Physiological Integrity

1313 questions

Question 1021Question →

An older adult client arrives at the recovery unit after undergoing surgical removal of a cataract in the left eye. When setting up the bed and assisting the client to rest, which positioning action should the practical nurse implement?

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Answer: Position the client flat on the back or onto the non-operative right side

Answer

Position the client flat on the back or onto the non-operative right side.
Placing the client on their back (supine) or on the unoperated side (the right side) is the standard postoperative intervention for cataract surgery. This position prevents the mattress or pillows from applying direct pressure to the operative eye, effectively minimizing intraocular pressure and preventing surgical site disruption.

Step-by-Step Solution

1
Identify the surgical procedure and the affected side.
The client had a left-eye cataract extraction.
Knowing the affected side determines which positioning strategies are safe to use.
2
Determine the primary physiological risk following this surgery.
The major risk is increased intraocular pressure (IOP) or direct trauma to the operative site.
Any increase in IOP can lead to bleeding, suture rupture, or impaired healing.
3
Select the position that minimizes pressure on the left eye.
Supine or right-sided lying positions are chosen.
These positions use gravity to keep pressure off the left eye and prevent accidental physical pressure against the mattress.

Key Concept

Following eye surgery, the client must be positioned to prevent any increase in intraocular pressure, which means avoiding lying on the operative side, bending the neck, or assuming a prone position.
Question 1022Question →

During a morning shift, a practical nurse (PN) brings routine oral medications to a 65-year-old client. The client's vital signs include a blood pressure of 128/78 mmHg128/78\text{ mmHg} and a heart rate of 76 beats/minute76\text{ beats/minute}. The client reports no medication allergies. Which of the following actions should the PN take to ensure safe administration? Select all that apply.

Select all that apply

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Answer: Compare the medication label to the medication administration record three times.; Assess the client's ability to swallow before providing the oral pills.; Document the medication administration immediately after the client takes the medication.

Answer

The nurse should compare the medication label to the MAR three times, assess the client's ability to swallow, and document the administration immediately after the medication is taken.
Safe medication administration requires strict adherence to safety protocols. Comparing the label to the medication administration record three times ensures the correct drug is selected. Assessing swallowing ability confirms the oral route is safe and prevents aspiration. Finally, documenting immediately after the client takes the drug ensures accurate records and prevents accidental double dosing.

Step-by-Step Solution

1
Identify the standard rights of medication administration.
Safe practice requires right client, medication, dose, route, time, and documentation.
Adhering to these rights systematically prevents medication errors.
2
Evaluate each action against safety guidelines and the practical nurse's scope of practice.
Checking the MAR three times, assessing swallowing, and immediate documentation directly align with safe practice.
These actions support the rights of medication administration and prioritize client safety.
3
Identify unsafe or out-of-scope practices among the choices.
Using a room number for identification and delegating medication administration to an unlicensed assistive personnel are incorrect.
Room numbers are not valid patient identifiers, and medication administration cannot be delegated to unlicensed staff.

Key Concept

Rights of Medication Administration and PN Scope of Practice
Question 1023Question →

A practical nurse is preparing an adult client with severe hepatic cirrhosis and ascites for a bedside abdominal paracentesis. Arrange the following pre-procedure actions in the correct chronological sequence to minimize the risk of procedural complications.

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Answer

The correct sequence is: Verify informed consent, instruct the client to empty their bladder, obtain baseline measurements, position the client upright, and finally set up the sterile tray.
The correct sequence prioritizes legal readiness, then proceeds to crucial physiological risk reduction. The client must void first to prevent accidental bladder perforation by the trocar. Once the bladder is empty, an accurate baseline weight, abdominal girth, and vital signs can be obtained. The client is then positioned upright to pool the fluid, and the sterile tray is opened last to maintain strict asepsis immediately prior to insertion.

Step-by-Step Solution

1
Verify informed consent.
Legal authorization is confirmed.
Must be completed before any physical preparation begins.
2
Instruct client to empty bladder.
Bladder size is reduced.
Prevents accidental puncture of the bladder during trocar insertion.
3
Obtain baseline measurements.
Accurate dry weight and baseline vital signs are recorded.
Crucial for detecting post-procedure hypovolemic shock caused by rapid fluid shifts.
4
Position the client upright.
Ascitic fluid pools in the lower abdomen.
Uses gravity to facilitate safe and effective fluid aspiration.
5
Prepare the sterile tray.
Sterile field is established.
Must be done immediately prior to the procedure to minimize contamination risk.

