Physiological Integrity

1313 questions

All types1,313 Multiple choice672 Multiple select289 Numeric68 Ordering284

A practical nurse is assisting a client with right-sided hemiplegia who is sitting on the edge of the bed to transfer into a wheelchair. In what order should the nurse perform the following actions? Arrange the steps from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence prioritizes environmental safety and leading with the strong side: Position the wheelchair on the left side, lock the wheels, apply a transfer belt, brace the right knee during the stand, and instruct the client to reach with their left hand.

Safe transfer of a client with hemiplegia requires moving toward the strong side. The environment is secured first (chair positioned on the strong left side, brakes locked). Next, the client is secured with a gait belt. During the pivot, the nurse protects the weak side by bracing the right knee, allowing the client to use their strong left arm and leg to guide the transfer safely.

Step-by-Step Solution

Analyze the client's deficit and prepare the environment.

The nurse identifies the left side as the strong side, positions the wheelchair on the left at a 45-degree angle, and locks all wheels.

Transfers must always be directed toward the unaffected side to maximize client participation and safety. Securing the environment prevents equipment from shifting during weight transfer.

Secure the client for physical movement.

The nurse applies a transfer (gait) belt around the client's waist.

The belt provides a secure grip for the nurse to control the client's descent if they begin to fall, avoiding pulling on the client's arms or shoulders.

Provide support to the compromised extremity during the lift.

The nurse braces the client's right knee with their own knee/foot while assisting the client to stand.

Right-sided hemiplegia means the right leg lacks motor control and strength; bracing it prevents the knee from buckling under the client's weight.

Utilize the strong side to complete the pivot and transfer.

The client reaches for the wheelchair armrest with their functional left hand before sitting.

Reaching with the strong arm maintains spatial orientation and provides a final point of stability as the client lowers into the chair.

Key Concept

Safe mobility and transfer techniques for clients with hemiplegia

Question 122Question →

A practical nurse (PN) is participating in the care of a client recovering from a colonoscopy with polyp removal performed earlier in the day. The client rings the call bell and reports severe, unrelenting abdominal cramping and nausea. Upon data collection, the PN notes the client's skin is cool to the touch, and the radial pulse is 118 beats per minute and thready. Which action should the PN take immediately?

Notify the registered nurse (RN) about the assessment findings.

Administer the prescribed as-needed antiemetic medication.

Reassure the client that cramping is a typical effect of the procedure.

Assist the client into a sitting position on the edge of the bed.

Show answer & explanation

Answer: Notify the registered nurse (RN) about the assessment findings.

Answer

Notify the registered nurse (RN) about the assessment findings.

The client is exhibiting signs of a potential bowel perforation and internal bleeding (severe cramping, cool skin, tachycardia, thready pulse). Because this is a life-threatening emergency requiring advanced assessment and medical intervention, the priority action within the practical nurse's scope of practice is to immediately escalate the findings to the registered nurse.

Step-by-Step Solution

Analyze the client's clinical presentation.

The client has severe abdominal cramping, cool skin, and a rapid, thready pulse following an invasive procedural intervention.

Identifying abnormal physiological findings is the first step in clinical decision-making.

Determine the potential underlying complication.

These manifestations strongly suggest bowel perforation and developing hypovolemic shock, which is a medical emergency.

Early recognition of life-threatening procedural complications is essential for client safety and physiological adaptation.

Select the appropriate PN intervention based on the scope of practice.

The PN must immediately communicate these critical findings to the RN.

The client requires RN-level assessment and likely emergency medical intervention that exceeds the PN scope of practice.

Key Concept

Recognizing Procedural Complications and Shock

Question 123Question →

A practical nurse (PN) is monitoring an adult client who underwent a large-volume therapeutic paracentesis $2$ hours ago. The client's baseline blood pressure was $138/82$ mm Hg and heart rate was $76$ beats/min. The client now reports mild lightheadedness and nausea. The PN notes the client's skin is slightly pale and cool. Current vital signs are: blood pressure $102/68$ mm Hg, heart rate $108$ beats/min, and respiratory rate $20$ breaths/min. The abdominal dressing is dry and intact. Which of the following is the priority nursing action?

Place the client in a supine position and immediately notify the registered nurse.

Administer a prescribed PRN oral antiemetic for the client's nausea.

Document the vital signs and reassess in one hour, as this is an expected physiological response.

Assist the client into a high-Fowler's position to promote optimal lung expansion and comfort.

Show answer & explanation

Answer: Place the client in a supine position and immediately notify the registered nurse.

Answer

The priority action is to place the client in a supine position and immediately notify the registered nurse.

Although the client's systolic blood pressure is technically above

100

mm Hg, it represents a significant drop from the baseline. This drop, accompanied by tachycardia, pallor, and lightheadedness, indicates early, subtle hypovolemic shock caused by intravascular fluid shifts following large-volume fluid removal. The priority is to maximize venous return to the vital organs by placing the client flat (supine) and to immediately escalate these critical findings to the registered nurse for rapid emergency intervention.

Step-by-Step Solution

Analyze the client's current clinical presentation and compare it to baseline findings.

The client has a significant drop in blood pressure (from

138/82

102/68

mm Hg), tachycardia (

108

beats/min), pallor, and lightheadedness.

