Physiological Integrity

A client with severe chronic obstructive pulmonary disease (COPD) and bilateral lower extremity edema is confined to bed rest 72 hours after undergoing surgical stabilization of a pelvic fracture. To promote optimal comfort, preserve skin integrity, and accommodate all underlying physiological needs, which positioning strategy should the practical nurse execute?

A practical nurse is planning morning hygiene and comfort care for a client who is 1 day postoperative following a right-sided total hip arthroplasty (posterior approach). The client reports mild joint stiffness and requests assistance with a bed bath and repositioning. Which action should the nurse take?

A client is recovering on the surgical unit following a right total hip arthroplasty utilizing a posterior approach. The practical nurse is preparing to turn the client to assess the sacral area. Which action represents the safest technique for this client?

A practical nurse (PN) enters the room of a client receiving total parenteral nutrition (TPN) and discovers that the central venous catheter tubing has accidentally disconnected from the hub. The client is suddenly gasping for air, clutching their chest, and appears cyanotic. In what order should the PN perform the following actions? Arrange the actions in the correct sequence from first to last.

A practical nurse is monitoring a client who began receiving a packed red blood cell (PRBC) transfusion 15 minutes ago. The client suddenly reports severe lower back pain, acute chills, and a sensation of chest tightness. Arrange the following nursing actions in the correct sequence of priority from first to last.

A practical nurse is collecting data from a client who is 2 hours postoperative following an abdominal hysterectomy. The client's vital signs are: blood pressure 98/60 mm Hg, heart rate 114 beats per minute, respiratory rate 18 breaths per minute, and oxygen saturation 96% on room air. The client reports incisional pain as 6 on a 0 to 10 pain scale. Which action should the practical nurse take first?

A 78-year-old client is admitted to the medical unit with a history of melena and fatigue. While collecting vital signs, the practical nurse notes a resting heart rate of 112 beats per minute, a blood pressure of 96/62 mm Hg, and acute disorientation to the current location. Which of the following actions should the nurse implement? Select all that apply.

An older adult client with a history of heart failure is prescribed a daily dose of oral furosemide. The most recent comprehensive metabolic panel reveals a serum potassium level of $2.6$ mEq/L ($2.6$ mmol/L). Which action should the practical nurse take?

A client diagnosed with bipolar disorder has been managed on a daily maintenance dose of oral lithium. Three days ago, the healthcare provider prescribed oral hydrochlorothiazide for newly diagnosed hypertension. During the morning assessment, the practical nurse notes the client is experiencing vomiting, profound muscle weakness, and new-onset coarse hand tremors. The client's morning serum sodium level is $128\text{ mEq/L}$ ($128\text{ mmol/L}$). Which action should the practical nurse take first?

A practical nurse is caring for a client who has just returned to the surgical unit following a total thyroidectomy. To promote comfort and prevent complications, which of the following positions should the nurse assist the client into?

A practical nurse (PN) is monitoring a client who is receiving a packed red blood cell (PRBC) transfusion. Fifteen minutes into the infusion, the client suddenly reports severe lower back pain, chills, and difficulty breathing. In which order should the PN perform the following actions? (Arrange the actions from first to last.)

A practical nurse is preparing to administer a scheduled dose of oral warfarin to a client diagnosed with atrial fibrillation. Which of the following actions must the nurse take before administering this medication?

During evening rounds, an older adult client receiving intravenous antibiotics for community-acquired pneumonia suddenly appears restless, mutters incoherently, and repeatedly attempts to pull out their peripheral catheter. The client's skin is pale and slightly clammy. Vital signs display a heart rate of 116 bpm, a respiratory rate of 24/min, and a blood pressure of 100/74 mm Hg, whereas the baseline blood pressure from the previous shift was 136/82 mm Hg. The urinary drainage bag contains 65 mL of concentrated urine representing the past 4 hours of output. Which action should the practical nurse implement first?

A practical nurse is preparing to transfer a client who has right-sided hemiparesis from the bed to a wheelchair. In what order should the nurse perform the following actions? Arrange the steps in the correct sequence from first to last.

An older adult client with generalized weakness is preparing to get out of bed for the first time today. In what order should the following actions be performed to safely transfer the client to a wheelchair? (Arrange the steps in the correct sequence, from first to last.)

A practical nurse is preparing to administer a large-volume cleansing enema to an adult client experiencing severe constipation. Arrange the following procedural steps in the correct sequential order to ensure client safety, procedure effectiveness, and comfort.

A resident in a rehabilitation facility is recovering from a left above-knee amputation performed 48 hours ago. The individual expresses feelings of stiffness and aching in the remaining hip. What is the most appropriate positioning strategy the practical nurse should utilize to optimize comfort and preserve joint mobility?

A client admitted with an exacerbation of heart failure is scheduled to receive oral furosemide and oral metoprolol. Prior to administration, the practical nurse obtains the following data: blood pressure 88/54 mm Hg, heart rate 116 beats/min, respiratory rate 22 breaths/min, and a morning serum potassium level of 3.1 mEq/L (3.1 mmol/L). Which action is the most appropriate for the practical nurse to take?

A client recovering from severe pneumonia is receiving intravenous antibiotics and continuous supplemental oxygen. The practical nurse enters the room to find the previously oriented client highly agitated, struggling to sit up, and picking aimlessly at the bed linens. Which action should the practical nurse take initially?

An assistive personnel (AP) calls the practical nurse to the room of an 84-year-old client who had a bowel resection two days ago. The client, who was previously alert, is now highly restless and disoriented. The client's pulse is 110 beats/min and blood pressure is 96/58 mmHg. Which action should the practical nurse take first?