Physiological Integrity

1313 questions

All types1,313 Multiple choice672 Multiple select289 Numeric68 Ordering284

A practical nurse is initiating a 24-hour urine collection for a client to evaluate renal function. To ensure the accuracy of the diagnostic test and reduce the risk of sample invalidation, in what order should the nurse implement the following steps?

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first prepare the client with equipment and instructions, then have them empty their bladder and discard the initial urine, followed by documenting this exact start time. Afterward, all subsequent urine is collected and stored on ice, ending with one final void at exactly the 24-hour mark.

For a 24-hour urine collection, the procedure begins by ensuring client understanding and readiness. The actual collection period must start with an empty bladder, so the first void is discarded and that specific time is noted as the start. All subsequent urine is kept chilled to preserve the sample. Exactly 24 hours later, a final void is obtained and added to the container to capture all urine produced during the time frame.

Step-by-Step Solution

Provide equipment and explain the procedure.

The client is prepared to participate correctly.

Ensures compliance and proper technique from the beginning of the test.

Have the client empty their bladder and discard the urine.

The bladder is empty.

The 24-hour period must start with an empty bladder so only newly formed urine is measured.

Document the start time.

The 24-hour clock officially begins.

Accurate timing is critical for the diagnostic validity of a timed urine test.

Collect all subsequent urine and keep it on ice.

Urine is safely preserved.

Cold storage prevents specimen degradation and bacterial overgrowth.

Collect a final void exactly 24 hours later.

The collection is complete.

Captures the very last urine produced within the precise 24-hour window.

Key Concept

Proper chronological technique for a 24-hour urine collection ensures the diagnostic validity of the specimen and reduces the risk of having to restart the test.

Estimated Time:1m 0s

Question 1062Question →

A practical nurse is preparing to administer scheduled morning medications, including oral digoxin and oral furosemide, to a client diagnosed with heart failure. Which of the following actions should the nurse perform? Select all that apply.

Select all that apply

Assess the client's apical pulse for 1 full minute prior to administering the digoxin.

Withhold the digoxin and notify the registered nurse if the client reports new-onset nausea and blurred vision.

Review the client's most recent serum potassium laboratory results before administering the furosemide.

Administer a prescribed intravenous push dose of furosemide if the client is unable to tolerate oral intake.

Verify the client's identity by confirming the room number and the name posted on the whiteboard above the bed.

Proceed with administering both medications if the client's most recent serum potassium level is

3.0\text{ mEq/L}

(

3.0\text{ mmol/L}

Show answer & explanation

Answer: Assess the client's apical pulse for 1 full minute prior to administering the digoxin.; Withhold the digoxin and notify the registered nurse if the client reports new-onset nausea and blurred vision.; Review the client's most recent serum potassium laboratory results before administering the furosemide.

Answer

The nurse should assess the apical pulse for 1 full minute, withhold digoxin for signs of toxicity like nausea and blurred vision, and review serum potassium levels before administering furosemide.

The correct actions reflect essential safety protocols for a practical nurse administering high-risk medications. Digoxin requires checking the apical pulse for a full minute to ensure the heart rate is high enough to tolerate the medication. Because digoxin has a narrow therapeutic range, any signs of toxicity (like new-onset nausea or blurred vision) mandate withholding the drug and notifying the RN. Furthermore, because the client is taking furosemide (a potassium-depleting diuretic), the nurse must check the potassium level, as hypokalemia greatly increases the risk of digoxin toxicity.

Step-by-Step Solution

Analyze the prescribed medications and their interactions.

Digoxin decreases heart rate and has a narrow therapeutic index. Furosemide causes potassium loss. Hypokalemia potentiates digoxin toxicity.

Understanding the pharmacology guides the necessary nursing assessments.

Identify the required pre-administration assessments for digoxin.

The apical pulse must be auscultated for a full minute, and the nurse must assess for signs of toxicity (GI and visual changes).

These assessments ensure it is safe to administer the cardiac glycoside.

Evaluate the practical nurse (PN) scope of practice regarding medication administration.

The PN can administer oral medications and monitor labs, but cannot administer IV push medications.

Adhering to the legal scope of practice prevents patient harm and professional liability.

Apply standard medication administration safety rights.

Two distinct identifiers (name, date of birth) must be used. Room numbers are invalid.

Proper identification prevents medication errors.

Key Concept

Safe administration of digoxin and furosemide requires meticulous monitoring of heart rate and potassium levels, recognizing signs of toxicity, and adhering to the practical nursing scope of practice.

Question 1063Question →

A practical nurse is preparing to administer phenytoin oral suspension to a client with a seizure disorder. The provider's prescription is for phenytoin $150\text{ mg}$ PO every 12 hours. The medication label indicates a concentration of $125\text{ mg}/5\text{ mL}$ .

How many $\text{mL}$ should the nurse administer for one dose? (Record the answer as a whole number. Do not include units in your answer.)

Show answer & explanation

Answer: 6

Answer

To calculate the correct volume of medication to administer, the nurse uses the formula:

\frac{\text{Desired Dose}}{\text{Dose on Hand}} \times \text{Quantity}

. Substituting the known values, the calculation is

\frac{150\text{ mg}}{125\text{ mg}} \times 5\text{ mL} = 1.2 \times 5\text{ mL} = 6\text{ mL}

. Therefore, the nurse should administer

6\text{ mL}

per dose.

Step-by-Step Solution

Identify the known variables for the dosage calculation.

Desired (D) =

150\text{ mg}

, Have (H) =

125\text{ mg}

, Quantity (Q) =

5\text{ mL}

Correctly identifying the prescription and medication label information is essential before performing any math.

