Physiological Integrity

1313 questions

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A client with severe chronic obstructive pulmonary disease (COPD) and a high risk for sacral pressure injuries is confined to bed. The client reports significant shortness of breath if the head of the bed is lowered below 45 degrees. Which action by the practical nurse is the most appropriate to promote skin integrity while maintaining respiratory function?

Use pillows to maintain a 30-degree laterally inclined position while keeping the head of the bed elevated.

Lower the head of the bed to a flat position for 15 minutes every two hours to relieve sacral pressure.

Place a ring-shaped cushion directly under the client's sacrum while maintaining the high-Fowler's position.

Elevate the client's legs above the level of the heart using a wedge pillow to redistribute weight away from the pelvis.

Show answer & explanation

Answer: Use pillows to maintain a 30-degree laterally inclined position while keeping the head of the bed elevated.

Answer

The most appropriate action is to use pillows to maintain a 30-degree laterally inclined position while keeping the head of the bed elevated.

In clients with severe orthopnea, the head of the bed must remain elevated to facilitate diaphragmatic excursion and oxygenation. To prevent shear and pressure on the sacrum while the head is elevated, the nurse should use a 30-degree laterally inclined position. This evidence-based angle effectively offloads the sacrum and greater trochanter without compromising the client's respiratory effort.

Step-by-Step Solution

Analyze the competing physiological needs of the client.

The client requires an elevated head of bed (above 45 degrees) for adequate ventilation (ABCs), but this upright position increases shearing forces and pressure on the sacrum.

Airway and breathing are always the highest priority, so the head of the bed cannot be lowered.

Evaluate positioning alternatives that accommodate both needs.

A 30-degree lateral turn shifts body weight off the sacrum and greater trochanter without requiring the client to lie flat.

This specific angle prevents pressure on bony prominences while allowing the upper body to remain supported and elevated for lung expansion.

Identify and eliminate contraindicated devices or positions.

Ring cushions (which cause ischemia) and leg elevation (which increases venous return and cardiac workload) are eliminated as unsafe.

Evidence-based practice prohibits the use of doughnut cushions, and cardiopulmonary principles contraindicate excessive venous return in severe respiratory compromise.

Key Concept

Basic Care and Comfort: Positioning and Pressure Injury Prevention

Question 1042Question →

A practical nurse is assigned to a client whose morning laboratory results indicate a serum potassium level of $3.1\text{ mEq/L}$ . The health care provider prescribes a one-time dose of potassium chloride $45\text{ mEq}$ orally. The medication is supplied in a bulk bottle as an oral solution containing $20\text{ mEq}/15\text{ mL}$ . How many milliliters of the medication should the nurse pour to administer this dose? (Record your answer to the nearest tenth. Do not include units in your answer.)

Show answer & explanation

Answer: 33.8

Answer

33.8

To calculate the correct administration volume for an oral liquid, use the formula:

(\text{Desired Dose} / \text{Dose on Hand}) \times \text{Volume}

. The desired dose prescribed is

45\text{ mEq}

. The dose on hand is

20\text{ mEq}

, which is contained in a volume of

15\text{ mL}

. Plugging these values into the formula yields:

(\frac{45}{20}) \times 15 = 2.25 \times 15 = 33.75\text{ mL}

. According to standard clinical rounding rules, because the hundredths digit is a

5

, the value is rounded up to the nearest tenth, resulting in

33.8\text{ mL}

Step-by-Step Solution

Identify the prescribed dose (Desired).

The desired dose is

45\text{ mEq}

This is the specific amount of potassium chloride ordered by the health care provider.

Identify the concentration of the available medication (Have and Volume).

The medication on hand is

20\text{ mEq}

per

15\text{ mL}

This information is needed to set up the dosage calculation equation.

Set up the dosage calculation equation.

\frac{45\text{ mEq}}{20\text{ mEq}} \times 15\text{ mL} = X\text{ mL}

The standard formula for liquid medication calculation is

(\text{Desired} / \text{Have}) \times \text{Volume}

Perform the calculation and round to the nearest tenth.

2.25 \times 15 = 33.75\text{ mL}

, which rounds to

33.8\text{ mL}

Standard rounding rules state that if the digit to the right of the target decimal place is 5 or higher, round up.

Key Concept

Medication dosage calculation for oral liquids using the desired over have formula

Question 1043Question →

During the morning medication pass at a rehabilitation facility, a practical nurse locates a resident in the busy communal dining room. The resident is due for their routine dose of oral gabapentin. What is the most appropriate action for the nurse to take before providing the tablet?

Request that the resident state their full name and date of birth while checking their wristband.

Hand the medication to the resident after visually recognizing their face from previous shifts.

Ask the dietary aide serving the table to verify the resident's identity before providing the tablet.

State the resident's name and the medication name loudly to ensure the correct person responds.

Show answer & explanation

Answer: Request that the resident state their full name and date of birth while checking their wristband.

Answer

The nurse should request that the resident state their full name and date of birth while checking their wristband.

Safe medication administration requires the nurse to personally verify the client's identity using two distinct identifiers, such as full name and date of birth, even in a communal setting. This ensures the right medication is given to the right client while maintaining their safety.

Step-by-Step Solution

Identify the clinical setting and the required task.

The nurse needs to administer a scheduled medication to a resident located in a public communal dining room.

Understanding the environment is essential to anticipate privacy concerns and safety risks during medication administration.

Apply the fundamental rights of medication administration.

The nurse must verify two distinct patient identifiers (such as name and date of birth) before giving the medication.

Standard safety protocols require strict adherence to the 'right patient' check to prevent medication errors.

Evaluate the proposed actions against safety and scope of practice standards.

Directly asking the resident for their identifiers while checking the wristband is the only action that ensures safety without violating privacy or delegating inappropriately.