Key Concept

Risk reduction during paracentesis preparation involves preventing bladder perforation, establishing baselines for shock detection, and ensuring proper gravity pooling of fluid.
Question 1024Question →

A practical nurse is caring for an older adult client receiving continuous enteral nutrition via a nasogastric tube. The client suddenly experiences forceful coughing, tachypnea, and expels enteral formula from their mouth. In which order should the practical nurse perform the following actions to minimize the client's risk for severe complications?

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Answer

The correct sequence is to first pause the feeding pump, then turn the client to a side-lying position, suction the oral cavity, auscultate lung sounds with oxygen saturation, and finally report the findings to the registered nurse.
In any acute respiratory emergency where a clear causative agent is actively being introduced, the absolute priority is to stop the agent (pause the pump). Following the ABCs (Airway, Breathing, Circulation), the next immediate steps are to physically protect the airway (lateral position) and clear it (suction). Only after the airway is secured and the immediate physical threat is neutralized should the practical nurse proceed to data collection (auscultation and oxygen saturation) and escalation of care (notifying the RN).

Step-by-Step Solution

1
Pause the continuous enteral feeding pump.
The flow of enteral formula into the client is halted.
This immediately removes the source of the aspiration, which is the absolute highest priority to prevent further volume from entering the lungs.
2
Turn the client into a lateral side-lying position.
The client's airway is protected by gravity.
This position facilitates the immediate drainage of the expelled formula out of the mouth rather than allowing it to pool and travel down into the trachea.
3
Use a Yankauer catheter to suction the oral cavity.
Visible formula is removed from the oropharynx.
Suctioning physically clears the upper airway, establishing patency and minimizing the risk of secondary aspiration of residual formula in the mouth.
4
Auscultate bilateral lung sounds and obtain an oxygen saturation reading.
Baseline respiratory compromise is quantified.
Once the airway is completely secured and the immediate threat is neutralized, the nurse must assess the extent of the client's physiological reaction to guide further medical interventions.
5
Report the clinical findings and interventions to the registered nurse.
The healthcare team is alerted to the critical event.
Escalation to the supervising RN is required so that higher-level interventions, such as a chest radiograph or provider notification, can be initiated based on the assessment data.

Key Concept

Prioritization of immediate life-saving interventions (stopping the source and protecting the airway) over data collection during an acute aspiration event.
Question 1025Question →

While preparing a client's morning medications, a practical nurse needs to combine prescribed doses of regular insulin and NPH insulin into one syringe. Place the actions required to safely prepare this mixed insulin injection into the correct chronological sequence.

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Answer

The correct sequence is to roll the NPH vial, inject air into the NPH vial, inject air into the regular insulin vial, withdraw the regular insulin, and finally withdraw the NPH insulin.
The standard procedure for mixing insulins dictates that the intermediate-acting NPH insulin (cloudy) must be gently rolled first to mix the suspension. To avoid negative pressure without contaminating the needle, air is injected into the NPH vial first, followed by injecting air into the regular insulin (clear) vial. The regular insulin is then withdrawn first ('clear before cloudy') to ensure that no intermediate-acting insulin accidentally contaminates the rapid or short-acting regular insulin vial. Finally, the NPH insulin is withdrawn.

Step-by-Step Solution

1
Roll the vial of NPH insulin gently between the palms of the hands.
The cloudy insulin suspension is mixed uniformly.
NPH insulin is a suspension that settles. Rolling mixes it gently without creating bubbles that could lead to an inaccurate dose.
2
Inject a volume of air equal to the prescribed dose into the NPH insulin vial.
The NPH vial is pressurized.
Injecting air first prevents the creation of a vacuum later. The needle touches only air, remaining uncontaminated for the next vial.
3
Inject a volume of air equal to the prescribed dose into the regular insulin vial.
The regular insulin vial is pressurized.
The regular insulin vial must be pressurized immediately before drawing up the medication.
4
Withdraw the prescribed dose of regular insulin into the syringe.
The clear insulin is drawn into the syringe.
The clear (regular) insulin is always drawn first to prevent the cloudy (NPH) insulin from entering and contaminating the regular insulin vial.
5
Withdraw the prescribed dose of NPH insulin into the syringe.
The exact dose of cloudy insulin is added to the syringe.
The cloudy insulin is drawn last to complete the mixture. If too much NPH is drawn inadvertently, the entire syringe must be discarded as the insulins are already mixed.

Key Concept

Safe Preparation of Mixed Insulins (Clear before Cloudy)
Question 1026Question →

A practical nurse (PN) is performing a routine dressing change for a client who is 4 days postoperative following an abdominal surgery. The client suddenly coughs forcefully, and the PN observes a loop of bowel protruding through the incision line. Arrange the following actions in the order the PN should perform them, from first to last.