Set up the dosage calculation formula.

\frac{150\text{ mg}}{125\text{ mg}} \times 5\text{ mL}

Using the standard dimensional analysis or desired-over-have method ensures accurate dose calculation.

Perform the mathematical calculation.

1.2 \times 5\text{ mL} = 6\text{ mL}

Solving the equation provides the final volume to be administered.

Key Concept

Oral Dosage Calculation

Estimated Time:1m 0s

Question 1064Question →

A 78-year-old client is admitted to the medical-surgical unit for a severe urinary tract infection and has been receiving oral ciprofloxacin for the past 48 hours. The practical nurse enters the room to administer the next scheduled dose. The client, who was alert and cooperative the previous evening, is now highly agitated, disoriented to place and time, and picking aimlessly at the bed linens. What is the most appropriate action for the practical nurse to take?

Withhold the antibiotic dose and immediately notify the registered nurse of the client's altered mental status.

Administer the medication as prescribed, recognizing that episodic confusion is a normal aspect of the aging process.

Apply bilateral soft wrist restraints to prevent the client from pulling the linens before giving the medication.

Proceed with administering the antibiotic and independently hold the client's other scheduled medications.

Show answer & explanation

Answer: Withhold the antibiotic dose and immediately notify the registered nurse of the client's altered mental status.

Answer

The practical nurse should withhold the antibiotic dose and immediately notify the registered nurse of the client's altered mental status.

Acute confusion (delirium) in an older adult is a medical emergency that can indicate a severe adverse reaction to the medication, such as fluoroquinolone-induced central nervous system toxicity, or a life-threatening worsening of the underlying infection. The practical nurse must prioritize safety by withholding the scheduled drug and immediately escalating these acute neurological changes to the registered nurse for a comprehensive assessment.

Step-by-Step Solution

Assess the client's current clinical presentation and compare it to their baseline status.

The client exhibits a sudden onset of extreme agitation and disorientation (acute confusion), which is a significant change from being alert and cooperative.

Identifying acute changes in mental status is critical for ensuring client safety and recognizing potential complications.

Correlate the assessment findings with potential pharmacological complications and the underlying disease process.

Acute confusion in an older adult receiving antibiotics may indicate drug toxicity (such as central nervous system adverse effects from fluoroquinolones) or a worsening of the underlying infection (such as the development of sepsis).

Recognizing severe adverse drug reactions or condition deterioration guides the decision regarding whether to proceed with medication administration.

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

The nurse must withhold the ciprofloxacin and escalate the findings to the registered nurse.

The registered nurse or healthcare provider must evaluate the acute change in condition before any further doses of potentially contributing medications are administered.

Key Concept

Pre-administration Assessment and Withholding Criteria

Question 1065Question →

A practical nurse is caring for a client who is on strict bed rest and receiving continuous oxygen therapy via a nasal cannula for severe pneumonia. Which basic care and comfort interventions should the nurse implement? Select all that apply.

Select all that apply

Apply a water-soluble lubricant to the nares to relieve dryness and irritation.

Place protective padding on the oxygen tubing where it rests over the ears.

Encourage the client to perform active range-of-motion exercises in bed.

Position the client completely flat in bed to ensure continuous, restorative rest.

Remove the oxygen cannula briefly when assisting the client with oral hygiene.

Show answer & explanation

Answer: Apply a water-soluble lubricant to the nares to relieve dryness and irritation.; Place protective padding on the oxygen tubing where it rests over the ears.; Encourage the client to perform active range-of-motion exercises in bed.

Answer

The correct interventions are applying a water-soluble lubricant to the nares, placing protective padding on the oxygen tubing over the ears, and encouraging active range-of-motion exercises.

Providing a water-soluble nasal lubricant, padding the oxygen tubing, and encouraging active range-of-motion exercises are appropriate nursing actions that promote physical comfort, prevent medical device-related skin breakdown, and minimize the systemic risks associated with strict bed rest.

Step-by-Step Solution

Analyze the client's condition and prescribed therapies.

The client has severe pneumonia, is on strict bed rest, and requires continuous oxygen via a nasal cannula.

Identifying the client's specific vulnerabilities (immobility, respiratory compromise, medical devices) dictates the appropriate basic care measures.

Evaluate each intervention for safety, efficacy, and relevance to comfort and basic care.

Lubricating the nares, padding the tubing, and performing range-of-motion exercises are safe and supportive measures.

These actions prevent skin breakdown, mucosal dryness, and complications of immobility without compromising the client's respiratory status.

Identify contraindicated actions that compromise client safety.

Positioning the client completely flat and removing the oxygen cannula for hygiene are unsafe.

A flat position impairs lung expansion, and removing oxygen during oral care ignores airway and breathing priorities.

Key Concept

Basic care for clients on bed rest with oxygen therapy focuses on maintaining skin integrity, preventing immobility complications, and supporting respiratory function.

Question 1066Question →

A practical nurse is preparing to administer a scheduled morning dose of digoxin to an adult client. The bedside vital sign monitor displays a heart rate of 54 beats/minute. Arrange the following nursing actions in the correct sequence to reduce the client's risk of potential complications.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first verify the heart rate by auscultating the apical pulse manually, then withhold the digoxin, notify the RN or healthcare provider, and finally document the actions and findings.

When a practical nurse identifies a potentially abnormal vital sign reading from an automated device, the first priority is to assess the client and verify the finding manually. Once an apical pulse below 60 beats/minute is confirmed, the nurse must withhold the digoxin to reduce the risk of toxicity. Subsequently, the nurse escalates the finding by notifying the RN or provider. Finally, all assessments, interventions, and notifications must be thoroughly documented in the client's medical record.