Identifying changes from baseline is essential to recognize developing complications rather than relying solely on absolute numeric thresholds.

Interpret the clinical significance of these assessment findings.

The findings indicate early hypovolemic shock resulting from rapid intravascular fluid shifts, a known complication of large-volume fluid removal.

Recognizing the pathophysiology of the complication determines the urgency of the response.

Determine the priority nursing action based on the airway, breathing, circulation (ABC) framework.

The priority is addressing the circulation deficit. The PN must maximize venous return by placing the client flat and immediately escalate to the RN.

Immediate physical intervention (positioning) and escalation are required to prevent severe cardiovascular collapse.

Key Concept

Hypovolemic Shock Recognition and Escalation Post-Paracentesis

Estimated Time:1m 30s

Question 124Question →

A client who underwent a transverse colectomy three days ago has a morning hemoglobin result of 7.9 g/dL. During the morning assessment, the nurse notes a heart rate of 115 beats per minute, a respiratory rate of 22 breaths per minute, and a blood pressure of 94/60 mm Hg. The client complains of new-onset lightheadedness when resting in bed. Which action is the priority for the nurse to implement?

Notify the registered nurse immediately about the vital signs and laboratory results.

Record the assessment data and recheck the client's blood pressure in one hour.

Give the client their scheduled oral iron tablet with breakfast to treat the anemia.

Teach the client to change positions slowly to minimize the feelings of lightheadedness.

Show answer & explanation

Answer: Notify the registered nurse immediately about the vital signs and laboratory results.

Answer

The priority action is to immediately notify the registered nurse regarding the client's vital signs and hemoglobin levels.

The correct action demonstrates an understanding of risk reduction by promptly identifying clinical indicators of hypovolemic shock—such as a critically low hemoglobin, tachycardia, hypotension, and lightheadedness—and escalating the situation to the registered nurse for rapid medical intervention.

Step-by-Step Solution

Analyze the client's laboratory results and vital signs.

The hemoglobin is critically low (7.9 g/dL), accompanied by tachycardia, hypotension, and lightheadedness.

Recognizing the combination of these findings indicates an acute complication such as internal bleeding or hypovolemic shock.

Determine the scope of practice for the practical nurse in an emergent situation.

The practical nurse must immediately escalate the findings to the registered nurse or healthcare provider.

Acute physiological deterioration requires immediate RN-level assessment and potential medical intervention (such as blood transfusions or fluid resuscitation) to stabilize the client.

Key Concept

Identifying early signs of hypovolemia and escalating critical findings

Question 125Question →

A practical nurse is initiating a 24-hour urine collection for a client on the medical-surgical unit to evaluate kidney function. In what chronological order should the nurse implement the steps for this diagnostic procedure? (Arrange from first to last)

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first discard the initial void, document the start time, collect all subsequent urine on ice for 24 hours, obtain a final void at the exactly 24-hour mark, and then transport the labeled container to the laboratory.

A 24-hour urine collection must measure only the urine produced within a strict 24-hour window. Therefore, the procedure begins by starting with an empty bladder (discarding the first void) and documenting that exact time. Over the next 24 hours, all subsequent urine must be collected and kept cold to preserve the specimen. At exactly 24 hours from the start time, the client voids one last time to empty the bladder of any urine produced during the final moments of the period. Finally, the complete and correctly labeled specimen is transported to the laboratory for analysis.

Step-by-Step Solution

Discard the initial void.

The bladder is emptied of urine formed prior to the testing period.

Including prior urine would falsely elevate the 24-hour analyte values.

Document the precise start time.

The 24-hour clock officially begins.

A precise start time is required to ensure the collection window lasts exactly 24 hours.

Collect all subsequent urine and keep it cold.

All urine produced during the testing window is preserved.

Missing any urine invalidates the test; refrigeration prevents chemical breakdown.

Obtain one last void at exactly 24 hours.

The 24-hour collection period is officially concluded.

This captures the very last amount of urine produced within the exact 24-hour timeframe.

Label and send the container to the laboratory.

The specimen is securely handed off for diagnostic processing.

Timely transport maintains specimen integrity.

Key Concept

24-Hour Urine Specimen Collection Protocol

Question 126Question →

While providing morning care for an older adult client 48 hours after an open reduction and internal fixation of a fractured right femur, the practical nurse notes a sudden change in status. The client is highly restless, unable to state their location, and has a respiratory rate of 24 breaths/minute with an oxygen saturation of 92% on room air. Furthermore, scattered pinpoint, non-blanching red spots are visible across the client's anterior chest. Which action is the priority for the practical nurse to take?

Elevate the head of the bed, apply supplemental oxygen, and urgently notify the registered nurse.

Assess the pedal pulses, skin temperature, and capillary refill of the right lower extremity.

Obtain a urine specimen to screen for infection and frequently reorient the client to the environment.

Document the current vital signs in the health record and plan to reassess the client's respiratory status in 30 minutes.

Show answer & explanation

Answer: Elevate the head of the bed, apply supplemental oxygen, and urgently notify the registered nurse.

Answer

The priority action is to elevate the head of the bed, apply supplemental oxygen, and urgently notify the registered nurse.

The client is exhibiting the classic clinical triad of fat embolism syndrome (hypoxemia, neurologic abnormalities, and a petechial rash), which is a severe medical emergency strongly associated with long bone fractures. The priority action for the practical nurse is to immediately support the client's airway and breathing by applying supplemental oxygen and to escalate the care by notifying the registered nurse or provider for urgent medical intervention.