Visual recognition, delegating to dietary staff, or announcing medical details publicly are unsafe and unethical practices.

Key Concept

Safe Medication Administration and Patient Identification

Question 1044Question →

During a shift at a rehabilitation center, a practical nurse is assigned to a client who had a right below-the-knee amputation two days ago. To promote physical mobility and prevent complications, which positioning strategy should the nurse implement?

Prop the right residual limb on pillows while the client rests on their back.

Keep the client seated in a chair for the majority of the shift to promote lung expansion.

Assist the client to lie on their stomach for thirty minutes a few times throughout the day.

Position a rolled blanket beneath the right hip to actively encourage external rotation.

Show answer & explanation

Answer: Assist the client to lie on their stomach for thirty minutes a few times throughout the day.

Answer

The correct action is to assist the client to lie on their stomach (prone position) for thirty minutes a few times throughout the day.

The correct answer involves placing the client in a prone position for 20 to 30 minutes several times daily. This intervention is crucial because it fully extends the hip joint and stretches the flexor muscles, thereby preventing the development of a hip flexion contracture, which is a significant mobility complication following a lower extremity amputation.

Step-by-Step Solution

Analyze the client's postoperative timeline.

The client is two days (48 hours) post-amputation.

Positioning interventions change significantly after the initial 24-hour period to shift focus from reducing swelling to maintaining mobility.

Identify the primary musculoskeletal risk at this stage of recovery.

The major risk is the development of a hip flexion contracture.

Prolonged sitting or elevation keeps the hip flexor muscles shortened and tightened.

Select the positioning strategy that directly counteracts this risk.

Assisting the client into a prone position.

Lying on the stomach fully extends the hip joint, effectively stretching the flexor muscles and preventing contracture formation.

Key Concept

Postoperative positioning and contracture prevention following a lower extremity amputation.

Question 1045Question →

A practical nurse is preparing to administer scheduled medications to a group of clients on a medical-surgical unit. Which actions by the nurse demonstrate adherence to safe medication administration practices? Select all that apply.

Select all that apply

Scanning the barcode on the client's identification band prior to drug administration.

Asking the client to state their full name and date of birth before giving the medication.

Accepting an assignment to administer an intravenous (IV) push dose of morphine for a client in severe pain.

Withholding a scheduled dose of an antihypertensive drug for a client with a blood pressure of 88/50 mm Hg and notifying the registered nurse (RN).

Verifying the client's identity by checking the room number and bed assignment before administering a drug.

Show answer & explanation

Answer: Scanning the barcode on the client's identification band prior to drug administration.; Asking the client to state their full name and date of birth before giving the medication.; Withholding a scheduled dose of an antihypertensive drug for a client with a blood pressure of 88/50 mm Hg and notifying the registered nurse (RN).

Answer

The correct actions are scanning the barcode on the identification band, asking the client to state their full name and date of birth, and withholding the antihypertensive drug for a low blood pressure while notifying the RN.

Safe medication administration requires strict adherence to identification protocols, such as scanning the client's barcode and asking them to state their name and date of birth. These two distinct methods ensure the correct client receives the medication. Furthermore, acting safely within the practical nursing scope involves recognizing when to withhold medications—such as holding an antihypertensive drug for a client with a critically low blood pressure—and promptly reporting the finding to the supervising RN.

Step-by-Step Solution

Analyze the requirements for safe client identification prior to medication administration.

The nurse must use at least two distinct, client-specific identifiers, such as name, date of birth, or barcode scanning.

Using proper identifiers prevents medication administration to the wrong client. Room numbers are not acceptable.

Evaluate the practical nurse's scope of practice regarding medication routes.

Intravenous (IV) push medications are generally outside the practical nurse's scope of practice.

IV push medications require advanced assessment skills and the ability to manage immediate, potentially life-threatening adverse reactions, which falls under the RN role.

Assess the appropriate nursing response to abnormal clinical parameters during a medication pass.

The nurse must withhold the antihypertensive medication for a client with hypotension (88/50 mm Hg) and report this finding to the RN.

Administering the medication would further lower the client's blood pressure, potentially causing shock or decreased organ perfusion.

Key Concept

Safe Medication Administration and Scope of Practice

Question 1046Question →

An older adult client with a history of heart failure is prescribed oral furosemide daily. Upon reviewing the morning laboratory results, the nurse notes a serum potassium level of $2.8 \text{ mEq/L}$ . Which action should the nurse take first?

Administer the furosemide as prescribed and document the laboratory result.

Assess the client's blood pressure prior to giving the scheduled dose.

Withhold the furosemide dose and report the finding to the registered nurse.

Provide a potassium-rich snack and proceed with administering the medication.

Show answer & explanation

Answer: Withhold the furosemide dose and report the finding to the registered nurse.

Answer

Withhold the furosemide dose and report the finding to the registered nurse.

The client's serum potassium level of

2.8 \text{ mEq/L}

is significantly below the normal range of

3.5

5.0 \text{ mEq/L}

, indicating severe hypokalemia. Furosemide is a potassium-wasting loop diuretic. Administering this medication would further deplete the client's potassium, significantly increasing the risk of life-threatening cardiac dysrhythmias. The safest and most appropriate action to reduce client risk is to withhold the dose and notify the supervising registered nurse or healthcare provider immediately.

Step-by-Step Solution

Identify the normal range for serum potassium.

The normal serum potassium level is between

3.5

and

5.0 \text{ mEq/L}

Establishing the baseline helps determine if the client's laboratory value is abnormal.

Evaluate the client's laboratory result against the normal range.

The client's level of

2.8 \text{ mEq/L}

is significantly below normal, indicating severe hypokalemia.

Recognizing critical laboratory values is a fundamental aspect of client safety and risk reduction.

Analyze the effect of the prescribed medication on the abnormal laboratory value.

Furosemide is a potassium-wasting loop diuretic, meaning it will cause the body to excrete even more potassium.