Step-by-Step Solution

Auscultate the apical pulse manually for one full minute.

The exact heart rate is accurately verified.

Automated monitors can be inaccurate, and digoxin requires a precise apical pulse measurement before administration.

Withhold the scheduled dose of digoxin.

The medication is not administered.

Administering digoxin to an adult with a heart rate below 60 beats/minute increases the risk of severe bradycardia and toxicity.

Notify the registered nurse (RN) or healthcare provider.

The healthcare team is made aware of the client's status.

Prompt communication ensures the client receives appropriate follow-up care or medication adjustments.

Document the vital signs and the withheld medication.

The client's medical record is updated.

Documentation provides a legal record of care and ensures all team members are aware that the dose was held.

Key Concept

Prioritization and risk reduction for clients receiving cardiac glycosides with borderline vital signs

Estimated Time:1m 0s

Question 1067Question →

A pediatric client weighing $44\text{ lb}$ is prescribed oral amoxicillin $300\text{ mg}$ every $8\text{ hours}$ . The established safe pediatric dosage range for amoxicillin is $20\text{ to }40\text{ mg/kg/day}$ in divided doses. The pharmacy dispenses an oral suspension concentrated at $250\text{ mg}/5\text{ mL}$ . Which action should the practical nurse take?

Administer

6\text{ mL}

of the oral suspension for the scheduled dose.

Proceed with administration after scanning the client's identification band.

Withhold the medication and notify the registered nurse that the daily dose exceeds the safe limit.

Administer

18\text{ mL}

of the oral suspension for the scheduled dose.

Show answer & explanation

Answer: Withhold the medication and notify the registered nurse that the daily dose exceeds the safe limit.

Answer

Withhold the medication and notify the registered nurse that the daily dose exceeds the safe limit.

To ensure medication safety, the practical nurse must systematically verify pediatric orders. First, convert the weight:

44\text{ lb} \div 2.2 = 20\text{ kg}

. Next, calculate the safe daily range:

20\text{ kg} \times 20\text{ mg} = 400\text{ mg/day}

, and

20\text{ kg} \times 40\text{ mg} = 800\text{ mg/day}

. The provider prescribed

300\text{ mg}

every

8\text{ hours}

(which means

3

doses per day). Total daily dose =

300\text{ mg} \times 3 = 900\text{ mg/day}

. Because

900\text{ mg/day}

exceeds the absolute maximum safe limit of

800\text{ mg/day}

, the nurse cannot safely administer the medication. The correct action is to withhold the dose and immediately notify the RN or prescribing provider.

Step-by-Step Solution

Convert the client's weight from pounds to kilograms.

44\text{ lb} \div 2.2\text{ lb/kg} = 20\text{ kg}

Safe pediatric dosages are based on body weight in kilograms.

Calculate the safe daily dosage range for this client.

Minimum:

20\text{ kg} \times 20\text{ mg/kg/day} = 400\text{ mg/day}

. Maximum:

20\text{ kg} \times 40\text{ mg/kg/day} = 800\text{ mg/day}

This establishes the safe parameters to compare against the provider's prescription.

Calculate the total daily dose prescribed by the provider.

300\text{ mg} \times 3\text{ doses/day} (every 8 hours) = 900\text{ mg/day}

The prescribed daily amount must be determined to verify safety.

Compare the prescribed dose to the safe range and determine the appropriate action.

900\text{ mg/day}

is greater than the maximum safe limit of

800\text{ mg/day}

. The medication must be withheld.

Administering a dose that exceeds established safe limits is outside the scope of practice and risks patient harm.

Key Concept

Pediatric Dosage Verification and Medication Safety

Question 1068Question →

A 65-year-old client is receiving inpatient care for the management of hypertension and angina. The medication administration record indicates a scheduled dose of oral diltiazem $60\text{ mg}$ . Prior to giving the medication, the practical nurse (PN) obtains a heart rate of 52 beats/min and a blood pressure of $94/56\text{ mmHg}$ . The client reports feeling lightheaded when attempting to sit on the edge of the bed. Which action is the priority for the PN?

Record the borderline vital signs in the chart and return in one hour to recheck the blood pressure before taking further action.

Obtain a normal saline fluid bolus and administer it via intravenous push to elevate the client's blood pressure.

Administer the diltiazem immediately without scanning the client's identification band to ensure the medication is given on time.

Withhold the scheduled diltiazem dose and immediately communicate the client's vital signs and symptoms to the registered nurse.

Show answer & explanation

Answer: Withhold the scheduled diltiazem dose and immediately communicate the client's vital signs and symptoms to the registered nurse.

Answer

The priority action is to withhold the scheduled dose of diltiazem and immediately notify the registered nurse of the client's vital signs and symptoms.

Diltiazem is a calcium channel blocker utilized to manage hypertension and angina by relaxing blood vessels and slowing the heart rate. Because the client is currently exhibiting symptomatic bradycardia (a heart rate of 52 beats/min) and hypotension (a blood pressure of

94/56\text{ mmHg}

with lightheadedness), administering this medication could precipitate a dangerous cardiovascular collapse. The practical nurse's priority is to ensure client safety by withholding the dose and immediately escalating the assessment findings to the registered nurse for further clinical evaluation.

Step-by-Step Solution

Evaluate the client's vital signs and reported symptoms prior to medication administration.

The client has a heart rate of 52 beats/min (bradycardia), a blood pressure of

94/56\text{ mmHg}

(hypotension), and reports lightheadedness.

Diltiazem is a calcium channel blocker that therapeutically lowers heart rate and blood pressure, making pre-administration assessment essential.

Determine the appropriate clinical intervention based on the assessment findings.

The medication must be withheld.

