Physiological Integrity

A practical nurse is preparing to administer a scheduled dose of liquid phenytoin suspension via a percutaneous endoscopic gastrostomy (PEG) tube to a client who is receiving continuous enteral feedings. To ensure therapeutic drug levels and maintain tube patency, arrange the following actions in the correct chronological order.

A client with a history of generalized seizures is prescribed phenytoin $5$ mg/kg/day PO divided into $2$ equal doses. The client weighs $176$ lb. The available medication is phenytoin oral suspension $125$ mg / $5$ mL. How many mL should the practical nurse administer per dose? (Record answer to the nearest whole number. Do not include units in the answer.)

A practical nurse is providing basic care for a client who is 48 hours postoperative following a right above-the-knee amputation (AKA). The client reports muscle spasms and discomfort in the affected limb. Which of the following nursing actions should the nurse implement to promote comfort and prevent complications? Select all that apply.

A client arrives at the surgical step-down unit after undergoing a left modified radical mastectomy with axillary node dissection. When planning the client's basic comfort and safety measures for the current shift, which actions should the nurse include? Select all that apply.

An LPN/LVN is caring for a 76-year-old client who is two days postoperative following a total hip arthroplasty. The client, who was previously alert and oriented, suddenly becomes agitated, disoriented, and attempts to climb out of bed. Which of the following is the priority action for the LPN/LVN to take?

A practical nurse (PN) is assisting a client with collecting a sputum specimen for culture and sensitivity. To ensure an accurate diagnostic sample and reduce the risk of sample contamination, in what order should the PN instruct the client to perform these steps?

A practical nurse (PN) is collecting data on a client who underwent a percutaneous liver biopsy 4 hours ago. The client's baseline vital signs were blood pressure 130/82 mm Hg and heart rate 72 beats/minute. Which current assessment finding presents the highest risk for a severe complication and requires immediate escalation to the registered nurse (RN)?

An older adult client admitted with acute bronchitis has been resting comfortably. The practical nurse (PN) notes that the client has suddenly become highly restless and confused. Based on this sudden change, which of the following physiological conditions should the PN suspect first?

An older adult client with a history of chronic obstructive pulmonary disease (COPD) and heart failure is receiving a continuous intravenous infusion of 0.9% sodium chloride. The practical nurse is preparing to administer scheduled morning medications, which include oral levofloxacin, oral furosemide, and subcutaneous enoxaparin. During the pre-administration assessment, the client appears restless. Vital signs are: heart rate 112 beats/min, blood pressure 90/58 mm Hg, and oxygen saturation 88% on 2 L/min via nasal cannula. The morning laboratory report shows a platelet count of 95,000/mm³ ($95 \times 10^9$/L). Based on these findings, which action should the practical nurse take first?

While performing a postoperative assessment, a licensed practical nurse (LPN) evaluates a client who underwent a percutaneous coronary intervention via the right femoral artery 4 hours ago. The client reports a new, continuous dull ache in the lower back. Inspection of the right groin reveals a dry surgical dressing with no localized swelling. Bilateral pedal pulses are palpable and symmetric. The client's baseline vital signs were blood pressure 144/82 mm Hg and heart rate 70 bpm. Current vital signs are blood pressure 104/62 mm Hg, heart rate 116 bpm, and respirations 20/min. Based on these findings, which action should the LPN take first?

A client who underwent a right above-the-knee amputation 48 hours ago reports lower back stiffness and requests assistance with repositioning. Which action should the practical nurse take to promote comfort and prevent postoperative complications?

A practical nurse is reviewing the electronic health record of a client admitted with an exacerbation of chronic obstructive pulmonary disease and generalized edema. The provider has prescribed oral furosemide and oral levofloxacin. The morning chemistry panel reveals a serum potassium level of 2.8 mEq/L (normal: 3.5-5.0 mEq/L). During data collection, the practical nurse notes the client's blood pressure is 102/60 mm Hg and heart rate is 115 beats/min. The registered nurse is occupied with another admission and asks the practical nurse to administer all scheduled morning medications. Which action should the practical nurse take?

A licensed practical nurse (LPN) is assigned to obtain a sterile urine culture specimen from a client who has a continuous indwelling urinary catheter. To ensure accurate diagnostic results and reduce the risk of client complications, arrange the following procedural steps in the correct chronological sequence. All steps must be used.

During the morning medication pass, a client with pulmonary edema is scheduled to receive a $40$ mg oral dose of furosemide. The medication drawer contains $20$ mg scored tablets. The client's most recent basic metabolic panel reveals a serum potassium concentration of $2.8$ mEq/L ($2.8$ mmol/L). Which action should the practical nurse (PN) take?

A practical nurse is reviewing the morning laboratory results for a client who receives a daily dose of furosemide. Which of the following laboratory findings presents the greatest physiological risk to the client and requires immediate notification to the registered nurse?

A practical nurse is preparing to place a regular bedpan for a client who is on strict bed rest and unable to lift their hips. After donning gloves and ensuring privacy, in what order should the nurse perform the following actions? Arrange the steps from first to last.

A client is receiving postoperative care on the medical-surgical unit following a lumbar laminectomy. The client reports mild discomfort from lying flat and requests assistance to turn onto their side. Which of the following techniques should the nurse implement to safely reposition this client?

During a scheduled safety check, the practical nurse finds a client with a history of chronic obstructive pulmonary disease (COPD) and mild dementia attempting to pull off their oxygen nasal cannula. The client appears highly restless and agitated. Current vital signs indicate a heart rate of 112 beats/min, respirations of 28 breaths/min, and an oxygen saturation of 85% on 2 L/min. What is the priority action for the practical nurse to take?

A client is receiving intravenous (IV) fluid therapy for severe dehydration caused by acute gastroenteritis. The practical nurse is collaborating with a registered nurse (RN) to manage the client's care. Which actions by the practical nurse demonstrate the correct application of risk reduction principles? Select all that apply.

A healthcare provider prescribes knee-high anti-embolism stockings for a client who is currently sitting in a bedside chair. Arrange the following steps for applying the stockings in the correct chronological order.