Understanding medication mechanisms prevents the administration of drugs that will worsen a client's condition.

Determine the safest nursing intervention.

The dose must be withheld and the finding escalated to the registered nurse or healthcare provider.

Prioritizing risk reduction prevents life-threatening complications, such as cardiac dysrhythmias associated with severe hypokalemia.

Key Concept

Laboratory Value Interpretation and Medication Safety

Question 1047Question →

A practical nurse is providing care for a client who just returned to the nursing unit following an esophagogastroduodenoscopy (EGD) performed with conscious sedation and a local throat anesthetic. Which basic care and comfort interventions should the nurse implement? Select all that apply.

Select all that apply

Keep the client strictly NPO until the return of the gag reflex is verified.

Position the client in a side-lying or semi-Fowler's position.

Offer oral throat lozenges immediately to relieve procedural throat discomfort.

Place the client flat in a supine position to promote hemodynamic stability.

Provide an emesis basin and facial tissues within the client's easy reach.

Show answer & explanation

Answer: Keep the client strictly NPO until the return of the gag reflex is verified.; Position the client in a side-lying or semi-Fowler's position.; Provide an emesis basin and facial tissues within the client's easy reach.

Answer

The correct interventions are maintaining NPO status until the gag reflex returns, utilizing a side-lying or semi-Fowler's position, and providing an emesis basin for oral secretions.

The correct interventions prioritize protecting the client's airway while promoting basic hygiene. Because a local anesthetic was applied to the throat, the gag reflex is temporarily absent. Keeping the client NPO until the reflex returns is a critical safety measure to prevent aspiration. Positioning the client on their side or in a semi-Fowler's position uses gravity to keep the airway clear and facilitate the drainage of saliva. Providing an emesis basin gives the client a safe way to dispose of oral secretions they cannot yet swallow.

Step-by-Step Solution

Identify the procedural risks associated with an esophagogastroduodenoscopy (EGD).

Recognize that conscious sedation and local throat anesthetics depress the central nervous system and temporarily abolish the gag reflex.

Understanding the physiological effects of the procedure dictates the necessary safety and comfort interventions.

Evaluate each intervention for airway safety.

Determine that keeping the client NPO and positioning them on their side or with the head elevated protects the airway. Giving lozenges or lying flat compromises the airway.

Airway protection (ABC prioritization) is the most critical aspect of immediate post-procedure basic care.

Select the interventions that safely promote comfort and hygiene.

Select providing an emesis basin, as it allows the client to manage secretions safely without swallowing.

Basic care and comfort must be provided in a manner that does not violate primary safety protocols.

Key Concept

Post-Procedure Airway and Aspiration Precautions

Question 1048Question →

While conducting hourly rounds, a practical nurse observes a client who is receiving an intravenous infusion of vancomycin for a severe bacterial infection. The infusion was initiated by the registered nurse twenty minutes ago. The client suddenly reports feeling extremely dizzy. The practical nurse notes a bright red, flushed appearance across the client's face, neck, and upper chest, and the client's blood pressure is $88/54\text{ mm Hg}$ (decreased from a baseline of $122/76\text{ mm Hg}$ ). Which of the following actions is the priority for the practical nurse?

Stop the intravenous vancomycin infusion immediately and notify the registered nurse.

Obtain a full set of vital signs and document the findings in the electronic health record.

Reassure the client that facial flushing is a harmless, expected response to this antibiotic.

Prepare to independently administer a prescribed intravenous push dose of diphenhydramine.

Show answer & explanation

Answer: Stop the intravenous vancomycin infusion immediately and notify the registered nurse.

Answer

The priority action is to immediately stop the intravenous vancomycin infusion and notify the registered nurse.

The client is experiencing Red Man syndrome, a known adverse reaction to intravenous vancomycin characterized by intense flushing, rash, and hypotension. Because this reaction can progress to severe cardiovascular collapse, the absolute priority action is to immediately stop the infusion to halt the delivery of the medication. Once the infusion is stopped, the practical nurse must promptly notify the registered nurse or health care provider, as the client will likely require fluid resuscitation or administration of an antihistamine.

Step-by-Step Solution

Analyze the client's clinical presentation.

The client has a sudden onset of dizziness, severe facial/neck flushing, and significant hypotension (

88/54\text{ mm Hg}

) shortly after starting an intravenous vancomycin infusion.

Recognizing the acute signs of an adverse medication reaction is the first step in clinical decision-making.

Identify the underlying complication.

The symptoms indicate Red Man syndrome, a potentially severe, rate-related infusion reaction associated with vancomycin.

Connecting the specific medication to the clinical manifestations determines the necessary emergency intervention.

Determine the priority intervention based on ABCs (Airway, Breathing, Circulation) and scope of practice.

The immediate threat to circulation (hypotension) must be halted by stopping the infusion. This action is safely within the practical nurse's scope.

Stopping the offending agent prevents further cardiovascular collapse and must precede additional assessment, documentation, or out-of-scope interventions.

Key Concept

Recognizing and prioritizing immediate interventions for adverse medication reactions (such as Red Man syndrome) within the practical nursing scope of practice.

Estimated Time:1m 0s

Question 1049Question →

A practical nurse is assisting with the care of a client who is 12 hours postoperative following a lumbar laminectomy with spinal fusion. The client reports severe lower back stiffness from remaining supine and requests assistance to turn onto their side. Which technique should the practical nurse implement to safely reposition this client?

Place a pillow between the client's legs and work with a second staff member to turn the client's entire body simultaneously using a draw sheet.

Instruct the client to reach across their chest to grasp the opposite side rail and gently pull their upper body over.

Elevate the head of the bed to 45 degrees to reduce lumbar strain before assisting the client to roll onto their side.

Ask the client to cross their arms over their chest while the nurse shifts their pelvis first, followed by their shoulders.