Administering a calcium channel blocker to a client who is already hypotensive, bradycardic, and symptomatic can cause severe cardiovascular compromise.

Identify the proper chain of command and scope of practice for the practical nurse.

The findings must be immediately reported to the registered nurse.

The registered nurse must evaluate the client's deteriorating condition and coordinate advanced interventions, as treatments like intravenous push medications are outside the practical nurse's scope.

Key Concept

Recognizing adverse cardiovascular effects and pre-administration holding parameters for calcium channel blockers.

Question 1069Question →

A practical nurse (PN) is assigned to the care team for a client admitted with severe acute pancreatitis. The client is receiving continuous enteral nutrition via a nasojejunal (NJ) tube and has a dedicated peripheral intravenous (IV) line. Which of the following planned actions by the PN demonstrate appropriate risk reduction and safe practice? (Select all that apply.)

Select all that apply

Flushing the nasojejunal (NJ) tube with 30 mL of sterile water every 4 hours and before and after administering prescribed liquid medications.

Assisting the client into a side-lying position with the knees flexed or elevating the head of the bed to 45 degrees.

Documenting the hourly urine output and immediately alerting the registered nurse (RN) if the volume drops below 30 mL/hr for two consecutive hours.

Assuming a resting apical pulse of 114 beats/min and a respiratory rate of 24 breaths/min are solely expected responses to the client's severe abdominal pain, and documenting them without further escalation.

Administering the morning medications and delaying the notification of a serum ionized calcium level of 3.6 mg/dL (0.9 mmol/L) until the provider rounds, as the client lacks visible muscle twitching.

Accepting the delegated task of calculating and adjusting the rate of the client's continuous intravenous insulin infusion based on sliding scale parameters.

Show answer & explanation

Answer: Flushing the nasojejunal (NJ) tube with 30 mL of sterile water every 4 hours and before and after administering prescribed liquid medications.; Assisting the client into a side-lying position with the knees flexed or elevating the head of the bed to 45 degrees.; Documenting the hourly urine output and immediately alerting the registered nurse (RN) if the volume drops below 30 mL/hr for two consecutive hours.

Answer

The correct actions include flushing the NJ tube to maintain patency, placing the client in a side-lying or semi-Fowler's position to ease breathing and abdominal tension, and strictly escalating a urine output drop below 30 mL/hr to prevent hypovolemic kidney injury.

Severe acute pancreatitis requires aggressive risk reduction. Proper NJ tube maintenance prevents occlusion and aspiration. The side-lying, knee-flexed, or elevated head of bed position minimizes tension on the inflamed peritoneum and optimizes lung expansion, reducing respiratory risks. Close monitoring of urine output is critical because massive fluid shifts (third-spacing) into the retroperitoneal cavity can cause hypovolemic shock and acute kidney injury; a drop below 30 mL/hr requires immediate escalation.

Step-by-Step Solution

Identify the client's pathophysiology and anticipate associated high-risk complications.

The client has severe acute pancreatitis, which carries severe risks for massive fluid third-spacing, hypovolemic shock, acute respiratory distress syndrome (ARDS), hypocalcemia (due to fat saponification), and nutritional deficits.

Understanding the disease process is necessary to differentiate between expected symptoms and life-threatening complications.

Evaluate the proposed nursing actions regarding basic care, positioning, and monitoring.

Flushing the NJ tube correctly prevents occlusion. Positioning with flexed knees or an elevated head of bed reduces peritoneal stretching and improves lung expansion. Alerting the RN for oliguria (<30 mL/hr) correctly identifies impending renal failure from hypovolemia.

These represent evidence-based risk reduction interventions entirely within the scope of a practical nurse.

Analyze the remaining actions for safety violations, missed escalation triggers, and scope of practice errors.

Dismissing tachycardia/tachypnea as just pain overlooks early shock. Delaying the report of a critically low ionized calcium (3.6 mg/dL) risks fatal tetany. Titrating an IV insulin drip exceeds the practical nurse's legal scope.

Failing to escalate critical data or accepting tasks beyond legal scope directly compromises client safety and violates risk reduction principles.

Key Concept

Reduction of Risk Potential in Severe Acute Pancreatitis

Question 1070Question →

A pediatric client who weighs $28.6\text{ lb}$ is being treated for a severe bacterial infection. The primary health care provider prescribes oral amoxicillin at a dosage of $40\text{ mg/kg/day}$ to be administered in equally divided doses every $8\text{ hours}$ . The medication bottle states a concentration of $250\text{ mg}/5\text{ mL}$ after reconstitution. How many milliliters should the practical nurse administer for a single dose? (Record the answer to the nearest tenth. Do not include units in the answer.)

Show answer & explanation

Answer: 3.5

Answer

3.5

To solve this calculation, first convert pounds to kilograms:

28.6\text{ lb} \div 2.2\text{ lb/kg} = 13\text{ kg}

. Next, determine the total daily dose:

13\text{ kg} \times 40\text{ mg/kg/day} = 520\text{ mg/day}

. Because the medication is prescribed every 8 hours, it is administered 3 times per 24 hours. The single dose is

520\text{ mg} \div 3 = 173.33\text{ mg/dose}

. Using the concentration of

250\text{ mg}

per

5\text{ mL}

, the volume to administer is

(173.33\text{ mg} \div 250\text{ mg}) \times 5\text{ mL} = 3.466\text{ mL}

. Rounding to the nearest tenth yields

3.5\text{ mL}

Step-by-Step Solution

Convert the client's weight from pounds to kilograms.

13\text{ kg}

The prescribed dosage is weight-based in mg/kg, so the weight must be in kilograms (

28.6 \div 2.2 = 13

Calculate the total daily dose of the medication.

