Physiological Integrity

A practical nurse (PN) is reviewing morning laboratory data and assessing assigned clients. Which of the following clinical findings indicate a risk for potential complications and require immediate escalation to the registered nurse? (Select all that apply)

A practical nurse is preparing to change a one-piece ostomy pouching system for a client with an established descending colostomy. In what order should the nurse perform the following actions? Arrange the steps in the correct sequence from first to last.

A practical nurse (PN) is preparing to administer 8 units of regular insulin and 14 units of NPH insulin subcutaneously to a client with diabetes mellitus. In which order should the PN perform the following steps to prepare the medication? Arrange the actions in the correct sequence from first to last.

A practical nurse is caring for a client who returned to the surgical unit 4 hours ago following a right-sided modified radical mastectomy with axillary lymph node dissection. Which actions should the nurse include in the client's basic care and comfort plan? Select all that apply.

A practical nurse (PN) discovers a client with type 1 diabetes mellitus unresponsive in bed. The client is profusely diaphoretic, and a stat capillary blood glucose reading is $34 \text{ mg/dL}$ ($1.9 \text{ mmol/L}$). The client does not have established intravenous (IV) access. Arrange the following emergency interventions in the safest priority sequence from first to last.

A client weighing $198\text{ lb}$ is prescribed enoxaparin sodium $1\text{ mg/kg}$ subcutaneously every 12 hours for the treatment of a deep vein thrombosis. The medication is supplied as a prefilled syringe containing $120\text{ mg}$ in $0.8\text{ mL}$. How many milliliters ($\text{mL}$) should the practical nurse administer for a single dose?

(Record the answer to the nearest tenth. Do not include units in the answer.)

A practical nurse (PN) is collecting data on an 82-year-old client who is 24 hours postoperative following an open cholecystectomy. Which of the following assessment findings should the PN report to the registered nurse (RN) immediately? (Select all that apply.)

An adult client has returned to the surgical unit after undergoing a lumbar laminectomy. The practical nurse is providing basic care and comfort measures. Which of the following actions should the nurse implement when turning and positioning this client? Select all that apply.

A practical nurse (PN) is caring for a client who is 4 hours post-operative following a partial bowel resection. The client's preoperative blood pressure was 122/76 mm Hg with a heart rate of 74 bpm. Current vital signs are: blood pressure 94/58 mm Hg, heart rate 114 bpm, respiratory rate 20 breaths/min, and temperature 98.8°F (37.1°C). The client reports mild nausea and incisional pain rated as 3 on a 0 to 10 scale. Which action should the PN take first?

During early morning rounds, the practical nurse encounters an older adult client who recently underwent a right femoral-popliteal arterial bypass. The client appears highly agitated, is trying to climb over the raised side rails, and incorrectly believes they are at a train station. The nurse observes that the client's right knee is sharply flexed against the side rail. Which initial action should the nurse prioritize to maintain proper body alignment and ensure client safety?

A client is recovering on the telemetry unit four hours after a percutaneous coronary intervention performed through the right femoral artery. When the practical nurse enters the room, the client complains of a new, persistent dull ache in the lower back and right flank. Current vital signs include a heart rate of 106 beats/min and a blood pressure of 104/64 mm Hg, compared to a pre-procedure baseline of 78 beats/min and 126/78 mm Hg. The femoral insertion site dressing remains clean, dry, and intact. Which action should the nurse take first?

During a bedside assessment, a licensed practical nurse evaluates an adult client who underwent a right-sided thoracentesis earlier in the shift. The client suddenly reports a sharp, localized chest pain and exhibits a dry, hacking cough. Current vital signs reveal a respiratory rate of 26 breaths per minute, a heart rate of 114 beats per minute, and an oxygen saturation of 90% on room air. Which action should the nurse prioritize?

A practical nurse (PN) is preparing to administer scheduled medications on a medical-surgical unit. Which actions by the PN demonstrate safe medication administration and adherence to the scope of practice? Select all that apply.

A practical nurse (PN) is evaluating clients on a medical-surgical unit prior to dispensing scheduled medications. Which of the following clinical scenarios require the PN to withhold the pharmacological therapy and immediately intervene by notifying the registered nurse (RN)? Select all that apply.

A practical nurse (PN) is assigned to collect a sterile urine specimen for culture and sensitivity from a client who has a continuous indwelling urinary catheter. Arrange the following nursing actions in the correct chronological order to safely collect the specimen and minimize the risk of complications.

A practical nurse (PN) is assigned to care for a 78-year-old client who returned to the unit 4 hours ago following a percutaneous coronary intervention (PCI) accessed via the right femoral artery. Which of the following actions by the PN are appropriate to reduce the risk of potential complications? Select all that apply.

An LPN/VN is preparing to transfer a client who recently underwent an exploratory laparotomy from the bed to a resting chair. To promote comfort and safety, in what order should the nurse execute these steps?

A practical nurse is caring for a client who underwent a diagnostic cardiac catheterization via the right femoral artery 2 hours ago. The client is on prescribed strict bed rest and reports intense lower back discomfort from lying completely flat. Which action should the practical nurse take to promote the client's comfort?

An 80-year-old client is recovering on the surgical unit two days after a colon resection. During a routine check, the practical nurse (PN) notes the client is restless, repeatedly attempting to remove their intravenous (IV) line, and has difficulty focusing on questions. The client's current vital signs are: heart rate 114 bpm, blood pressure 104/62 mm Hg (baseline 138/76 mm Hg), and respiratory rate 22 breaths/minute. Which action should the PN take first?

An ambulatory care client has just been transferred to the short-stay surgical unit following a right eye cataract extraction. As the practical nurse assists the client into bed for the recovery period, which of the following positions is most appropriate to promote comfort and prevent postoperative complications?