Step-by-Step Solution

Analyze the client's clinical presentation.

The client presents with hypoxia (SpO2 92%, RR 24), neurological compromise (restlessness, disorientation), and a petechial rash on the chest.

Identifying symptom clusters is essential to determine the underlying pathophysiology.

Connect the symptom cluster to the client's medical history.

The triad of hypoxemia, neurological changes, and a petechial rash in a client with a recent long bone (femur) fracture indicates fat embolism syndrome (FES).

Fat embolism syndrome is a specific, life-threatening complication of orthopedic trauma that requires immediate recognition.

Determine the priority nursing intervention based on the ABCs (Airway, Breathing, Circulation).

The practical nurse must address the compromised breathing and oxygenation first by applying oxygen and elevating the head of the bed, followed by immediate escalation to the registered nurse.

Systemic life-threatening emergencies must be treated before localized assessments or routine data collection.

Key Concept

Fat Embolism Syndrome Recognition and ABC Prioritization

Question 127Question →

A practical nurse is planning care for a client who is 12 hours post-operative following a lumbar laminectomy. Which interventions should the nurse include to promote comfort and maintain safety? (Select all that apply.)

Select all that apply

Use a logrolling technique with the assistance of another staff member when turning the client.

Place a pillow between the client's legs prior to turning them onto their side.

Elevate the head of the bed to a 90-degree angle when assisting the client with meals.

Offer a fracture bedpan for elimination needs to minimize lifting of the lower back.

Delegate the initial post-operative assessment of the client's lower extremity motor strength to assistive personnel.

Show answer & explanation

Answer: Use a logrolling technique with the assistance of another staff member when turning the client.; Place a pillow between the client's legs prior to turning them onto their side.; Offer a fracture bedpan for elimination needs to minimize lifting of the lower back.

Answer

The correct interventions are using a logrolling technique with assistance, placing a pillow between the legs before turning, and offering a fracture bedpan for elimination.

Following a lumbar laminectomy, the primary goal of basic care is to maintain the spine in neutral alignment to prevent injury to the surgical site. Using a logrolling technique with a second staff member and placing a pillow between the legs ensures the client's body moves as a single unit without twisting. Utilizing a fracture bedpan prevents the client from having to lift their hips, which would flex the lumbar spine.

Step-by-Step Solution

Identify the client's surgical procedure and post-operative constraints.

The client had a lumbar laminectomy, which requires strict maintenance of spinal alignment.

Understanding the procedure dictates the necessary positioning and mobility precautions.

Evaluate each proposed intervention against spinal precautions and the practical nurse's scope of practice.

Logrolling, using a leg pillow, and using a fracture bedpan maintain spinal alignment. High Fowler's position violates positioning rules, and delegating an initial assessment violates scope of practice.

All care must ensure client safety and fall within legal nursing boundaries.

Key Concept

Post-operative basic care and positioning for spinal surgery

Question 128Question →

A practical nurse is preparing to administer morning medications to a group of assigned clients. Which of the following actions by the nurse demonstrate safe pharmacological practice? Select all that apply.

Select all that apply

Verifying a client's identity by checking their identification band and asking them to state their full name and date of birth.

Withholding a scheduled dose of oral morphine for a client who has a resting respiratory rate of 10 breaths per minute and notifying the registered nurse.

Administering an intravenous (IV) push dose of ondansetron to a client who is experiencing severe postoperative nausea.

Leaving a sealed unit-dose package of an oral antibiotic on the bedside table for a client who is currently in the restroom.

Reviewing a client's most recent serum potassium level prior to administering a scheduled daily dose of oral digoxin.

Administering a live attenuated influenza vaccine to a client who is currently receiving immunosuppressive corticosteroid therapy.

Show answer & explanation

Answer: Verifying a client's identity by checking their identification band and asking them to state their full name and date of birth.; Withholding a scheduled dose of oral morphine for a client who has a resting respiratory rate of 10 breaths per minute and notifying the registered nurse.; Reviewing a client's most recent serum potassium level prior to administering a scheduled daily dose of oral digoxin.

Answer

The correct actions are verifying identity with two unique identifiers, withholding the opioid for bradypnea (respiratory rate < 12), and checking the potassium level before giving digoxin.

Verifying identity with two unique identifiers, withholding opioids for respiratory depression (rate < 12), and monitoring potassium levels before digoxin administration all represent safe, within-scope pharmacological practices that protect the client from harm.

Step-by-Step Solution

Evaluate the action of verifying identity with two identifiers.

This action is correct and required.

It ensures the right medication is given to the right client, fulfilling a core right of medication administration.

Evaluate the action of withholding morphine for a respiratory rate of 10.

This action is a correct safety intervention.

Opioids depress the respiratory drive. A rate below 12 breaths per minute warrants withholding the drug and notifying the RN.

Evaluate the action of administering an IV push medication.

This action is inappropriate.

IV push administration falls outside the practical nurse's scope of practice, regardless of the severity of the client's symptoms.

Evaluate the action of leaving medication at the bedside.

This action violates safe medication administration rules.

The nurse cannot verify that the correct client took the medication at the scheduled time if it is left unattended.