Show answer & explanation

Answer: Place a pillow between the client's legs and work with a second staff member to turn the client's entire body simultaneously using a draw sheet.

Answer

The nurse must use the logrolling technique with the assistance of another staff member, turning the client's body as a single unit with a pillow between the legs.

The correct approach for repositioning a client after a spinal fusion is logrolling. This technique requires at least two staff members using a draw sheet (friction-reducing sheet) to turn the client's head, shoulders, spine, and pelvis simultaneously as a single unit. Placing a pillow between the client's legs prevents adduction of the upper leg, which helps maintain the spine in neutral alignment during the turn.

Step-by-Step Solution

Identify the client's surgical procedure and the specific postoperative precautions required.

The client had a lumbar laminectomy with spinal fusion, which requires keeping the spine in strict neutral alignment.

Spinal fusion involves bone grafts and hardware that must remain completely stable during the initial healing phase to prevent injury or failure of the fusion.

Evaluate each repositioning technique for its impact on spinal alignment.

Only turning the body simultaneously as a single unit (logrolling) prevents spinal torsion. Other methods cause twisting of the shoulders relative to the pelvis.

Logrolling distributes movement equally across the entire spine, whereas independent movement or segmented rolling bends or twists the vertebral column.

Key Concept

Postoperative mobility and positioning following spinal surgery requires the logrolling technique to maintain neutral spinal alignment and prevent injury to the surgical site.

Question 1050Question →

An older adult client with a history of asthma and atrial fibrillation is admitted to a medical unit. The health care provider prescribes several new daily medications. Which actions by the practical nurse demonstrate safe pharmacological management? Select all that apply.

Select all that apply

Verify the client's identity using their full name and date of birth before giving oral digoxin.

Withhold the prescribed oral propranolol and notify the registered nurse after assessing audible wheezing.

Administer the scheduled dose of warfarin despite a morning international normalized ratio (INR) of 4.8.

Accept a verbal order during rounds to administer an intravenous push dose of metoprolol.

Confirm the client's room number and bed assignment as the second identifier when the barcode system is offline.

Reinforce previous instructions to rinse the oral cavity with water after using a prescribed budesonide inhaler.

Show answer & explanation

Answer: Verify the client's identity using their full name and date of birth before giving oral digoxin.; Withhold the prescribed oral propranolol and notify the registered nurse after assessing audible wheezing.; Reinforce previous instructions to rinse the oral cavity with water after using a prescribed budesonide inhaler.

Answer

The correct actions are to verify identity using the client's name and date of birth, withhold the propranolol due to active wheezing, and reinforce instructions to rinse the mouth after using the budesonide inhaler.

Safe pharmacological management encompasses strict adherence to the rights of medication administration, including using two acceptable client identifiers (like name and date of birth). Practical nurses must also recognize critical contraindications, such as the danger of administering a non-selective beta-blocker (propranolol) to an asthmatic client who is actively wheezing, as it can worsen bronchospasm. Finally, reinforcing prior teaching regarding self-care measures, such as rinsing the mouth after using an inhaled corticosteroid to prevent candidiasis, is an essential and appropriate component of the practical nurse's scope of practice.

Step-by-Step Solution

Evaluate each action against the standard rights of medication administration.

Using full name and date of birth is correct; using a room number is incorrect and violates safety protocols.

Two unique, client-specific identifiers are required to prevent medication errors.

Analyze the prescribed medications against the client's medical history and current assessment findings.

Propranolol must be withheld in an asthmatic client with audible wheezing.

Non-selective beta-blockers like propranolol can trigger severe bronchospasms in clients with a history of asthma.

Determine if the actions align with the practical nurse's scope of practice.

Reinforcing teaching about budesonide is within the scope; accepting and giving IV push medications is outside the scope. Additionally, administering warfarin with a critically high INR represents a failure to escalate critical data.

The PN must practice within legal boundaries, which excludes IV push administration and requires reporting abnormal physiological findings before proceeding.

Key Concept

Safe medication administration requires adherence to the rights of medication administration, understanding contraindications (such as beta-blockers in asthma), and functioning within the practical nurse scope of practice.

Estimated Time:1m 30s

Question 1051Question →

A practical nurse is caring for a pediatric client who weighs $22\text{ lbs}$ ( $10\text{ kg}$ ) and has a tympanic temperature of $102.1^\circ\text{F}$ ( $38.9^\circ\text{C}$ ). The health care provider's prescription reads: "Ibuprofen $100\text{ mg}$ PO every $6\text{ hours}$ PRN for temperature greater than $101.5^\circ\text{F}$ ( $38.6^\circ\text{C}$ )." The pharmacy dispenses an oral suspension containing $100\text{ mg}/5\text{ mL}$ . The client's caregiver reports administering a dose of oral acetaminophen at home $2\text{ hours}$ prior to arrival. Which action by the nurse is the most appropriate?

Administer

5\text{ mL}

of the ibuprofen suspension to the client using a calibrated oral syringe.

Withhold the ibuprofen because it should not be administered within

4\text{ hours}

of the caregiver's acetaminophen dose.

Administer

11\text{ mL}

of the ibuprofen suspension to match a weight-based calculation using the client's weight in pounds.

Notify the health care provider to increase the dose because

100\text{ mg}

is below the therapeutic range for a

22\text{ lb}

client.

Show answer & explanation

Answer: Administer $5\text{ mL}$ of the ibuprofen suspension to the client using a calibrated oral syringe.

Answer

The correct action is to administer

5\text{ mL}

of the ibuprofen suspension to the client using a calibrated oral syringe.