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Answer

The PN must first call for immediate assistance while remaining with the client, then position the client to decrease abdominal tension, cover the evisceration with sterile moist dressings, and finally monitor vital signs for shock.
Wound evisceration is a critical surgical emergency. The nurse's first priority is to call for help while staying with the client to ensure safety and rapidly mobilize the team. Next, positioning the client in low Fowler's with flexed knees reduces intra-abdominal pressure. Third, covering the wound with sterile, saline-soaked dressings protects the tissue viability. Finally, obtaining vital signs establishes a baseline to monitor for impending shock.

Step-by-Step Solution

1
Stay with the client and call for immediate assistance.
Additional nursing staff is alerted to bring supplies and notify the provider.
An evisceration is a medical emergency requiring teamwork; the nurse cannot leave the client unattended to gather sterile supplies.
2
Place the client in a low Fowler's position with the knees flexed.
Intra-abdominal pressure is minimized.
Flexing the hips and knees relaxes the abdominal wall, preventing further visceral protrusion from the wound.
3
Cover the protruding organs with sterile, saline-soaked dressings.
The exposed bowel is kept moist and protected from contaminants.
Drying of the viscera can cause irreversible tissue damage. Using sterile technique prevents severe intra-abdominal infection.
4
Assess the client's vital signs to monitor for symptoms of shock.
The client's hemodynamic status is documented.
Evisceration can trigger a massive fluid shift or hemorrhage leading to hypovolemic shock, requiring close monitoring.

Key Concept

Management of Wound Evisceration
Question 1027Question →

A practical nurse is monitoring a client who is recovering from major abdominal surgery. What data collection findings should the nurse identify as early indicators of hypovolemic shock? (Select all that apply.)

Select all that apply

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Answer: Heart rate of 118 beats/minute; New-onset restlessness and anxiety; Urine output of 50 mL over the last 4 hours

Answer

The correct early indicators are a heart rate of 118 beats/minute, new-onset restlessness and anxiety, and a urine output of 50 mL over the last 4 hours.
In early hypovolemic shock, the body's compensatory mechanisms immediately activate to maintain cardiac output and vital organ perfusion. The sympathetic nervous system increases the heart rate (tachycardia) to compensate for lower stroke volume. Decreased blood flow to the brain rapidly causes early mental status changes, presenting as restlessness and anxiety. Additionally, the kidneys respond to decreased perfusion by retaining water and sodium, which significantly decreases urine output to preserve intravascular volume.

Step-by-Step Solution

1
Analyze the client's clinical situation and primary risk factors.
The client recently underwent major abdominal surgery, placing them at high risk for internal bleeding and fluid volume deficit.
Identifying the primary risk helps the nurse anticipate specific physiological complications like hypovolemic shock.
2
Evaluate each assessment finding against the body's expected compensatory mechanisms for fluid loss.
Tachycardia, restlessness, and significant oliguria match the sympathetic nervous system's response to decreased circulating blood volume.
During early shock, the body attempts to compensate by increasing heart rate, shunting blood from non-vital areas, and retaining fluid to maintain blood pressure and perfusion to vital organs.

Key Concept

Early Signs of Hypovolemic Shock
Question 1028Question →

A practical nurse is administering a prescribed dose of intramuscular iron dextran to a client with severe iron deficiency anemia. To prevent tissue irritation and staining, the nurse utilizes the Z-track method. Arrange the following actions in the correct chronological sequence for this procedure.

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Answer

The correct sequence is to pull the skin laterally, insert the needle at a 90-degree angle, inject the medication slowly, leave the needle in place for 10 seconds, and finally withdraw the needle while releasing the skin.
The Z-track method is explicitly designed to prevent dark-colored or highly irritating medications, such as iron dextran, from leaking into the subcutaneous tissue and causing permanent skin staining or irritation. By displacing the skin prior to insertion, the needle track through the subcutaneous tissue and the muscle layer become misaligned once the skin is released, sealing the medication within the muscle.