Evaluate the action of reviewing the potassium level before digoxin administration.

This action is a correct and necessary precaution.

Low potassium levels can precipitate dangerous digoxin toxicity, making this a vital pre-administration data collection step.

Evaluate the action of giving a live vaccine to a client on corticosteroids.

This action is contraindicated.

Clients on immunosuppressive therapy cannot safely receive live attenuated vaccines due to the risk of active infection.

Key Concept

Safe Medication Administration and Scope of Practice

Question 129Question →

A practical nurse is caring for a client who is receiving a continuous intravenous heparin infusion for a deep vein thrombosis. The client's baseline vital signs at the start of the shift were: heart rate 74/min and blood pressure 128/78 mm Hg. The nurse notes the current vital signs are: heart rate 114/min and blood pressure 102/64 mm Hg. Morning laboratory results indicate an activated partial thromboplastin time (aPTT) of 68 seconds and a hemoglobin level of 10.8 g/dL, which is a decrease from 13.2 g/dL the previous day. The client also reports a new, continuous, dull ache in the lower back. Which action should the nurse take first?

Administer the prescribed PRN oral acetaminophen for the reported back pain.

Document the findings in the electronic health record as the aPTT is within the therapeutic range.

Notify the registered nurse immediately regarding the assessment findings.

Perform deep palpation of the client's lumbar region to assess the severity of the pain.

Show answer & explanation

Answer: Notify the registered nurse immediately regarding the assessment findings.

Answer

The correct action is to notify the registered nurse immediately regarding the assessment findings.

The client is exhibiting classic signs of a retroperitoneal bleed, a severe complication of anticoagulant therapy. The combination of new-onset lower back pain (referred pain from blood pooling), tachycardia, mild hypotension, and a significant drop in hemoglobin indicates internal hemorrhage. Even though the aPTT is in the expected therapeutic range, bleeding can still occur. The practical nurse must immediately escalate these findings to the registered nurse to initiate rapid medical intervention.

Step-by-Step Solution

Analyze the client's vital signs and physical complaints.

The client exhibits new-onset tachycardia, a downward trend in blood pressure, and a new dull ache in the lower back.

To identify any acute deviations from baseline that could indicate a complication of therapy.

Correlate the physical assessment findings with the laboratory results and current medications.

The client is on a high-alert anticoagulant (heparin) and has experienced a significant drop in hemoglobin (2.4 g/dL decrease) over 24 hours.

To recognize physiological patterns indicating adverse effects, such as internal bleeding.

Synthesize the collected data to identify the specific potential risk.

The combination of back pain, dropping hemoglobin, and early signs of shock strongly suggests a retroperitoneal hemorrhage.

Retroperitoneal bleeding is a known, life-threatening complication of systemic anticoagulation that often presents with insidious flank or back pain.

Determine the appropriate scope of practice and priority nursing action.

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

Life-threatening complications require immediate RN assessment and provider intervention to stop the bleeding and stabilize the client.

Key Concept

Early recognition and escalation of anticoagulant-induced hemorrhage

Question 130Question →

An 82-year-old client is being treated on the medical-surgical unit for a severe lower respiratory tract infection. During afternoon rounds, a visiting family member tells the practical nurse (PN) that the client seems "much more restless and confused" compared to the morning. Which subsequent assessment findings should the PN identify as early warning signs of systemic hypoperfusion or impending shock? Select all that apply.

Select all that apply

Inability to identify their current location, which represents a change from the morning assessment

A resting apical heart rate that has steadily climbed to 114 beats per minute

A decrease in systolic blood pressure of 25 mm Hg from the admission baseline

Reports of moderate chest wall discomfort when coughing or taking deep breaths

A documented urinary output of 340 mL over the most recent 8-hour period

Show answer & explanation

Answer: Inability to identify their current location, which represents a change from the morning assessment; A resting apical heart rate that has steadily climbed to 114 beats per minute; A decrease in systolic blood pressure of 25 mm Hg from the admission baseline

Answer

The early warning signs of systemic hypoperfusion include a change in mental status (disorientation), an increasing resting heart rate (tachycardia), and a significant relative decrease in systolic blood pressure.

Early physiological adaptation to shock involves sympathetic nervous system activation, leading to tachycardia as the body attempts to maintain cardiac output. As compensation begins to fail, the systolic blood pressure drops (even if not yet strictly hypotensive, a relative drop of 25 mm Hg is significant). Furthermore, the brain is highly sensitive to hypoperfusion and hypoxia, meaning sudden confusion or restlessness is a critical, early sign of decompensation, particularly in older adults.

Step-by-Step Solution

Analyze the client's clinical presentation and age.

The client is an 82-year-old with a severe infection who is exhibiting new-onset restlessness and confusion.

Older adults often present atypically with infections or shock. Changes in mentation are frequently the earliest indicators of physiological compromise.

Evaluate the hemodynamic parameters for signs of compensation.

A rising heart rate (114 bpm) and dropping systolic blood pressure (decrease of 25 mm Hg) are identified.

The body attempts to maintain cardiac output by increasing heart rate. A dropping blood pressure indicates that these compensatory mechanisms are beginning to fail.

Differentiate between expected localized symptoms and acute systemic deterioration.

Chest discomfort during coughing and a urine output of 340 mL over 8 hours are identified as expected or normal findings.