520\text{ mg/day}

Multiply the client's weight in kg by the prescribed daily dosage (

13 \times 40 = 520

Determine the amount of medication required for a single dose.

173.33\text{ mg/dose}

The order states every 8 hours, which means 3 times a day (24 / 8 = 3). Divide the total daily dose by 3 (

520 \div 3 = 173.333...

Calculate the volume needed for one dose and round to the nearest tenth.

3.5\text{ mL}

Use the available concentration (

250\text{ mg}/5\text{ mL}

) to find the volume:

(173.33 \div 250) \times 5 = 3.466\text{ mL}

. Rounding to the nearest tenth gives

3.5

Key Concept

Weight-based pediatric dosage calculation and conversion

Question 1071Question →

During shift rounds on a rehabilitation unit, the nurse plans care for a client who underwent a right above-the-knee amputation three days ago. To prevent the development of a flexion contracture, which positioning intervention is most appropriate to implement?

Assist the client into a prone position for 30 minutes several times a day.

Elevate the residual limb on a firm pillow while the client is resting in bed.

Maintain the head of the bed at a 90-degree angle for the majority of the shift.

Encourage the client to sit upright in a bedside chair for at least four continuous hours.

Show answer & explanation

Answer: Assist the client into a prone position for 30 minutes several times a day.

Answer

Assisting the client into a prone position for 30 minutes several times a day is the correct intervention to prevent hip flexion contractures.

Placing the client in a prone position for 20 to 30 minutes multiple times a day allows the hip joint to extend fully. This stretching of the flexor muscles is a critical basic care intervention to prevent hip flexion contractures following an above-the-knee amputation, which is essential for future prosthetic use.

Step-by-Step Solution

Identify the client's surgical procedure and the time elapsed since surgery.

The client is 72 hours post-operative following a right above-the-knee amputation.

Postoperative timelines dictate appropriate comfort and mobility interventions; care changes significantly after the initial 24-hour period.

Determine the most significant mobility complication associated with this specific amputation.

Hip flexion contractures are a major risk that can prevent the client from being able to use a prosthetic limb.

Maintaining proper joint alignment is a fundamental aspect of basic care and mobility management.

Select the positioning strategy that directly counteracts continuous hip flexion.

Prone positioning extends the hip joint.

Lying flat on the abdomen straightens the hip flexors, preventing the muscles from tightening and shortening into a contracture.

Key Concept

Prevention of flexion contractures following lower extremity amputation

Question 1072Question →

A client being treated for a deep vein thrombosis is receiving daily oral warfarin. During morning data collection, the client reports passing dark, tarry stools. The client's skin is pale, and the practical nurse notes a blood pressure of $88/52\text{ mm Hg}$ and an apical pulse of $114\text{ beats/min}$ . The morning international normalized ratio (INR) result is $4.8$ . Which action should the practical nurse take first?

Withhold the scheduled warfarin dose and immediately alert the registered nurse.

Notify the primary health care provider to request a stat order for intravenous phytonadione.

Assist the client to a resting position in bed and recheck the vital signs in one hour.

Administer the scheduled warfarin because an INR of 4.8 is within the therapeutic target for deep vein thrombosis.

Show answer & explanation

Answer: Withhold the scheduled warfarin dose and immediately alert the registered nurse.

Answer

The correct action is to withhold the scheduled warfarin dose and immediately alert the registered nurse.

The client is exhibiting undeniable signs of active gastrointestinal hemorrhage (melena) and hypovolemic shock (hypotension and tachycardia), compounded by a dangerously elevated INR of 4.8. The most critical nursing action is to prevent further harm by withholding the anticoagulant and immediately escalating the situation to the registered nurse, who will perform an advanced assessment and collaborate with the health care provider for emergency stabilization.

Step-by-Step Solution

Analyze the client's subjective and objective physical findings.

The client has dark, tarry stools (melena), pale skin, hypotension (

88/52\text{ mm Hg}

), and tachycardia (

114\text{ beats/min}

These combined findings are classic indicators of active gastrointestinal bleeding and impending hypovolemic shock.

Interpret the laboratory data in the context of the prescribed medication.

The INR is

4.8

The therapeutic INR range for a deep vein thrombosis is

2.0

3.0

. A result of

4.8

is critically elevated, placing the client at severe risk for hemorrhage.

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

The medication must be withheld, and the registered nurse must be notified immediately.

The practical nurse cannot administer a medication that is actively causing harm. Because the client is unstable, the registered nurse must immediately take over assessment and coordinate emergency interventions with the provider.

Key Concept

Monitoring for adverse pharmacological effects and recognizing the need for immediate escalation in unstable clients.

Question 1073Question →

A practical nurse is monitoring a client who returned from the post-anesthesia care unit 4 hours ago following an open cholecystectomy. Over the past two hours, the client's heart rate has steadily increased from $84$ to $118\text{ beats/min}$ , and the blood pressure has decreased from $128/82\text{ mmHg}$ to $102/64\text{ mmHg}$ . The client appears restless and states, "I feel extremely weak." Which of the following actions should the nurse take first?

Notify the supervising registered nurse immediately about the vital sign changes.

Document the findings as expected postoperative changes and reassess in one hour.

Administer the prescribed as-needed analgesic for postoperative discomfort.

Assist the client into a high-Fowler's position to promote chest expansion.

Show answer & explanation

Answer: Notify the supervising registered nurse immediately about the vital sign changes.

Answer

Notify the supervising registered nurse immediately about the vital sign changes.

