Physiological Integrity

During an afternoon shift on a long-term care unit, a resident who underwent a left-eye cataract removal earlier that morning asks for help getting comfortable in bed. Which positioning technique should the practical nurse use for this resident?

While monitoring an older adult client who had a bowel resection earlier today, the practical nurse (PN) reviews the most recent vital signs and clinical data. The client is at increased risk for hypovolemic shock due to surgical blood loss. Which assessment finding should the PN identify as the body's earliest physiological adaptation to fluid volume deficit?

Upon entering the room of a client who underwent a bowel resection earlier in the shift, the practical nurse observes that the client is unusually restless and continuously picking at the bedsheets. The client's heart rate is 118 beats/min and blood pressure is 102/64 mm Hg, which represents a change from preoperative readings of 82 beats/min and 138/78 mm Hg. The client repeatedly states, 'I feel so thirsty.' Which action should the practical nurse take first?

A practical nurse (PN) is administering an intramuscular (IM) injection of iron dextran, a medication known to cause severe skin irritation and staining, to an adult client. The PN will utilize the Z-track method. Arrange the following steps of this procedure in the correct chronological order.

A practical nurse is providing basic care for a client who is two days postoperative following a right total hip arthroplasty (posterior approach). Which of the following care and positioning interventions should the nurse include in the client's daily routine? Select all that apply.

A practical nurse (PN) is collecting data on a client who had an ileostomy created three days ago. The client has had a high volume of liquid ostomy output over the past 12 hours. Which of the following clinical findings should the PN identify as early indicators of fluid volume deficit? Select all that apply.

While completing afternoon rounds, a practical nurse evaluates a 72-year-old individual who underwent a right femoral-popliteal bypass graft earlier in the day. The client is displaying new-onset agitation. Current physiological parameters reveal a heart rate of 114 beats per minute, blood pressure of 102/54 mm Hg, and a respiratory rate of 22 breaths per minute. A review of the preoperative record indicates a baseline blood pressure of 146/84 mm Hg. The surgical dressing over the incision site remains clean, dry, and intact. Which clinical action should the practical nurse prioritize?

An older adult client with a history of heart failure is prescribed a daily dose of oral digoxin. Before providing the medication, the practical nurse notes an apical pulse of 74 beats/minute and a newly resulted serum potassium level of 2.8 mEq/L (2.8 mmol/L). Which action should the practical nurse take first?

A practical nurse (PN) is preparing to administer amoxicillin/clavulanate to a pediatric client who weighs $31.9\text{ lb}$. The healthcare provider prescribed $45\text{ mg/kg/day}$ by mouth, divided into equal doses to be given every $12$ hours. The pharmacy provides an oral suspension with a concentration of $400\text{ mg}/5\text{ mL}$. How many $\text{mL}$ should the PN administer for each dose? (Record answer to the nearest tenth. Do not include units in answer.)

Following a right eye retinal detachment repair utilizing an intraocular gas bubble injection (pneumatic retinopexy), a client is transferred to the surgical unit. The provider's prescriptions specify strict positioning to ensure the gas bubble maintains continuous contact with the posterior retina. Which of the following positions should the practical nurse assist the client to maintain?

An older adult client is receiving care on a medical-surgical unit two days after a partial gastrectomy. The practical nurse (PN) notes that the client has become newly agitated. Current vital signs reveal a heart rate of 118 beats/min, a respiratory rate of 26 breaths/min, and a blood pressure of 92/54 mmHg. The client's vital signs from four hours ago were a heart rate of 82 beats/min, a respiratory rate of 16 breaths/min, and a blood pressure of 128/74 mmHg. Which of the following actions should the PN take? (Select all that apply.)

A practical nurse is monitoring a client who recently started taking warfarin, an oral anticoagulant. Which findings indicate an increased risk for severe complications and require immediate escalation to the registered nurse? (Select all that apply)

A client with bipolar disorder is prescribed oral lithium carbonate. The practical nurse is implementing the client's plan of care. Which of the following actions should the practical nurse take to ensure safe pharmacological therapy? (Select all that apply.)

A practical nurse is caring for a client who underwent a percutaneous kidney biopsy 3 hours ago. The client reports new-onset severe flank pain. The current vital signs are: heart rate 116 beats per minute and blood pressure 86/54 mm Hg. The morning laboratory report shows a hemoglobin level of 7.9 g/dL. Which action should the practical nurse take first?

During mealtime on the rehabilitation unit, a practical nurse observes a client with a recent stroke holding unchewed food inside their cheek. The client then produces a weak, gargling cough. Which immediate intervention should the nurse implement?

A practical nurse is caring for a client receiving treatment for hypertension. The client's medication administration record includes scheduled oral doses of spironolactone $50\text{ mg}$ and amlodipine $5\text{ mg}$. Upon reviewing the morning assessment data, the nurse notes a blood pressure of $128/82\text{ mmHg}$, a serum sodium level of $138\text{ mEq/L}$, and a serum potassium level of $5.9\text{ mEq/L}$. Which action should the practical nurse take first?

A practical nurse (PN) is caring for a client who is receiving continuous enteral tube feedings. The client suddenly begins to cough forcefully and expel vomitus. In which order should the PN perform the following actions? Arrange the actions from first to last.

A practical nurse is reviewing the electronic health record of an adult client who has been receiving a continuous intravenous heparin infusion for a pulmonary embolism for the past four days. The practical nurse notes the following morning laboratory results:

- Activated partial thromboplastin time (aPTT): $62$ seconds (Control: $30$ seconds)
- Hemoglobin: $13.2 \text{ g/dL}$
- Platelet count: $105,000 \text{ /mm}^3$ (Baseline on admission: $240,000 \text{ /mm}^3$)

During the morning assessment, the client's vital signs are within expected parameters, but the client reports a new onset of coldness, intense pain, and tingling in the right foot. Which action should the practical nurse take first?

A nurse is caring for a 72-year-old client being treated for a complicated urinary tract infection. The client's partner states, "My spouse is usually very sharp, but today they are extremely drowsy and talking about things that do not make sense." Assessment reveals a temperature of 97.6°F (36.4°C), apical pulse of 109 bpm, respirations of 22 breaths/min, and blood pressure of 92/52 mm Hg. Based on these findings, which intervention is the priority?

A practical nurse is assisting a client with the collection of a clean-catch midstream urine specimen for a culture and sensitivity test. Arrange the following steps in the correct chronological order to ensure an uncontaminated specimen is obtained.