Pleuritic pain is expected with a respiratory infection, and an output of over 30 mL/hr demonstrates adequate renal perfusion, ruling them out as signs of shock.

Key Concept

Recognition of early hemodynamic compromise and hypoperfusion in older adults, prioritizing ABCs over expected localized symptoms.

Question 131Question →

A practical nurse (PN) is caring for a client who had a vaginal delivery two hours ago. The client's heart rate is 116 beats per minute, and blood pressure is 94/58 mm Hg. The client is restless and states, "I feel very lightheaded." Which action should the PN take first?

Palpate the client's uterine fundus and evaluate the amount of vaginal bleeding

Document the vital signs as an expected physiological response to childbirth

Administer the prescribed as-needed oral analgesic for uterine cramping

Reassure the client that feeling lightheaded is a normal effect of maternal fatigue

Show answer & explanation

Answer: Palpate the client's uterine fundus and evaluate the amount of vaginal bleeding

Answer

The practical nurse should first palpate the client's uterine fundus and evaluate the amount of vaginal bleeding.

The client is exhibiting classic signs of early hypovolemic shock (tachycardia, hypotension, restlessness, lightheadedness). In the immediate postpartum period, the most common cause is uterine atony leading to hemorrhage. The practical nurse must immediately assess the fundus and vaginal bleeding to determine if hemorrhage is occurring, which addresses the 'Circulation' priority of the ABC framework.

Step-by-Step Solution

Analyze the client's clinical presentation.

The client has tachycardia (116 bpm), low blood pressure (94/58 mm Hg), restlessness, and lightheadedness two hours after birth.

Recognizing abnormal vital signs is the first step in identifying physiological instability.

Correlate the findings with potential postpartum complications.

These symptoms are classic early indicators of hypovolemic shock, likely due to postpartum hemorrhage.

Connecting data to potential risks guides the nurse toward the correct priority action.

Determine the priority nursing intervention using the ABC (Airway, Breathing, Circulation) framework.

Assessing the uterine fundus and lochia addresses Circulation by identifying the source of potential blood loss.

Immediate assessment of the circulatory status takes precedence over routine documentation, pain management, or providing reassurance.

Key Concept

Prioritization of Circulation in Postpartum Hemorrhage

Question 132Question →

A practical nurse is preparing to administer a scheduled morning dose of oral clozapine to a client diagnosed with schizophrenia. Prior to administration, the nurse reviews the client's most recent complete blood count (CBC) results, which indicate a white blood cell (WBC) count of $2,800/\text{mm}^3$ and an absolute neutrophil count (ANC) of $900/\text{mm}^3$ . Which of the following is the most appropriate action by the nurse?

Withhold the dose of clozapine and immediately report the laboratory results to the registered nurse.

Administer the medication as prescribed and closely monitor the client for signs of infection.

Calculate and administer a reduced dosage of the medication to minimize the risk of further bone marrow suppression.

Explain the risks of agranulocytosis to the client and obtain a new signed consent before administering the dose.

Show answer & explanation

Answer: Withhold the dose of clozapine and immediately report the laboratory results to the registered nurse.

Answer

The nurse should withhold the medication and report the critical laboratory results to the registered nurse.

Clozapine can cause severe agranulocytosis. An ANC below

1,000/\text{mm}^3

indicates severe neutropenia. The standard protocol requires withholding the medication and immediately notifying the provider or registered nurse to initiate protective precautions and alternative treatment.

Step-by-Step Solution

Analyze the laboratory values.

The WBC count is

2,800/\text{mm}^3

(normal is typically

4,500

11,000/\text{mm}^3

) and the ANC is

900/\text{mm}^3

(normal is greater than

1,500/\text{mm}^3

Identifying abnormal laboratory results is essential before administering medications that can affect blood cell counts.

Correlate the laboratory findings with the prescribed medication.

Clozapine is an atypical antipsychotic known to cause agranulocytosis (severe neutropenia), which is life-threatening.

Understanding the adverse effects of clozapine guides safe administration practices.

Determine the appropriate nursing intervention based on scope of practice.

The nurse must withhold the medication and escalate the critical findings to the supervising registered nurse or healthcare provider.

Administering the medication could lead to fatal infection, and adjusting the dose or bypassing escalation is outside the practical nurse's scope.

Key Concept

Clozapine requires strict monitoring of WBC and ANC due to the risk of agranulocytosis; critical lows require withholding the drug and immediate escalation.

Question 133Question →

A practical nurse is planning immediate post-procedure care for a client who has just returned to the unit following a percutaneous liver biopsy. Which nursing action correctly mitigates the risk of a severe complication?

Positioning the client on their right side with a rolled towel placed directly under the biopsy site.

Placing the client in a high-Fowler's position to promote optimal lung expansion and oxygenation.

Delaying notification to the registered nurse for a new resting heart rate of 105 beats per minute if the blood pressure is stable.

Assigning the unlicensed assistive personnel to perform the initial baseline evaluation of the puncture dressing.

Show answer & explanation

Answer: Positioning the client on their right side with a rolled towel placed directly under the biopsy site.

Answer

Positioning the client in a right lateral decubitus position with a rolled towel under the puncture site to apply direct hemostatic pressure.

