, positioning for optimal lung expansion, and immediately escalating to the registered nurse is required.

The PN must stabilize the client using basic supportive measures while securing advanced RN or provider intervention.

Key Concept

Fat Embolism Syndrome Recognition and Acute ABC Prioritization

Question 938Question →

A client who underwent a percutaneous liver biopsy one hour ago is currently resting in a right side-lying position. The client now reports a new onset of dull right shoulder pain. Upon assessment, the practical nurse notes a heart rate of $108\text{ beats/min}$ and a blood pressure of $106/62\text{ mm Hg}$ . The client's baseline vital signs prior to the procedure were a heart rate of $74\text{ beats/min}$ and a blood pressure of $132/82\text{ mm Hg}$ . Which action is the priority for the practical nurse to take next?

Administer the prescribed as-needed oral analgesic to treat the client's shoulder pain.

Document the assessment findings and repeat the vital signs in 30 minutes.

Assist the client into a supine position to relieve the pressure on the right side.

Immediately report the assessment findings to the supervising registered nurse.

Show answer & explanation

Answer: Immediately report the assessment findings to the supervising registered nurse.

Answer

The priority action is to immediately report the assessment findings to the supervising registered nurse, as the client is exhibiting classic signs of internal hemorrhage.

The client is demonstrating early signs of hemorrhagic shock (resting tachycardia and a significant drop in blood pressure) along with referred pain to the right shoulder, which occurs when blood accumulates under the diaphragm and irritates the phrenic nerve. Because bleeding is a major, life-threatening risk following a highly vascular procedure like a liver biopsy, the practical nurse must recognize these combined signs and immediately escalate the situation to the registered nurse for emergency intervention.

Step-by-Step Solution

Analyze the client's post-procedure symptoms.

The client has a new onset of dull right shoulder pain.

Right shoulder pain after a liver biopsy is a classic sign of referred pain caused by blood irritating the phrenic nerve under the diaphragm.

Compare the current vital signs to the client's pre-procedure baseline.

The heart rate has increased from

74

108\text{ beats/min}

(tachycardia), and the blood pressure has decreased from

132/82

106/62\text{ mm Hg}

(relative hypotension).

Trending vital signs is essential to identify early physiological deterioration.

Synthesize the clinical findings to determine the risk potential.

The combination of referred shoulder pain, tachycardia, and dropping blood pressure strongly indicates internal hemorrhage at the biopsy site.

The liver is a highly vascular organ, making hemorrhage the most significant immediate risk following a percutaneous biopsy.

Determine the most appropriate action within the practical nurse's scope of practice.

The nurse must prioritize circulation (ABCs) and immediately escalate the unstable findings to the registered nurse.

Unstable clients with signs of active bleeding require immediate RN and provider intervention; delaying escalation to administer pain medication or continuing routine monitoring could result in severe client harm.

Key Concept

Recognizing and Escalating Signs of Hemorrhage Post-Biopsy

Estimated Time:1m 30s

Question 939Question →

Following a shift handoff on a medical-surgical unit, a practical nurse evaluates a client who was admitted for gastrointestinal bleeding 24 hours ago. The client's family member states that the client is unusually restless and seems disoriented this morning. The electronic health record shows a current heart rate of 114 bpm and a blood pressure of 98/60 mm Hg, compared to admission vital signs of 84 bpm and 134/78 mm Hg. Which action should the practical nurse take first?

Report the change in mental status and vital signs to the registered nurse immediately.

Reassure the family member that temporary disorientation is a normal reaction to hospitalization.

Document the vital signs in the chart and plan to recheck them during the next scheduled rounds.

Dim the room lights and close the door to provide a low-stimulation environment.

Show answer & explanation

Answer: Report the change in mental status and vital signs to the registered nurse immediately.

Answer

Report the change in mental status and vital signs to the registered nurse immediately.

The client is exhibiting early signs of hypovolemic shock (tachycardia, hypotension) and inadequate cerebral perfusion (restlessness, disorientation) stemming from the gastrointestinal bleeding. Within the practical nurse's scope of practice, recognizing acute physiological instability requires immediately notifying the registered nurse or provider so that rapid life-saving interventions can be initiated.

Step-by-Step Solution

Analyze the client's clinical presentation and vital sign trends.

The client has a new onset of restlessness, disorientation, tachycardia (114 bpm), and a decrease in blood pressure (98/60 mm Hg) compared to baseline.

Identifying deviations from baseline is critical for recognizing early physiological decompensation.

Correlate the findings with the client's admission diagnosis.

The symptoms indicate potential hypovolemic shock and inadequate cerebral perfusion due to active or worsening gastrointestinal bleeding.

Connecting symptoms to the underlying disease process determines the urgency of the situation.

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

The immediate priority is to notify the registered nurse.

Acute, unstable changes require escalation for advanced assessment, fluid resuscitation, and potential medical intervention.

Key Concept

Early Recognition of Hypovolemic Shock

Question 940Question →

A practical nurse is caring for a client who had a percutaneous liver biopsy 2 hours ago. The client's heart rate has increased from 80 to 118 beats per minute, and blood pressure has decreased from 122/76 mm Hg to 92/58 mm Hg. Which action should the practical nurse take first?

Notify the registered nurse (RN) immediately.

Document the vital signs and recheck them in 30 minutes.

Administer the prescribed as-needed pain medication.

Increase the rate of the maintenance intravenous fluids.

Show answer & explanation

Answer: Notify the registered nurse (RN) immediately.

Answer

Notify the registered nurse (RN) immediately.

The correct answer is to notify the RN immediately. A percutaneous liver biopsy involves inserting a needle into a highly vascular organ, putting the client at significant risk for internal bleeding. Tachycardia (increased heart rate) and hypotension (decreased blood pressure) are classic early signs of hemorrhage and hypovolemic shock. Because this is a life-threatening emergency, the practical nurse must escalate the findings immediately to the RN, who will coordinate with the healthcare provider for further interventions.

Step-by-Step Solution

Analyze the client's current vital signs compared to the baseline.

The heart rate has significantly increased (tachycardia) and the blood pressure has decreased (hypotension).

Identifying abnormal trends in vital signs helps recognize physiological deterioration.

Correlate the vital sign changes with the recent procedure.

A liver biopsy carries a high risk of hemorrhage. The vital sign changes strongly suggest active internal bleeding.

Understanding procedure-specific risks is essential for anticipating and identifying life-threatening complications.

Determine the priority action based on the practical nurse's scope of practice.

The client is experiencing a life-threatening complication that must be immediately reported to the RN for collaborative emergency management.

Prompt escalation ensures the client receives timely medical interventions.

Key Concept

Early recognition of shock and appropriate escalation within the practical nursing scope of practice.

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