The combination of an increasing heart rate, a decreasing blood pressure, restlessness, and weakness in a postoperative client are classic early signs of hypovolemic shock, likely due to internal hemorrhage. Within the practical nursing scope of practice, the immediate priority is to recognize these critical changes and escalate them to the supervising registered nurse for further assessment and collaborative intervention.

Step-by-Step Solution

Analyze the client's vital sign trends over the past two hours.

The heart rate has increased significantly (

84

118\text{ beats/min}

) while the blood pressure has dropped (

128/82

102/64\text{ mmHg}

Identifying trends is crucial for recognizing compensatory mechanisms in postoperative clients.

Correlate the vital signs with the client's physical presentation.

The client is restless and complains of extreme weakness.

Restlessness and weakness, combined with tachycardia and hypotension, strongly suggest decreased tissue perfusion and potential hemorrhage.

Determine the priority nursing action based on the LPN scope of practice.

The LPN must immediately escalate these critical findings to the registered nurse.

The client is showing signs of instability and potential shock, which requires immediate RN-level assessment and provider notification.

Key Concept

Early recognition of shock and postoperative hemorrhage

Question 1074Question →

A 21-year-old client is recovering on the surgical unit 5 hours after undergoing an adult tonsillectomy. A family member summons the practical nurse, stating that the client appears highly anxious and is swallowing continuously. The nurse obtains vital signs, noting a heart rate of 112 beats per minute, a respiratory rate of 20 breaths per minute, and a blood pressure of 104/66 mm Hg, compared to a preoperative baseline of 124/76 mm Hg. The client points to their neck and grimaces, indicating significant throat discomfort. Which action should the practical nurse implement first?

Inspect the back of the throat using a penlight and immediately notify the supervising registered nurse.

Administer the prescribed liquid oral analgesic to alleviate the client's severe throat pain.

Document the findings as expected postoperative recovery and reassess the client in one hour.

Increase the continuous intravenous fluid rate independently to stabilize the client's blood pressure.

Show answer & explanation

Answer: Inspect the back of the throat using a penlight and immediately notify the supervising registered nurse.

Answer

The practical nurse should inspect the back of the throat using a penlight and immediately notify the supervising registered nurse.

The correct action involves gathering rapid, focused assessment data (looking for blood in the throat) and immediately reporting these critical findings. Continuous swallowing, restlessness, an increasing heart rate, and decreasing blood pressure are classic indicators of postoperative hemorrhage following a tonsillectomy. Escaping blood often drains down the back of the throat, causing the client to swallow repeatedly. Because this is a life-threatening complication that threatens both airway and circulation, the practical nurse must escalate the situation to the registered nurse or provider without delay.

Step-by-Step Solution

Analyze the clinical presentation and vital sign trends.

The client exhibits continuous swallowing, anxiety, tachycardia (112 bpm), and a decrease in baseline blood pressure.

These specific behavioral and physiological signs strongly suggest active bleeding in the postoperative tonsillectomy client.

Determine the priority framework for intervention.

Airway and Circulation (hemorrhage risk) take precedence over pain management.

Bleeding in the airway can lead to rapid compromise and hypovolemic shock, requiring immediate life-saving action.

Select the appropriate nursing action within the practical nurse's scope of practice.

The nurse gathers focused visual data (inspecting the throat) and immediately escalates the findings.

A practical nurse must safely collect relevant data and report critical changes to the registered nurse or healthcare provider to ensure timely medical intervention.

Key Concept

Recognizing early signs of hemorrhage and escalating care appropriately within the practical nursing scope of practice.

Question 1075Question →

A 72-year-old client diagnosed with bipolar disorder is maintained on oral lithium carbonate. The primary care provider recently added an oral prescription of hydrochlorothiazide to manage the client's newly diagnosed hypertension. Upon evaluating the morning laboratory data, the practical nurse notes a serum lithium level of $0.9\text{ mEq/L}$ and a serum sodium level of $128\text{ mEq/L}$ . The client reports a mild headache, nausea, and increased lethargy. Which action should the practical nurse take first?

Hold both scheduled medications and promptly notify the registered nurse regarding the client's laboratory results and physical symptoms.

Administer the medications as prescribed and reassure the client that mild lethargy is a normal age-related change when starting a new antihypertensive.

Administer the lithium carbonate because the level is within the therapeutic range, but hold the hydrochlorothiazide due to the hyponatremia.

Confirm the client's identity using their spoken name and room number, then administer both medications to maintain the therapeutic lithium level.

Show answer & explanation

Answer: Hold both scheduled medications and promptly notify the registered nurse regarding the client's laboratory results and physical symptoms.

Answer

The practical nurse must withhold both medications and notify the registered nurse immediately due to the high risk of severe lithium toxicity caused by hyponatremia.

The correct action is to hold both medications and notify the registered nurse. The client's sodium level is critically low (

128\text{ mEq/L}

). Because the kidneys process lithium and sodium similarly, low sodium levels trigger the kidneys to aggressively reabsorb lithium to compensate. Administering more lithium in the presence of hyponatremia—especially alongside a sodium-depleting thiazide diuretic like hydrochlorothiazide—will rapidly lead to life-threatening lithium toxicity, despite the currently normal lithium level. The client's headache, nausea, and lethargy are early indicators of this dangerous physiological shift.

Step-by-Step Solution

Analyze the laboratory values in the context of the prescribed medications.

The lithium level (

0.9\text{ mEq/L}

) is therapeutic (normal:

0.6-1.2\text{ mEq/L}

), but the sodium level (

128\text{ mEq/L}

) indicates significant hyponatremia (normal:

135-145\text{ mEq/L}

Identifying abnormal baseline laboratory data is critical before administering medications that directly affect fluid and electrolyte balance.