The liver is highly vascular, making hemorrhage the most significant risk following a percutaneous liver biopsy. Positioning the client on their right side (right lateral decubitus position) with a rolled towel or small pillow under the puncture site uses the client's own body weight to apply direct, continuous pressure to the liver capsule. This mechanical compression promotes hemostasis and minimizes the risk of internal bleeding.

Step-by-Step Solution

Identify the primary complication risk following a percutaneous liver biopsy.

The liver is a highly vascular organ, making severe internal hemorrhage the most critical and immediate post-procedure risk.

Recognizing the specific procedural complication allows the nurse to prioritize targeted preventative interventions.

Determine the anatomical location of the liver and the mechanism required to achieve hemostasis.

The liver is located in the right upper quadrant of the abdomen; applying external, mechanical pressure to this area promotes blood clotting at the puncture site.

Direct mechanical pressure compresses the bleeding vessels, significantly reducing the risk of hemorrhage.

Select the nursing intervention that effectively applies continuous pressure to the biopsy site.

Positioning the client in a right lateral decubitus (right side-lying) position with a towel or small pillow under the site utilizes the client's own body weight to maintain necessary pressure.

This evidence-based positioning directly mitigates the risk of life-threatening bleeding without requiring constant manual pressure by the nurse.

Key Concept

Post-procedure liver biopsy positioning for hemostasis

Estimated Time:1m 30s

Question 134Question →

A practical nurse (PN) is preparing to collect an aerobic wound culture from a client's stage 3 pressure injury. To ensure accurate laboratory results and reduce the risk of specimen contamination, arrange the following actions in the correct chronological sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct chronological sequence is: 1) Remove the soiled dressing, 2) Cleanse the wound bed with sterile normal saline, 3) Rotate a sterile swab over granulation tissue, 4) Place the swab into the sterile transport tube, and 5) Label the specimen container at the bedside.

The correct sequence ensures the culture reflects the true infectious organism rather than surface flora. Removing the dressing allows for assessment. Cleansing the wound prior to swabbing is a critical risk-reduction step to eliminate surface exudate. The swab is then applied to healthy granulation tissue, immediately placed in a transport medium to protect the sample, and labeled at the bedside to prevent identification errors.

Step-by-Step Solution

Remove the soiled dressing and assess the wound bed.

The wound is exposed for evaluation.

Allows the nurse to observe the wound's status before initiating the collection procedure.

Cleanse the wound bed with sterile normal saline.

Surface exudate and normal flora are washed away.

Prevents the culture from growing surface contaminants that do not represent the actual tissue infection.

Rotate a sterile swab over an area of healthy granulation tissue.

A sample of the infecting microorganism is obtained.

Pathogens actively causing infection are most concentrated in viable, granulating tissue.

Place the culture swab securely into the sterile transport tube.

The specimen is sealed in a supportive medium.

Protects the aerobic bacteria from dying or being contaminated by the external environment.

Label the specimen container in the presence of the client.

The specimen is correctly identified with the client's information.

Bedside labeling is a standard safety practice to eliminate the risk of sample mix-ups.

Key Concept

Proper specimen collection techniques for aerobic wound cultures to reduce the risk of inaccurate laboratory data.

Question 135Question →

During the second post-operative day after a right below-the-knee amputation, the practical nurse is planning positioning strategies for the client. Which specific action should the nurse implement to prevent the development of a hip flexion contracture?

Assist the client into a prone position for 30 minutes three to four times daily.

Elevate the right residual limb continuously on a soft pillow.

Maintain the head of the bed in a high-Fowler's position during waking hours.

Place a trochanter roll along the outer aspect of the right hip and thigh.

Show answer & explanation

Answer: Assist the client into a prone position for 30 minutes three to four times daily.

Answer

Assist the client into a prone position for 30 minutes three to four times daily.

Placing the client in a prone position for 20 to 30 minutes several times a day fully extends the hip joints. This stretches the hip flexor muscles, which is the most effective basic care measure to prevent flexion contractures following a lower extremity amputation. Contractures can severely impede the future fitting and use of a prosthetic limb.

Step-by-Step Solution

Analyze the clinical scenario to identify the client's primary risk.

The client is 48 hours post-operative from a lower extremity amputation and is at high risk for hip flexion contractures due to muscle shortening.

Identifying the specific post-operative complication allows the nurse to select the correct preventive basic care measure.

Evaluate the anatomical effect of each positioning option on the hip joint.

Lying prone fully extends the hip joint, while elevating the limb or sitting upright promotes hip flexion.

The intervention must actively stretch the hip flexors to counteract the natural tendency to pull the limb into a bent, flexed position.

Key Concept

Proper post-operative positioning to prevent hip flexion contractures following lower extremity amputation.

Question 136Question →

A practical nurse (PN) is collecting data on a client who is 4 hours post-operative following a total thyroidectomy. Which of the following assessment findings indicate a potential critical complication requiring immediate escalation to the registered nurse (RN)? (Select all that apply.)

Select all that apply

Client reports new onset of numbness and tingling around the mouth.

A high-pitched, harsh respiratory sound heard during inspiration.

Client exhibits frequent swallowing and continuous throat clearing.

Serosanguineous drainage of 15 mL in the closed-suction drain.

Serum calcium level of 9.2 mg/dL (2.3 mmol/L).

Incisional pain rated as 4 on a 0 to 10 numerical pain scale.