Step-by-Step Solution

1
Pull the overlying skin and subcutaneous tissue laterally approximately 1 to 1.5 inches.
The skin and subcutaneous tissue planes are shifted.
Displacing the tissue creates an offset pathway that will trap the medication once the tissue is released.
2
Insert the needle firmly at a 90-degree angle into the ventrogluteal muscle.
The needle penetrates through the displaced skin and subcutaneous tissue into the muscle.
A 90-degree angle ensures the medication is delivered deeply into the muscle layer.
3
Depress the plunger slowly to inject the medication into the muscle.
The iron dextran is delivered into the ventrogluteal muscle.
Slow injection allows the muscle fibers to accommodate the fluid volume, reducing pain.
4
Keep the needle in place for 10 seconds after the medication is fully injected.
The medication begins to absorb into the surrounding muscle tissue.
Providing a brief waiting period prevents the medication from immediately tracking back up the puncture path.
5
Withdraw the needle smoothly and immediately release the displaced skin.
The skin slides back to its original position.
Releasing the skin misaligns the needle tracks in the skin, subcutaneous tissue, and muscle, effectively sealing the irritating medication deep inside.

Key Concept

Z-track Intramuscular Injection Technique
Estimated Time:1m 30s
Question 1029Question →

A 68-year-old client is 12 hours postoperative following a partial nephrectomy. The client uses the call light to report incisional pain rated 8 on a 0 to 10 scale. Upon entering the room, the practical nurse (PN) notes the client is restless, slightly diaphoretic, and confused about the current day of the week. Vital signs are temperature 98.4°F (36.9°C), pulse 116 bpm, respiratory rate 22/min, and blood pressure 106/62 mm Hg. The client's preoperative blood pressure was 142/84 mm Hg. Which action should the PN take FIRST?

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Answer: Inspect the surgical dressing and dependent areas for bleeding, then immediately notify the registered nurse.

Answer

The correct action is to inspect the surgical dressing and dependent areas for bleeding, then immediately notify the registered nurse.
The correct answer directly addresses the most immediate threat to the client's life. Restlessness, new-onset confusion, tachycardia, and a significant drop in blood pressure from baseline are early compensatory signs of hypovolemic shock, likely due to postoperative hemorrhage. The practical nurse must quickly assess for visible bleeding (dressing, drains, or pooling underneath the client) and immediately escalate the findings to the registered nurse for rapid intervention.

Step-by-Step Solution

1
Analyze the client's symptoms and vital sign trends compared to the baseline.
The client has tachycardia, a significant drop in blood pressure from baseline, restlessness, and new-onset confusion.
Identifying deviations from baseline helps differentiate normal postoperative recovery from acute complications.
2
Synthesize the findings to identify the underlying physiological problem.
The combination of narrowed pulse pressure, tachycardia, diaphoresis, and altered mental status indicates inadequate systemic perfusion.
These are classic early compensatory signs of hypovolemic shock, highly likely resulting from internal hemorrhage following a vascular surgery like a nephrectomy.
3
Apply the Airway, Breathing, Circulation (ABC) prioritization framework to determine the immediate nursing action within the PN scope of practice.
Circulation takes priority over pain management or routine documentation. The PN must gather focused data on the source of bleeding and escalate the situation.
Rapid identification and reporting of hemorrhage are required for emergency intervention to prevent severe hypovolemic shock and cardiovascular collapse.

Key Concept

Early Recognition of Hypovolemic Shock and Prioritization
Estimated Time:1m 15s
Question 1030Question →

To evaluate a client's risk for falls related to suspected fluid volume deficit, orthostatic vital sign monitoring is prescribed. Arrange the procedural steps for performing this assessment in the correct clinical sequence.

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Answer

First, position the client supine for 3 to 5 minutes, then measure baseline vital signs. Next, assist the client to stand, wait 1 to 3 minutes, and finally measure the standing vital signs.
Proper measurement of orthostatic vital signs requires establishing a stable supine baseline first (after 3 to 5 minutes of rest). Once baseline measurements are recorded, the client is assisted to an upright position. A critical waiting period of 1 to 3 minutes is then necessary to observe the body's compensatory mechanisms before taking the final standing measurements.

Step-by-Step Solution

1
Position the client supine and wait for 3 to 5 minutes.
The cardiovascular system reaches a resting baseline state.
Establishing a true resting baseline is essential for an accurate comparison.
2
Measure and record the baseline blood pressure and pulse rate.
Resting physiological parameters are documented.
These values serve as the control measurement before gravity affects blood return.
3
Assist the client into a standing position.
The client is upright, causing blood to pool in the lower extremities.
Standing provokes the physiological response being evaluated.
4
Wait for 1 to 3 minutes after the position change.
The body attempts to compensate for the fluid shift through vasoconstriction and increased heart rate.
Reading vital signs immediately upon standing may capture normal transient changes rather than true orthostatic instability.
5
Obtain and record the standing blood pressure and pulse rate.
Standing vital signs are documented.
These measurements are compared to the supine baseline to identify orthostatic hypotension (a significant drop in systolic or diastolic pressure).