The correct action is to administer

5\text{ mL}

of the medication. The prescribed dose of

100\text{ mg}

is safe for a

10\text{ kg}

child, as the standard pediatric dose for ibuprofen is

5

10\text{ mg/kg}

per dose (

10\text{ kg} \times 10\text{ mg/kg} = 100\text{ mg}

). To determine the correct volume, the nurse divides the desired dose by the available concentration:

(100\text{ mg} / 100\text{ mg}) \times 5\text{ mL} = 5\text{ mL}

. Acetaminophen and ibuprofen belong to different medication classes, so they can be safely administered within two hours of each other to manage a persistent high fever. A calibrated oral syringe ensures precise measurement.

Step-by-Step Solution

Verify the client's weight in kilograms.

The client weighs

10\text{ kg}

Pediatric medication dosing is strictly based on kilograms to prevent potentially fatal overdosing or underdosing.

Determine if the prescribed dose is within the safe pediatric range.

The standard dose is

5

10\text{ mg/kg}

. For a

10\text{ kg}

child, the maximum safe single dose is

100\text{ mg}

, which exactly matches the prescription.

Nurses must independently verify that a prescribed dose is safe before administration, even if the order is written clearly.

Calculate the required liquid volume to administer.

Using the formula

(\text{Desired} / \text{Have}) \times \text{Volume}

(100\text{ mg} / 100\text{ mg}) \times 5\text{ mL} = 5\text{ mL}

This calculation determines the exact physical amount of liquid to draw into the syringe.

Evaluate drug interactions and administration timing.

The administration is safe. Ibuprofen (an NSAID) and acetaminophen (a non-opioid analgesic/antipyretic) have different mechanisms of action.

Because they are metabolized differently, they can be safely alternated or given within two hours of each other for high fevers without compounding toxicity.

Key Concept

Pediatric Dosage Calculation and Antipyretic Administration

Estimated Time:2m 0s

Question 1052Question →

A nurse is providing morning care for a client who had a right total hip arthroplasty (posterior approach) 48 hours ago. The client needs assistance with bathing, dressing, and using the restroom. Which interventions should be included to ensure proper joint positioning and client comfort? Select all that apply.

Select all that apply

Secure a foam abduction pillow between the lower extremities during rest periods.

Adjust the bedrest to a full upright sitting angle during meal consumption.

Utilize a long-handled reacher to help the client don lower-body clothing.

Turn the client onto the right hip to reduce skin breakdown risk on the posterior torso.

Ensure a raised commode chair is placed over the standard toilet.

Prop the right foot to allow inward rotation of the leg while supine.

Show answer & explanation

Answer: Secure a foam abduction pillow between the lower extremities during rest periods.; Utilize a long-handled reacher to help the client don lower-body clothing.; Ensure a raised commode chair is placed over the standard toilet.

Answer

The correct interventions are securing a foam abduction pillow, utilizing a long-handled reacher, and ensuring a raised commode chair is used.

Proper basic care for a posterior total hip arthroplasty involves preventing the three primary mechanisms of dislocation: hip flexion greater than 90 degrees, leg adduction (crossing the midline), and internal rotation. Securing a foam abduction pillow prevents adduction during rest. Utilizing a long-handled reacher allows the client to dress without bending forward, keeping flexion below 90 degrees. Ensuring a raised commode chair is used prevents the hips from dropping below the knees, which also avoids excessive flexion during elimination.

Step-by-Step Solution

Identify the surgical procedure and its specific biomechanical risks.

The client had a right total hip arthroplasty via posterior approach, which requires preventing hip flexion greater than 90 degrees, leg adduction, and internal rotation.

These specific movements place excessive stress on the posterior joint capsule and can cause the prosthetic head to dislocate.

Evaluate each basic care action against these movement restrictions.

Abduction pillows, raised commodes, and long-handled reachers effectively prevent adduction and severe flexion. Upright sitting, rolling onto the operative side, and inward rotation violate these precautions.

Basic care and ADL assistance must align with prescribed mobility restrictions to ensure client safety and joint stability.

Key Concept

Basic care and mobility for a client following a total hip arthroplasty (posterior approach) requires strict adherence to positional precautions (avoiding flexion > 90 degrees, adduction, and internal rotation) to prevent joint dislocation.

Estimated Time:2m 0s

Question 1053Question →

An older adult client who recently experienced a cerebrovascular accident has residual left-sided hemiparesis. The practical nurse is helping the client put on a clean, front-buttoning shirt. In what order should the nurse complete the following actions? Arrange the steps in the correct sequence from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first sit the client upright, dress the weak left arm, pull the shirt around the back, have the client insert their strong right arm, and finally button the shirt.

The correct sequence prioritizes client safety by first establishing a secure seated position. When dressing a client with unilateral weakness (hemiparesis), the cardinal clinical rule is to dress the affected or weaker side first. This minimizes the need to move or stretch the impaired limb, thereby reducing the risk of joint injury and pain. After the weak arm (left) is dressed, the shirt is brought around the back, allowing the client to use their unaffected arm (right) to independently slide into the remaining sleeve. Finally, securing the buttons and smoothing the fabric completes the process and prevents pressure from wrinkled clothing.

Step-by-Step Solution

Assist the client to a safe, upright seated position.

The client is stable and ready for the activity.

Establishing a secure position is the primary safety priority before initiating any activities of daily living.

Slide the left sleeve over the client's left arm.

The affected side is dressed.

Dressing the weaker side first (left side, due to left-sided hemiparesis) prevents overextension and potential injury to the affected shoulder and arm.

Pull the shirt across the client's back toward the right side.

The shirt is positioned for the strong arm.

This transitions the garment securely so the client can use their unaffected side for the next step.

Instruct the client to insert their right arm into the right sleeve.

The strong side is dressed.

The unaffected arm has the mobility to reach and push through the sleeve without requiring excessive manipulation.

Fasten the buttons and smooth out wrinkles.

The dressing process is complete.

Properly securing the clothing provides warmth and dignity, while smoothing fabric prevents friction and skin breakdown.