Show answer & explanation

Answer: Client reports new onset of numbness and tingling around the mouth.; A high-pitched, harsh respiratory sound heard during inspiration.; Client exhibits frequent swallowing and continuous throat clearing.

Answer

The correct findings requiring escalation are: numbness and tingling around the mouth, a high-pitched respiratory sound on inspiration, and frequent swallowing.

Following a thyroidectomy, the most critical risks are airway obstruction (evidenced by stridor), postoperative hemorrhage causing hematoma (evidenced by frequent swallowing as blood pools), and hypocalcemia from parathyroid damage (evidenced by circumoral paresthesia). These findings signify potential life-threatening emergencies that require immediate escalation to the RN for rapid intervention.

Step-by-Step Solution

Analyze the surgical procedure and its specific risks.

Total thyroidectomy carries high risks for airway compromise (due to neck swelling or hematoma) and hypocalcemia (due to parathyroid gland damage).

Identifying procedural risks helps distinguish between expected postoperative findings and emergent complications.

Evaluate each finding against known airway complications.

Stridor (harsh respiratory sound) indicates airway obstruction, and frequent swallowing indicates internal bleeding/hematoma formation. Both require immediate escalation.

Airway patency is the highest priority (ABC framework) in post-operative care.

Evaluate each finding against known metabolic complications.

Numbness and tingling around the mouth (circumoral paresthesia) is a classic early sign of hypocalcemia. A calcium level of 9.2 mg/dL is normal.

Prompt recognition of hypocalcemia prevents progression to tetany or seizures.

Identify expected postoperative findings.

Mild pain (4/10) and small amounts of serosanguineous drainage (15 mL) are normal and do not require emergency escalation.

Differentiating normal recovery from complications prevents inappropriate escalation of care.

Key Concept

Postoperative monitoring for a thyroidectomy requires vigilant assessment for airway compromise (stridor, hematoma) and parathyroid damage (hypocalcemia).

Question 137Question →

A practical nurse is preparing to provide oral hygiene to a client who is comatose following a traumatic brain injury. Arrange the following actions in the order the nurse should perform them to ensure client safety and comfort. All options must be used.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first position the client laterally, then place the towel and basin, insert the padded tongue blade, cleanse the mouth while suctioning, and finally apply lip lubricant.

When providing oral hygiene to an unconscious or comatose client, the greatest risk is aspiration of fluids or secretions into the lungs because the client lacks an intact swallowing and gag reflex. Therefore, the nurse must first turn the client to a lateral (side-lying) position so that fluids naturally drain out of the mouth. Once the airway is protected, the nurse prepares the area with a towel and basin. A padded tongue blade is then used to safely keep the mouth open without risking injury. The nurse cleans the mouth while immediately suctioning any fluids to further prevent aspiration. Finally, water-soluble lubricant is applied to protect the lips from drying and cracking.

Step-by-Step Solution

Determine the highest priority action based on the client's neurological status.

Positioning the client in a lateral (side-lying) position is identified as the first and most critical step.

A comatose client lacks an intact gag reflex. Airway protection is the absolute priority; the lateral position allows fluids to drain out of the mouth by gravity, preventing aspiration.

Identify the preparatory steps for the procedure.

Placing a towel and emesis basin is identified as the second step.

After the client is in a safe position, the nurse protects the client's gown and bed linens from secretions and cleaning solutions.

Determine the safest method to access the oral cavity.

Inserting a padded tongue blade is selected as the third step.

Unconscious clients may reflexively bite down. The nurse must never insert fingers into the client's mouth. A padded tongue blade safely keeps the mouth open for cleaning.

Sequence the core intervention of oral care.

Cleansing the oral cavity while actively suctioning is identified as the fourth step.

Once the mouth is safely open, the nurse cleans the teeth and gums. Continuous or frequent suctioning is required to remove introduced fluids and loosened secretions.

Identify the final comfort measure.

Applying a water-soluble lubricant to the lips is the final step.

After the oral cavity is cleaned and secretions are removed, applying lubricant prevents drying, cracking, and potential tissue breakdown of the lips.

Key Concept

Airway protection and aspiration prevention during dependent oral care

Question 138Question →

A practical nurse (PN) is caring for a 74-year-old client who has been receiving continuous nasogastric (NG) tube suctioning for the past 48 hours due to a small bowel obstruction. Which of the following assessment findings indicate a potential complication and should be reported immediately to the registered nurse (RN)? Select all that apply.

Select all that apply

Apical pulse of 112 beats/min with thready peripheral pulses

New onset of agitation and disorientation to time and place

Client reports of severe leg cramps and generalized muscle weakness

Hypoactive bowel sounds auscultated in all four abdominal quadrants

Urine output of 150 mL collected in the indwelling catheter over the past 4 hours

Capillary refill time of 2 seconds in the bilateral upper extremities

Show answer & explanation

Answer: Apical pulse of 112 beats/min with thready peripheral pulses; New onset of agitation and disorientation to time and place; Client reports of severe leg cramps and generalized muscle weakness

Answer

The abnormal findings that indicate potential complications and require immediate reporting are the apical pulse of 112 beats/min with thready pulses, the new onset of agitation and disorientation, and the reports of severe leg cramps with muscle weakness.