Key Concept

Orthostatic Vital Sign Measurement
Question 1031Question →

The practical nurse (PN) reviews the electronic health record (EHR) of a client admitted with an acute exacerbation of ulcerative colitis. The client is receiving continuous intravenous hydration and methylprednisolone.

Parameter04:00 (Previous)08:00 (Current)
Heart Rate88 bpm114 bpm
Blood Pressure118/76 mmHg102/64 mmHg
Temperature37.4°C (99.3°F)37.6°C (99.7°F)
Bowel Movements2 (liquid, bloody)4 (liquid, bright red)
Hemoglobin11.2 g/dL9.0 g/dL

Based on the clinical trajectory and current data, which action should the PN take first to reduce the client's risk for severe complications?

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Answer: Immediately alert the supervising registered nurse regarding the hemodynamic trends and recent hemoglobin result

Answer

Immediately alert the supervising registered nurse regarding the hemodynamic trends and recent hemoglobin result
The client is demonstrating classic early signs of hypovolemic shock due to acute gastrointestinal bleeding. The rapidly dropping hemoglobin (decrease of 2.2 g/dL in just 4 hours), paired with resting tachycardia (114 bpm) and a narrowing pulse pressure, clearly indicates active blood loss. The most critical action within the practical nurse scope is to immediately escalate these findings to the supervising registered nurse so that life-saving interventions can be initiated.

Step-by-Step Solution

1
Analyze the vital sign trends across the four-hour period.
The heart rate increased significantly from 88 to 114 bpm, while the blood pressure decreased from 118/76 to 102/64 mmHg.
Recognizing early compensatory mechanisms (tachycardia) is crucial for identifying impending hemodynamic instability.
2
Evaluate the laboratory data and physical output against the vital signs.
The hemoglobin dropped rapidly by 2.2 g/dL, which correlates with the increase in bright red bloody stools, confirming active internal hemorrhage.
Linking the objective lab data with the physical assessment findings provides the complete clinical picture of acute blood loss.
3
Determine the highest priority action within the practical nursing scope of practice.
Escalate the findings immediately to the registered nurse or healthcare provider.
Active hemorrhage leading to early hypovolemic shock requires advanced interventions (e.g., blood transfusions, massive fluid resuscitation) that necessitate immediate provider notification.

Key Concept

Recognition and Escalation of Early Hypovolemic Shock
Question 1032Question →

A client who underwent a supratentorial craniotomy two days ago requires morning hygiene care and a complete bed linen change. The client is alert, reports a mild headache, and has stable vital signs. Which approach must the practical nurse use when delivering this basic care?

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Answer: Keep the head of the bed elevated at 30 degrees during the procedure and ensure the client's neck remains in a neutral, midline alignment.

Answer

The practical nurse must maintain the head of the bed at a 30-degree elevation and keep the client's neck in a neutral, midline position throughout the hygiene care and linen change.
Following a craniotomy, preventing increased intracranial pressure (ICP) is a critical nursing priority. Maintaining the head of the bed at 30 degrees and keeping the neck in a neutral, midline alignment promotes optimal venous return from the brain via the jugular veins. Even during basic care activities such as bathing or linen changes, these strict positional precautions must be maintained to ensure physiological integrity.

Step-by-Step Solution

1
Identify the client's postoperative status and specific physiological risks.
The client had a supratentorial craniotomy two days ago, placing them at high risk for increased intracranial pressure (ICP).
Understanding the surgical history dictates which routine care modifications are strictly necessary.
2
Evaluate standard hygiene procedures against postoperative constraints.
Standard bed baths and linen changes often involve lowering the head of the bed; however, this standard practice is contraindicated for this specific client.
A flat position decreases cerebral venous drainage, which can dangerously elevate ICP.
3
Select the intervention that provides necessary basic care while maintaining physiological safety.
The nurse modifies the care delivery by keeping the head of the bed elevated and preventing any neck flexion during turning.
A 30-degree elevation with neutral neck alignment optimizes venous return from the brain, preventing ICP spikes during routine movement.

Key Concept

Post-craniotomy physiological positioning during basic care
Question 1033Question →

A client who underwent a right total hip arthroplasty (posterior approach) two days ago is unable to transfer to the bathroom and requests assistance with a bowel movement. Which action should the practical nurse take to safely assist the client with elimination?

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Answer: Provide a fracture bedpan and instruct the client to lift their hips using an overhead trapeze.