Key Concept

Activities of Daily Living (ADLs): Dressing a Client with Hemiparesis

Question 1054Question →

A practical nurse is reviewing morning laboratory results before administering scheduled oral medications to a client with chronic kidney disease and atrial fibrillation.

Scheduled Medications	Dose
Calcitriol	$0.25\text{ mcg}$
Calcium acetate	$667\text{ mg}$
Sevelamer	$800\text{ mg}$
Digoxin	$0.125\text{ mg}$

Laboratory Test	Result
Serum calcium	$11.8\text{ mg/dL}$
Serum phosphorus	$6.2\text{ mg/dL}$
Serum potassium	$4.5\text{ mEq/L}$
Serum digoxin level	$1.1\text{ ng/mL}$

Which action should the practical nurse take?

Withhold the calcitriol, calcium acetate, and digoxin; administer the sevelamer; and notify the registered nurse.

Administer the calcium acetate and sevelamer with breakfast, withhold the calcitriol, and report the findings during shift handoff.

Withhold all scheduled medications, independently initiate continuous cardiac monitoring, and immediately contact the health care provider.

Administer the calcitriol and digoxin after verifying the client's room number, withhold the sevelamer and calcium acetate, and notify the registered nurse.

Show answer & explanation

Answer: Withhold the calcitriol, calcium acetate, and digoxin; administer the sevelamer; and notify the registered nurse.

Answer

Withhold the calcitriol, calcium acetate, and digoxin; administer the sevelamer; and notify the registered nurse.

The client's serum calcium is critically elevated (

11.8\text{ mg/dL}

). Calcitriol (active vitamin D) and calcium acetate must be withheld because they will further increase serum calcium. Furthermore, hypercalcemia significantly increases the risk of digoxin toxicity and fatal dysrhythmias, even when the serum digoxin level is within the normal therapeutic range. Therefore, digoxin must also be withheld. Sevelamer is a non-calcium-based phosphate binder that safely addresses the hyperphosphatemia (

6.2\text{ mg/dL}

) without worsening the hypercalcemia. The practical nurse must notify the registered nurse of these critical findings.

Step-by-Step Solution

Analyze the laboratory results against normal reference ranges.

Serum calcium (

11.8\text{ mg/dL}

) and phosphorus (

6.2\text{ mg/dL}

) are critically elevated. Potassium (

4.5\text{ mEq/L}

) and digoxin (

1.1\text{ ng/mL}

) are within normal limits.

Identifying abnormal physiological values is the first step in determining medication safety.

Evaluate the mechanism of action for the prescribed phosphate binders and vitamins.

Calcitriol increases calcium absorption, and calcium acetate adds calcium. Sevelamer lowers phosphorus without adding systemic calcium.

The client has hypercalcemia, so any medication that further increases calcium (calcitriol, calcium acetate) must be withheld.

Evaluate the digoxin order in the context of the client's electrolyte imbalances.

Digoxin must be withheld despite the normal serum level.

Hypercalcemia sensitizes the myocardium to digoxin, significantly increasing the risk of toxicity and fatal dysrhythmias.

Determine the appropriate practical nursing action based on scope of practice.

Administer only the sevelamer, withhold the unsafe medications, and immediately report the critical laboratory values to the supervising registered nurse.

This action protects the client from pharmacological harm and follows the correct chain of command.

Key Concept

Pharmacological management of chronic kidney disease and the critical interaction between hypercalcemia and digoxin toxicity.

Question 1055Question →

A practical nurse is preparing to administer a morning dose consisting of $5\text{ units}$ of regular insulin and $15\text{ units}$ of NPH insulin to a client with type 2 diabetes mellitus. After performing hand hygiene, in what order should the nurse perform the following actions to safely prepare the mixed injection? Arrange the steps in the correct chronological sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first roll the NPH vial, then cleanse both vials, inject air into the NPH vial, inject air into the regular insulin vial, withdraw the regular insulin, and finally withdraw the NPH insulin.

The correct sequence for mixing insulins follows the 'Clear before Cloudy' principle. The nurse must first prepare the medication by rolling the NPH suspension and disinfecting the vials. Air must be injected into the cloudy vial first, followed by the clear vial, to pressurize them. The clear (regular) insulin is then withdrawn first to ensure no cloudy (NPH) insulin accidentally enters and contaminates the clear insulin vial.

Step-by-Step Solution

Roll the NPH insulin vial gently between the palms.

The NPH suspension is evenly mixed.

NPH insulin settles and must be mixed gently to avoid bubbles that could lead to inaccurate dosing.

Cleanse the rubber stoppers of both vials.

The injection sites on the vials are disinfected.

Standard infection control practice dictates disinfecting vials prior to needle insertion.

Inject air into the NPH (cloudy) vial.

The NPH vial is pressurized without contaminating the needle.

Pressurizing the vial prevents a vacuum. Doing this first ensures the needle remains sterile for the regular insulin vial.

Inject air into the regular (clear) insulin vial.

The regular insulin vial is pressurized.

Pressurizing the vial prevents a vacuum and prepares it for immediate withdrawal.

Withdraw the regular (clear) insulin.

5\text{ units}

of clear insulin are drawn into the syringe.

Clear insulin must be drawn first ('clear before cloudy') to prevent NPH from accidentally contaminating the regular insulin vial.

Withdraw the NPH (cloudy) insulin.

15\text{ units}

of NPH are drawn into the syringe for a total volume of

20\text{ units}

The intermediate-acting insulin is drawn last to complete the mixed dose safely.

Key Concept

When mixing insulins, the regular (clear, short-acting) insulin must be drawn up before the NPH (cloudy, intermediate-acting) insulin to prevent contamination of the rapid-acting insulin.