Continuous nasogastric suctioning rapidly depletes the body of fluids and electrolytes, particularly potassium. An apical pulse of 112 beats/min with thready pulses directly points to hypovolemia and impending shock. New-onset agitation and disorientation indicate diminished cerebral perfusion or a profound electrolyte disturbance, requiring emergent evaluation. Severe leg cramps and generalized muscle weakness are classic, immediate indicators of symptomatic hypokalemia. These acute physiological shifts must be reported to the RN for timely intervention.

Step-by-Step Solution

Analyze the client's current treatments and associated risks.

The client is undergoing continuous NG tube suctioning, which removes significant amounts of fluid, stomach acid, and electrolytes (especially potassium).

Identifying the therapy's physiological impact helps anticipate specific complications like fluid volume deficit, hypokalemia, and metabolic alkalosis.

Evaluate each assessment finding against normal limits and expected disease manifestations.

Tachycardia/thready pulses, acute confusion, and muscle cramping are abnormal and indicate deterioration. Hypoactive bowel sounds, 150 mL urine output over 4 hours, and a 2-second capillary refill are expected or normal findings.

Differentiating between expected findings of a bowel obstruction and acute signs of systemic instability is essential for safe prioritization.

Select the findings that reflect physiological instability.

The circulatory, neurological, and electrolyte-related abnormalities are identified as the priority complications to report.

Acute changes affecting ABCs (circulation/perfusion) and severe electrolyte shifts fall outside the PN scope of independent management and require RN intervention.

Key Concept

Recognizing systemic complications of fluid and electrolyte depletion

Question 139Question →

A licensed practical nurse (LPN) is assigned to a client who had a total hip arthroplasty the previous day. Upon entering the room, the LPN observes that the client is pale, restless, and diaphoretic. The electronic health record indicates a morning hemoglobin level of 7.9 g/dL, which is a significant decrease from the post-operative value of 10.8 g/dL. Current vital signs include a heart rate of 116 beats per minute and a blood pressure of 90/56 mm Hg. What is the most appropriate initial action for the LPN to take?

Increase the rate of the continuous intravenous fluid infusion to improve blood pressure.

Administer the client's scheduled oral analgesic to promote comfort and reduce restlessness.

Promptly notify the supervising registered nurse about the client's current status.

Record the vital signs and hemoglobin drop in the chart for the provider to review during rounds.

Show answer & explanation

Answer: Promptly notify the supervising registered nurse about the client's current status.

Answer

The most appropriate initial action is to promptly notify the supervising registered nurse about the client's current status.

The client is exhibiting classic signs of hypovolemic shock (tachycardia, hypotension, restlessness, diaphoresis) and internal bleeding (dropping hemoglobin) following major surgery. The LPN's priority action when identifying an unstable, deteriorating client is to immediately notify the supervising registered nurse or healthcare provider so that life-saving interventions can be initiated.

Step-by-Step Solution

Analyze the client's clinical presentation, vital signs, and laboratory data.

The client displays tachycardia, hypotension, restlessness, diaphoresis, and a dropping hemoglobin level.

Identifying these cues is essential to recognize early signs of hypovolemic shock caused by post-operative hemorrhage.

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

The most critical action is to immediately escalate these life-threatening findings.

The LPN must collaborate with the registered nurse or provider when a client becomes unstable, as managing shock requires advanced interventions.

Key Concept

Recognizing early signs of shock and escalating critical findings

Estimated Time:1m 0s

Question 140Question →

An 8-year-old client weighing $39.6\text{ lb}$ is being treated for a severe respiratory infection in an outpatient clinic. The healthcare provider prescribes cefdinir oral suspension at $40\text{ mg/kg/day}$ to be administered in equally divided doses every $8\text{ hours}$ . The pharmacy dispenses a reconstituted suspension with a concentration of $250\text{ mg}/5\text{ mL}$ . How many milliliters will the nurse administer for a single dose?

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

Show answer & explanation

Answer: 4.8

Answer

4.8

The correct calculation requires sequential conversion: establishing the weight in kg, determining the 24-hour milligram total, dividing by the number of daily administrations (every 8 hours = 3 doses), and utilizing dimensional analysis with the dispensed concentration to find the liquid volume per dose.

Step-by-Step Solution

Convert the client's weight from pounds to kilograms.

18\text{ kg}

The medication dosage is prescribed in mg/kg, requiring the weight to be in metric units (

39.6\text{ lb} \div 2.2 = 18\text{ kg}

Calculate the total daily medication requirement.

720\text{ mg/day}

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

18\text{ kg} \times 40\text{ mg/kg/day} = 720\text{ mg/day}

Calculate the amount of medication required for a single dose.

240\text{ mg/dose}

The medication is given every 8 hours, which equals 3 doses per 24-hour period. Divide the daily total by 3 (

720\text{ mg} \div 3 = 240\text{ mg/dose}

Calculate the volume in milliliters to administer for one dose.

4.8\text{ mL}

Use the formula (Desired / Have) * Volume.

(240\text{ mg} \div 250\text{ mg}) \times 5\text{ mL} = 0.96 \times 5\text{ mL} = 4.8\text{ mL}

Key Concept

Weight-based pediatric dosage calculation and liquid medication volume conversion.

Estimated Time:2m 0s

PreviousPage 7 / 66Next

Physiological Integrity

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Answer

Step-by-Step Solution

Key Concept