Evaluate the pharmacological interaction between hydrochlorothiazide and lithium carbonate.

Hydrochlorothiazide is a thiazide diuretic that causes sodium loss. When serum sodium is depleted, the kidneys reabsorb lithium instead of excreting it, which rapidly leads to lithium toxicity.

Understanding complex drug interactions and renal pharmacokinetics prevents the administration of harmful medication combinations.

Correlate the client's physical symptoms with the clinical laboratory data.

The client's mild headache, nausea, and increased lethargy are early neurological signs of both hyponatremia and impending lithium toxicity.

Connecting physical symptoms to laboratory abnormalities confirms a deteriorating clinical status that requires immediate intervention.

Determine the safest action within the practical nursing scope of practice.

The safest and most appropriate action is to withhold both the hydrochlorothiazide and the lithium carbonate and immediately report all findings to the supervising registered nurse.

The practical nurse must protect the client from harm by withholding contraindicated medications and promptly escalating critical changes in condition.

Key Concept

Lithium toxicity risk is significantly increased by hyponatremia, often caused by sodium-depleting medications like thiazide diuretics; the practical nurse must recognize this interaction, withhold the medications, and report to the registered nurse.

Question 1076Question →

During morning medication rounds, a nurse reviews the chart of a client diagnosed with heart failure. The client is scheduled to receive a daily dose of oral furosemide. The morning laboratory report indicates a serum potassium level of $2.6\text{ mEq/L}$ . What is the most appropriate immediate action for the nurse to take?

Withhold the furosemide and immediately notify the registered nurse of the laboratory results.

Administer the prescribed dose and document the findings in the electronic health record.

Change the administration route to an intravenous push to manage the client's fluid volume more carefully.

Proceed with administering the medication as long as the client's current heart rate and blood pressure are stable.

Show answer & explanation

Answer: Withhold the furosemide and immediately notify the registered nurse of the laboratory results.

Answer

Withhold the furosemide and immediately notify the registered nurse of the laboratory results.

The correct action is to withhold the medication and notify the supervising registered nurse. A serum potassium level of

2.6\text{ mEq/L}

indicates severe hypokalemia (the normal range is approximately

3.5

5.0\text{ mEq/L}

). Because furosemide is a potassium-depleting loop diuretic, administering it would further lower the potassium level, placing the client at extremely high risk for potentially fatal cardiac arrhythmias.

Step-by-Step Solution

Identify the critical laboratory value.

The client's potassium level is

2.6\text{ mEq/L}

(normal is typically

3.5

5.0\text{ mEq/L}

), indicating severe hypokalemia.

Recognizing abnormal data is the first step in risk reduction before administering medications.

Correlate the laboratory value with the prescribed medication.

Furosemide is a loop diuretic known to cause potassium loss.

Administering the medication will worsen the client's hypokalemia, increasing the risk for fatal cardiac arrhythmias.

Determine the safest nursing intervention within the practical nurse scope of practice.

Withhold the medication and escalate the finding to the registered nurse or healthcare provider.

Preventing patient harm requires stopping the contraindicated medication and ensuring the care team is informed for further orders.

Key Concept

Recognizing critical laboratory values and withholding contraindicated medications to prevent adverse outcomes.

Question 1077Question →

An LPN is evaluating a client who underwent a laparoscopic cholecystectomy 6 hours ago. The client's preoperative blood pressure was 128/76 mm Hg with a heart rate of 72 beats/min. Current data collection reveals a blood pressure of 102/68 mm Hg, a heart rate of 104 beats/min, and a respiratory rate of 22 breaths/min. The client appears restless, and the indwelling urinary catheter has drained a total of 45 mL of urine over the past two hours. The surgical incisions are intact with trace serosanguinous drainage. Which of the following actions is the priority for the nurse to take?

Reassess the vital signs and urinary output in one hour to determine if a trend is developing.

Administer the prescribed as-needed anti-anxiety medication to treat the client's restlessness.

Report the assessment data to the supervising registered nurse immediately.

Independently increase the continuous intravenous fluid infusion rate to address the low urine output.

Show answer & explanation

Answer: Report the assessment data to the supervising registered nurse immediately.

Answer

Report the assessment data to the supervising registered nurse immediately.

The client is exhibiting a classic presentation of early hypovolemic shock, characterized by tachycardia, a decreasing blood pressure compared to baseline, low urine output (less than 30 mL/hr), and restlessness (an early sign of decreased cerebral perfusion and hypoxia). The priority action for the practical nurse is to immediately report these critical findings to the registered nurse for advanced assessment and collaborative medical intervention.

Step-by-Step Solution

Analyze the preoperative baseline vital signs.

Baseline blood pressure was 128/76 mm Hg and heart rate was 72 beats/min.

Establishing a baseline is necessary to identify significant post-operative changes.

Evaluate the current vital signs and physical assessment findings against the baseline.

The blood pressure has dropped to 102/68 mm Hg, the heart rate has increased to 104 beats/min, urine output is low (22.5 mL/hr), and the client is restless.

Comparing current data to baseline reveals a pattern indicative of a developing complication, specifically decreased cardiac output and poor tissue perfusion.

Determine the underlying pathophysiology and prioritize the necessary nursing action.

The combination of tachycardia, dropping blood pressure, oliguria, and restlessness strongly suggests early hypovolemic shock, likely from internal bleeding.

Recognizing these subtle but critical signs allows the practical nurse to take immediate action within their scope.

Select the safest and most appropriate intervention based on the practical nurse's scope of practice.

The priority is to immediately escalate these critical findings to the registered nurse.

An unstable client requiring advanced clinical assessment and potential medical intervention must be managed by the registered nurse and healthcare provider.