Question 1056Question →

A 68-year-old client is receiving care for severe acute pancreatitis. On the second day of admission, the client suddenly becomes extremely restless, disoriented to time and place, and complains of intense thirst. Current clinical data reveals a temperature of 99.2°F (37.3°C), a heart rate of 118 beats/minute, a blood pressure of 100/78 mm Hg, and a respiratory rate of 26 breaths/minute. The client's urine output has been 35 mL over the past two hours. Which action is the priority for the practical nurse to take?

Stay with the client, instruct a colleague to immediately alert the registered nurse, and prepare for fluid resuscitation.

Document the vital signs and continue monitoring, as mild hypotension is an expected finding with this diagnosis.

Administer the prescribed as-needed subcutaneous opioid analgesic to manage suspected escalating abdominal pain.

Implement fall precautions and dim the room lights to decrease sensory stimulation for the confused client.

Show answer & explanation

Answer: Stay with the client, instruct a colleague to immediately alert the registered nurse, and prepare for fluid resuscitation.

Answer

The priority action is to stay with the client, have a colleague notify the registered nurse, and prepare for immediate fluid resuscitation.

The correct answer identifies the need for immediate escalation due to a physiological crisis. Severe acute pancreatitis causes systemic inflammation leading to massive fluid shifts from the intravascular space into the interstitial space (third-spacing). The client's presentation—tachycardia, tachypnea, a narrow pulse pressure, extreme thirst, oliguria, and altered mental status—are textbook signs of compensatory hypovolemic shock. The practical nurse must prioritize safety by staying with the unstable client while delegating the immediate notification of the registered nurse to initiate life-saving fluid resuscitation.

Step-by-Step Solution

Analyze the client's vital signs and clinical presentation.

Identification of tachycardia, tachypnea, a significantly narrowed pulse pressure (100/78 mm Hg = 22 mm Hg), oliguria, and new-onset altered mental status.

Recognizing subtle changes in physiological data is the first step in identifying a life-threatening complication.

Synthesize the assessment findings with the client's primary diagnosis of severe acute pancreatitis.

Recognition that pancreatitis causes massive third-spacing of fluids, placing the client at extremely high risk for hypovolemic shock.

Connecting the diagnosis to the physiological findings confirms that the restlessness and vital sign trends are due to hypoperfusion, not pain or simple delirium.

Determine the priority nursing intervention based on the severity of the client's condition.

The client is hemodynamically unstable and requires immediate escalation to the registered nurse while maintaining continuous bedside observation.

In emergent situations involving ABC compromise, the practical nurse's priority is rapid escalation of care while ensuring immediate client safety.

Key Concept

Recognition of compensatory hypovolemic shock and third-spacing

Question 1057Question →

A practical nurse is caring for a client receiving oral morphine sulfate for cancer-related pain. The client's spouse states, "My partner is in a lot of pain, please give the next dose of medication." Upon assessment, the nurse observes that the client is somnolent, difficult to arouse, and has a respiratory rate of $10\text{ breaths per minute}$ . Which action should the nurse take first?

Provide the prescribed oral morphine to manage the pain as requested by the spouse.

Withhold the scheduled medication and immediately notify the registered nurse of the client's respiratory status.

Prepare to independently administer intravenous naloxone to reverse the suspected opioid toxicity.

Give the medication quickly to relieve the pain, bypassing the barcode scanning process due to the urgency.

Show answer & explanation

Answer: Withhold the scheduled medication and immediately notify the registered nurse of the client's respiratory status.

Answer

The practical nurse should withhold the scheduled medication and immediately notify the registered nurse of the client's respiratory status.

The correct action is to withhold the medication and notify the registered nurse. A respiratory rate of

10\text{ breaths per minute}

and somnolence are classic signs of opioid toxicity. Giving further doses of morphine could lead to fatal respiratory arrest. The practical nurse is acting safely and within their scope of practice by holding the medication and reporting the critical findings up the chain of command.

Step-by-Step Solution

Assess the client's vital signs and level of consciousness prior to opioid administration.

The client is somnolent with a respiratory rate of

10\text{ breaths per minute}

Opioids like morphine can cause life-threatening central nervous system and respiratory depression.

Prioritize the assessment findings using the Airway, Breathing, Circulation (ABC) framework.

The compromised respiratory rate and somnolence take priority over the spouse's request for pain management.

A respiratory rate below

12\text{ breaths per minute}

is a critical sign of respiratory depression.

Determine the appropriate intervention within the practical nurse scope of practice.

The nurse withholds the dose and escalates the critical findings to the registered nurse.

The practical nurse must protect the client from further harm and report abnormal findings to the supervising nurse for advanced intervention.

Key Concept

Opioid-induced respiratory depression and the practical nurse's role in safe medication administration.

Question 1058Question →

An older adult client with type 2 diabetes mellitus is prescribed $12\text{ units}$ of regular insulin and $20\text{ units}$ of NPH insulin subcutaneously. Arrange the steps the practical nurse must follow to safely prepare this mixed dose in a single syringe in the correct chronological order.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: Roll the NPH vial, cleanse both stoppers, inject air into NPH, inject air into regular, withdraw regular, then withdraw NPH.

When mixing NPH and regular insulin, the standard safety protocol is 'clear before cloudy'. The practical nurse must first suspend the NPH by rolling, disinfect both vials, and inject the required air into the NPH vial without touching the liquid. Next, the nurse injects air into the regular insulin vial and immediately draws up the regular (clear) insulin. Finally, the nurse draws up the NPH (cloudy) insulin. This strict sequence prevents contamination of the rapid-acting regular insulin vial with the longer-acting NPH insulin.

Step-by-Step Solution

Roll the vial of NPH insulin gently between the palms.

The cloudy suspension is mixed evenly.

NPH insulin settles when resting. Rolling prevents bubbles that shaking would cause, ensuring an accurate dose.

Scrub the rubber stoppers of both insulin vials with alcohol wipes.