Answer

The most appropriate and safe action is to provide a fracture bedpan and instruct the client to lift their hips using an overhead trapeze.
Providing a fracture pan prevents extreme hip flexion because it is significantly flatter than a standard bedpan. Instructing the client to use an overhead trapeze allows them to lift their weight safely without twisting the spine or dislodging the hip prosthesis.

Step-by-Step Solution

1
Identify the surgical precautions for the client's specific procedure.
A posterior approach total hip arthroplasty requires avoiding hip flexion greater than 90 degrees, adduction across the midline, and internal rotation.
Adhering to these limitations prevents the head of the femur from popping out of the acetabular cup (dislocation).
2
Evaluate elimination devices based on the identified physical restrictions.
Standard bedpans and standard-height commodes require hip flexion that often exceeds 90 degrees.
The equipment used for basic care and comfort must be adapted to keep the hip joint in a safe alignment.
3
Select the intervention that facilitates elimination while maintaining joint stability.
Using a fracture pan combined with an overhead trapeze minimizes hip flexion and avoids rolling onto the operative hip.
A fracture pan's flat end slips easily under the buttocks, and the trapeze allows the client to bear weight on the upper body and unaffected leg safely.

Key Concept

Basic care adaptations for postoperative positioning precautions
Question 1034Question →

An older adult client is 24 hours postoperative following a right total hip arthroplasty using a posterior approach. The client suddenly exhibits acute confusion, severe restlessness, and reports urgent bladder fullness. The client is currently prescribed strict bed rest. Which action is most appropriate for the practical nurse (PN) to take to safely assist this client with elimination?

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Answer: Place an abduction wedge between the client's legs and assist the client to roll onto the unaffected left side to position a fracture pan.

Answer

The practical nurse should use a fracture pan and roll the client onto the unaffected side while maintaining leg abduction with a wedge.
Following a total hip arthroplasty with a posterior approach, it is critical to prevent hip flexion greater than 90 degrees, adduction across the midline, and internal rotation. A fracture pan is required for elimination because its flat end slips easily under the buttocks, minimizing how much the client must be lifted or flexed. Rolling the client onto the unaffected side with an abduction wedge securely in place keeps the operative leg in a safe, neutral position during the procedure, effectively addressing the client's immediate elimination need while ensuring the surgical joint remains stable.

Step-by-Step Solution

1
Acknowledge the client's basic care need and physiological state.
Identify the immediate need to relieve bladder fullness safely.
Urinary retention and bladder distention can directly cause or exacerbate acute confusion and restlessness in older adult clients.
2
Select the appropriate elimination equipment for the client's surgical status.
Choose a fracture pan rather than a standard bedpan.
A fracture pan has a low profile that slides easily under the buttocks, preventing the need to excessively lift the hips or bend the lower back.
3
Execute safe positioning techniques based on surgical precautions.
Place an abduction wedge between the legs and roll the client toward the unaffected (left) side.
For a posterior total hip arthroplasty, maintaining abduction prevents the operative leg from crossing the midline, significantly reducing the risk of posterior hip dislocation during the basic care procedure.

Key Concept

Basic Elimination Care and Postoperative Positioning Precautions
Estimated Time:1m 30s
Question 1035Question →

A practical nurse is caring for a client who is on postoperative day 2 following an exploratory laparotomy with a large midline abdominal incision. The client reports moderate incisional pain and nausea. Which basic care and comfort actions should the nurse implement? Select all that apply.

Select all that apply

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Answer: Assist the client to hold a folded blanket or pillow firmly over the incision when coughing.; Elevate the head of the bed to a semi-Fowler's position with the client's knees slightly bent.; Provide frequent oral care, including swabbing the mouth with moistened sponges.

Answer

The correct actions are assisting the client to splint the incision when coughing, positioning them in a semi-Fowler's position with slightly bent knees, and providing frequent oral care.
Splinting the abdominal incision provides external support and minimizes pain during necessary respiratory exercises like coughing. Assisting the client into a semi-Fowler's position with slightly flexed knees relaxes the abdominal muscles and decreases tension on the surgical wound, effectively minimizing pain. Providing frequent oral care alleviates the physical discomfort associated with nausea and dry mucous membranes.