Key Concept

Reduction of Risk Potential: Early Recognition of Complications and Scope of Practice

Question 1078Question →

A practical nurse is assisting an older adult client with right-sided hemiplegia and known dysphagia with their afternoon meal. During the feeding, the client's voice suddenly becomes gurgly, and they begin to exhibit a weak, ineffective cough. Which action should the nurse implement first?

Stop the feeding immediately, ensure the client remains in a high Fowler's position, and clear the oral cavity.

Offer the client a small sip of clear water to help swallow the remaining food and clear the throat.

Lower the head of the bed slightly and assist the client to roll onto their affected right side to facilitate drainage.

Reassure the client that coughing is a normal part of relearning to swallow and advise them to eat more slowly.

Show answer & explanation

Answer: Stop the feeding immediately, ensure the client remains in a high Fowler's position, and clear the oral cavity.

Answer

The priority action is to immediately stop the feeding, maintain the client in a high Fowler's position, and clear the oral cavity to protect the airway.

A gurgly voice and a weak, ineffective cough in a client with dysphagia are cardinal signs of active aspiration. The absolute first priority is to protect the airway. This is accomplished by immediately stopping the feeding, maintaining the client in a fully upright (high Fowler's) position to prevent further downward transit of food, and clearing any residual food from the oral cavity.

Step-by-Step Solution

Recognize the clinical signs of active aspiration.

The nurse identifies that a gurgly, wet-sounding voice combined with a weak, ineffective cough means food or liquid has entered the trachea.

Rapid recognition of airway compromise is the first step in the nursing process (assessment/data collection) before taking action.

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

The nurse immediately halts the meal to prevent any further material from entering the mouth or airway.

Stopping the source of the aspiration is the most critical immediate intervention to protect the airway.

Implement appropriate positioning and clearance techniques.

The nurse keeps the client upright (high Fowler's) and clears any residual food from the mouth.

An upright position uses gravity to keep stomach contents down, and clearing the mouth prevents further aspiration of residual food.

Key Concept

Aspiration Precautions and Airway Prioritization during Basic Care

Question 1079Question →

A client who underwent a lumbar puncture one hour ago has been transported back to the medical unit. The client reports a mild headache. When providing basic care and comfort, which actions should the practical nurse implement? Select all that apply.

Select all that apply

Maintain the client in a flat, supine position as prescribed.

Encourage the client to increase oral fluid intake, unless contraindicated.

Dim the overhead lights and maintain a quiet room environment.

Elevate the head of the bed to a high-Fowler's position to alleviate the headache.

Apply physical restraints immediately if the client becomes mildly restless from the discomfort.

Prioritize administering a warm compress for the headache before evaluating a sudden onset of shortness of breath.

Show answer & explanation

Answer: Maintain the client in a flat, supine position as prescribed.; Encourage the client to increase oral fluid intake, unless contraindicated.; Dim the overhead lights and maintain a quiet room environment.

Answer

The correct actions are maintaining a flat, supine position, encouraging oral fluid intake, and dimming the lights to maintain a quiet environment.

After a lumbar puncture, basic care and comfort measures prioritize preventing cerebrospinal fluid leakage and promoting a restful environment. Maintaining a flat, supine position is essential to minimize a spinal headache. Encouraging oral fluids helps replenish cerebrospinal fluid volume, and dimming the lights provides non-pharmacological comfort.

Step-by-Step Solution

Analyze the client's procedure and current symptoms.

The client had a lumbar puncture and is experiencing a mild headache, which is a common complication.

Understanding the physiological effects of the procedure guides the selection of safe and effective comfort measures.

Identify appropriate basic care and comfort interventions.

Appropriate interventions include flat positioning to prevent CSF leak, hydration to replenish fluids, and a low-stimulus environment.

These specific basic care actions directly mitigate the causes and symptoms of a post-procedure headache.

Evaluate the remaining options against safety and prioritization principles.

Reject elevating the head of the bed, applying restraints immediately, and ignoring acute respiratory symptoms.

These actions violate post-procedure positioning protocols, restraint guidelines, and the ABC prioritization framework.

Key Concept

Post-Lumbar Puncture Basic Care and Comfort

Question 1080Question →

A practical nurse is caring for a client receiving continuous peripheral intravenous (IV) fluids. During data collection, the nurse observes that the IV insertion site is swollen, cool to the touch, and pale. Arrange the following nursing actions in the correct sequence to manage this finding. All options must be used.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first stop the infusion, then remove the catheter, elevate the extremity, apply a compress, and finally document the event.

When an IV infiltration occurs, the immediate priority is to stop the flow of fluid into the subcutaneous tissue to prevent further edema and damage. Next, the catheter must be removed as it is no longer safely positioned in the vein. Following removal, elevating the extremity and applying a compress will help reduce swelling and discomfort. Finally, the nurse must document the incident, the interventions performed, and the client's response. This sequence ensures risk reduction and client safety.

Step-by-Step Solution

Identify the complication based on clinical signs.

The signs of swelling, pallor, and coolness indicate IV infiltration.

Recognizing the complication dictates the immediate emergency response required to minimize tissue injury.

Prioritize direct client safety interventions.

The infusion is stopped and the intravenous catheter is removed.

Stopping the source of the problem prevents further fluid leakage and harm to the surrounding tissue.

Provide symptom relief and site management.

The extremity is elevated and a therapeutic compress is applied.

These supportive actions reduce swelling, promote fluid reabsorption, and decrease client discomfort.

Complete necessary administrative duties.

The event and interventions are documented in the medical record.

Documentation must occur only after the client is stabilized and immediate care is provided.

Key Concept

Management of Intravenous Infiltration

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