The entry points on the vials are disinfected.

This prevents the introduction of pathogens into the sterile vials when they are punctured.

Inject

20\text{ units}

of air into the NPH insulin vial.

The pressure in the NPH vial is equalized without contaminating the needle.

Air prevents a vacuum. The needle must stay above the fluid so it remains clean for the regular insulin vial.

Inject

12\text{ units}

of air into the regular insulin vial.

The pressure in the regular insulin vial is equalized.

This allows for easy withdrawal of the medication. The needle is left in place for the next step.

Withdraw exactly

12\text{ units}

of regular insulin.

The syringe contains the clear, short-acting insulin.

Regular insulin must be drawn first ('clear before cloudy') to prevent NPH from contaminating the regular insulin vial.

Insert the needle into the NPH insulin vial and withdraw exactly

20\text{ units}

The syringe contains a total of

32\text{ units}

of mixed insulin.

NPH is drawn last. Extreme precision is required because if too much is withdrawn, it cannot be pushed back without contaminating the vial.

Key Concept

Safe sequence for mixing regular (short-acting) and NPH (intermediate-acting) insulin.

Question 1059Question →

A practical nurse is planning morning hygiene care for an immobile client who receives continuous enteral tube feedings. The client requires a complete bed bath and a bottom sheet change, which will necessitate temporarily lowering the head of the bed. Which action should the nurse take to safely provide this basic care?

Position the client in a right lateral recumbent position with the bed flat so the feeding can continue safely during the bath.

Lower the head of the bed to 15 degrees and leave the feeding infusion running, working as quickly as possible to minimize the time the client is flat.

Pause the continuous feeding pump, lower the head of the bed to perform the care, and elevate the head of the bed to at least 30 degrees before restarting the infusion.

Instruct assistive personnel to complete the bed bath and tell them to turn off the feeding pump if the client begins to cough.

Show answer & explanation

Answer: Pause the continuous feeding pump, lower the head of the bed to perform the care, and elevate the head of the bed to at least 30 degrees before restarting the infusion.

Answer

Pause the continuous feeding pump, lower the head of the bed to perform the care, and elevate the head of the bed to at least 30 degrees before restarting the infusion.

To prevent aspiration, the head of the bed must remain elevated at 30 to 45 degrees while continuous enteral feedings are infusing. When basic care, such as a bed bath or linen change, requires lowering the bed to properly turn the client, the nurse must first pause the feeding pump. The infusion can only be safely restarted after the care is complete and the client's head is repositioned to an elevation of at least 30 degrees.

Step-by-Step Solution

Analyze the client's risk factors based on the medical intervention.

Identified that continuous enteral feeding poses a high risk for aspiration if the client is not positioned correctly.

Gravity is required to keep stomach contents from refluxing into the esophagus and airway during active tube feedings.

Evaluate the requirements for the planned basic care procedure.

Recognized that completing a full bed bath and changing the bottom linens typically requires lowering the head of the bed to allow for side-to-side turning.

Maintaining proper body mechanics and ensuring skin folds are properly cleaned and dried is difficult when the bed is elevated.

Prioritize interventions to maintain airway safety.

Determined that the feeding infusion must be paused prior to altering the bed's elevation.

Protecting the airway (Airway, Breathing, Circulation) is the highest priority; leaving the feeding on while flat compromises the airway.

Establish safe parameters for resuming the intervention.

Concluded that the head of the bed must be returned to a minimum 30-degree elevation before the pump is turned back on.

A minimum 30-degree elevation is the standard evidence-based practice to prevent aspiration in clients receiving enteral nutrition.

Key Concept

Aspiration precautions during continuous enteral feedings and basic hygiene care.

Estimated Time:1m 15s

Question 1060Question →

A practical nurse is assigned to care for a client who is experiencing severe constipation and requires a large-volume cleansing enema. In what sequence should the nurse perform the following administration steps?

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: assist the client into the left lateral Sims' position, lubricate the tube, insert the tube while the client exhales, elevate the solution container, and finally release the tubing clamp.

Administering a cleansing enema requires a systematic approach to ensure both client safety and procedural efficacy. First, the client must be placed in the left lateral Sims' position because the descending colon is on the left side, allowing gravity to assist fluid flow. Next, the tube must be lubricated to prevent tissue trauma during entry. The tube is then gently inserted 3 to 4 inches past the internal sphincter. After the tube is safely in place, the container is elevated 12 to 18 inches above the anus to establish safe hydrostatic pressure (preventing fluid from entering too forcefully). Finally, the clamp is opened to allow the fluid to instill slowly and comfortably.

Step-by-Step Solution

Assist the client into a left lateral Sims' position with the right knee flexed.

The client's descending colon is positioned downward.

Gravity will help the fluid flow naturally into the sigmoid and descending colon.

Lubricate the distal 2 to 3 inches (5 to 7.5 cm) of the rectal tube with a water-soluble lubricant.

The insertion tip is prepared for smooth entry.

Lubrication reduces friction and prevents traumatic injury to the sensitive rectal mucosa.

Instruct the client to exhale slowly while gently inserting the rectal tube 3 to 4 inches (7.5 to 10 cm) toward the umbilicus.

The tube passes safely through the anal sphincter into the rectum.

Exhaling relaxes the sphincter, and aiming toward the umbilicus follows the anatomical contour of the lower bowel.

Elevate the solution container 12 to 18 inches (30 to 45 cm) above the level of the client's anus.

Safe hydrostatic pressure is established.

Holding the bag too high causes rapid instillation and painful cramping, while holding it too low prevents adequate flow.

Release the tubing clamp to allow the warm solution to instill slowly into the colon.

The enema solution begins to enter the client's lower GI tract.

Administration can safely commence once proper positioning, insertion, and pressure height are confirmed.

Key Concept

Cleansing Enema Administration Sequence

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