Step-by-Step Solution

1
Analyze the client's surgical history and current symptoms.
The client had major abdominal surgery (laparotomy) and is currently experiencing incisional pain and nausea.
Identifying the affected body system and specific symptoms guides the selection of appropriate, targeted comfort measures.
2
Evaluate interventions that directly address abdominal incisional pain.
Splinting the incision with a pillow and placing the client in a semi-Fowler's position with flexed knees are safe, effective methods to reduce abdominal muscle tension and pain.
Basic care interventions for abdominal surgery aim to minimize mechanical stress on the healing wound.
3
Determine appropriate comfort measures for nausea.
Frequent oral hygiene safely promotes comfort without risking aspiration or violating dietary restrictions.
Oral care removes unpleasant tastes and moistens mucous membranes, which can ease nausea.
4
Identify unsafe or out-of-scope interventions.
Flat positioning worsens abdominal pain, calf massage creates a high risk for pulmonary embolism, and delegating assessment tasks violates safe assignment guidelines.
Patient safety and adherence to legal scope of practice are paramount when planning care.

Key Concept

Basic comfort measures and safe positioning for clients following abdominal surgery.
Question 1036Question →

A practical nurse is preparing to administer a scheduled oral dose of metoprolol to a client diagnosed with hypertension. The client's current vital signs are blood pressure 130/82130/82 mm Hg and heart rate 7878 beats/min. Which action must the nurse perform immediately before administering the medication to ensure client safety?

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Answer: Verify the client's identity using two distinct, acceptable identifiers.

Answer

Verify the client's identity using two distinct, acceptable identifiers.
Ensuring the correct client receives the medication is a critical component of the 'six rights' of medication administration. Standard nursing practice guidelines require the use of at least two acceptable client identifiers (e.g., full name, date of birth, or assigned identification number) when providing care or administering medications.

Step-by-Step Solution

1
Review the client's vital signs and the medication order.
The blood pressure (130/82130/82 mm Hg) and heart rate (7878 beats/min) are within safe parameters to administer the scheduled metoprolol.
Beta-blockers can lower blood pressure and heart rate, so assessing vital signs is a required pre-administration check.
2
Identify the standard safety protocol immediately prior to medication administration.
The priority action is verifying the 'right client' using two approved identifiers.
This is a fundamental step in the rights of medication administration to prevent giving the drug to the wrong individual.

Key Concept

Medication Administration Rights: Client Identification
Estimated Time:45s
Question 1037Question →

A practical nurse is assisting with the admission of a client who has just returned to the nursing unit following a percutaneous liver biopsy. Which of the following positions should the nurse assist the client into?

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Answer: Right side-lying position with a small rolled towel placed under the puncture site

Answer

Right side-lying position with a small rolled towel placed under the puncture site
The liver is a highly vascular organ located on the right side of the body. Placing the client in a right side-lying position, especially with a towel or small pillow under the lower ribs, uses the client's own body weight to apply direct pressure to the biopsy site. This targeted mechanical compression is critical for promoting hemostasis and preventing internal hemorrhage.

Step-by-Step Solution

1
Identify the procedure performed and its primary anatomical location.
The client underwent a percutaneous liver biopsy; the liver is a highly vascular organ located on the right side of the abdomen.
Understanding the anatomy and the specific nature of the procedure is essential for anticipating potential complications.
2
Determine the highest priority post-procedure risk associated with this specific biopsy.
The greatest physiological risk following a liver biopsy is hemorrhage due to the liver's extensive blood supply.
Post-procedure nursing care must focus immediately on minimizing bleeding at the puncture site.
3
Select the position that physiologically mitigates the identified risk of hemorrhage.
Positioning the client on their right side with a towel under the site utilizes gravity and body weight to compress the liver against the chest wall.
Mechanical compression promotes hemostasis and prevents blood from pooling or hemorrhaging internally.

Key Concept

Post-Procedure Positioning for Hemostasis
Question 1038Question →

An adult client who was recently diagnosed with bacterial conjunctivitis is prescribed ciprofloxacin ophthalmic solution. The practical nurse enters the client's room to instill the medication. In which order should the nurse perform the following actions? Arrange the steps in the correct chronological sequence from first to last.

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Answer

The correct sequence for administering ophthalmic drops is: Perform hand hygiene and put on gloves, position the client's head backward, expose the conjunctival sac by pulling the lower eyelid down, instill the drops into the sac, and finally apply pressure to the inner canthus.
Administering eye drops requires a strict aseptic technique and specific steps to ensure localized medication delivery. First, the nurse must perform hand hygiene and don gloves to prevent infection. Next, positioning the client with the head tilted back and eyes looking upward minimizes the blink reflex. The nurse then pulls the lower eyelid down to expose the conjunctival sac, which is the proper anatomical location for receiving drops. After instilling the drops into the sac, applying gentle pressure to the inner canthus prevents the medication from flowing into the tear duct, thereby avoiding unwanted systemic absorption.

Step-by-Step Solution

1
Perform hand hygiene and don clean gloves.
Infection control measures are established before contact.
The eye is highly susceptible to infection, making hand hygiene the critical first action.
2
Position the client by having them tilt their head back and look upward.
The client is in the optimal position for administration.
Looking up and tilting the head back moves the cornea away from the lower lid and reduces the natural blink reflex.
3
Pull the lower eyelid down to reveal the conjunctival sac.
A small pocket is created for the medication.
Drops should never be placed directly on the cornea because it can cause trauma and discomfort.
4
Instill the drops into the conjunctival sac.
The medication is safely and accurately delivered.
Dropping the medication into the sac ensures proper distribution across the eye surface when the client gently closes their eye.
5
Apply pressure to the inner canthus (nasolacrimal duct).
Systemic absorption of the eye drops is prevented.
Occluding the nasolacrimal duct keeps the medication localized to the eye and prevents it from entering the systemic circulation.

Key Concept

Safe Administration of Ophthalmic Medications
Estimated Time:1m 0s
Question 1039Question →

An older adult client is receiving morning care 48 hours after undergoing a right above-the-knee amputation. When implementing hygiene, mobility, and comfort measures, which actions are appropriate for the practical nurse to take? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Assist the client into a prone position for 20 to 30 minutes multiple times a day.; Wash the residual limb with mild soap and water, ensuring the skin is patted completely dry.; Instruct the client to perform active range-of-motion exercises on the unaffected extremities.

Answer

The appropriate actions are assisting the client into a prone position periodically, washing and thoroughly drying the residual limb, and instructing the client to perform active range-of-motion exercises on unaffected extremities.
Correct basic care for an amputation after 24 hours prioritizes the prevention of contractures and the maintenance of skin integrity. Periodic prone positioning directly stretches the hip flexor muscles, counteracting the tendency for the joint to contract. Gentle hygiene with thorough drying prevents skin breakdown and fungal growth. Encouraging range-of-motion on unaffected limbs promotes systemic circulation and preserves the strength needed for future transfers and ambulation.

Step-by-Step Solution

1
Evaluate the client's postoperative timeframe and surgical type.
The client is 48 hours post-op from an above-the-knee amputation (AKA).
Timeframe dictates positioning rules; after 24 hours, preventing contractures becomes the primary positioning goal.
2
Identify positioning interventions that prevent hip flexion contractures.
Prone positioning is indicated; elevation on pillows and prolonged high-Fowler's positioning are contraindicated.
Hip flexors must be stretched (prone) rather than continuously flexed (sitting or elevated) to ensure future ambulation with a prosthesis.
3
Select appropriate basic hygiene and mobility measures.
Gentle washing with thorough drying and active range-of-motion for unaffected limbs are selected.
These measures safely maintain skin integrity and prevent complications of immobility within the LPN scope of practice.

Key Concept

Postoperative Basic Care and Comfort: Amputation Positioning and Hygiene
Question 1040Question →

A practical nurse is reinforcing teaching for a client who is non-weight-bearing on the right lower extremity and is learning to ascend a flight of stairs using axillary crutches. Arrange the following actions in the correct chronological sequence from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence for ascending stairs with crutches while non-weight-bearing is: establish a tripod stance, shift weight to the crutches, step up with the unaffected leg, shift weight to the unaffected leg, and finally bring the crutches and affected leg up.
The correct sequence follows the fundamental principle of ascending stairs with an assistive device: 'up with the good.' The client must first establish a stable tripod base and shift weight to the crutches. This allows the unaffected leg to step up securely. Once the strong leg is on the upper step, the client shifts weight onto it, utilizing its strength to lift the body, the crutches, and the affected leg to the new level.

Step-by-Step Solution

1
Assume a stable tripod stance at the bottom of the stairs.
A secure base of support is established.
Safety must be ensured before initiating any vertical movement.
2
Shift the body weight entirely onto the handgrips of both crutches.
The unaffected leg is unweighted.
Weight must be supported by the upper body to allow the strong leg to move.
3
Advance the unaffected left leg upward onto the next step.
The strong leg is positioned on the higher level.
The unaffected leg must go up first to power the lift.
4
Transfer the body weight from the crutches onto the unaffected left leg.
The crutches and the affected leg are now unweighted.
The strong leg must bear the weight to lift the rest of the body.
5
Bring both crutches and the non-weight-bearing right leg up to the step.
The client successfully completes the ascension of one step.
The crutches and affected leg follow the strong leg to the new level.

Key Concept

Assistive Device Mobility: Ascending Stairs with Crutches
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