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A practical nurse is reviewing the medication administration record for a client who is 24 hours postoperative following a bowel resection. The client is scheduled to receive oral metoprolol. Current vital signs are: blood pressure 92/58 mm Hg, apical pulse 116 beats/min, and respirations 22 breaths/min. The client's urine output for the last 4 hours was 85 mL. Which action should the practical nurse take first?
A client with end-stage renal disease is admitted to a medical-surgical unit. The client recently established an advance directive designating their adult child as the durable power of attorney for healthcare (DPOA). The client, who is fully alert and oriented, tells the practical nurse, "I do not want to go to my hemodialysis treatment today or ever again." The adult child arrives shortly after and demands that the nurse arrange for transport to dialysis, stating, "I am the DPOA, and I make the medical decisions now." Which action should the practical nurse take?
The practical nurse (PN) is collecting data on a client who is 4 hours postpartum following a vaginal delivery of a large-for-gestational-age newborn. Which assessment findings indicate a complication of physiological adaptation requiring immediate notification of the registered nurse (RN)? Select all that apply.
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A practical nurse (PN) is providing care for a client who is 12 hours postoperative following a total thyroidectomy. Which of the following actions by the PN demonstrate appropriate risk reduction and clinical prioritization? Select all that apply.
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A practical nurse (PN) is caring for a 78-year-old client who was admitted with a fractured femur and is receiving scheduled doses of oral oxycodone for pain management. During the night shift, the PN finds the client newly agitated, picking at the bedsheets, and unable to recognize family members. The client's vital signs are blood pressure 102/68 mm Hg, heart rate 94 beats/min, respiratory rate 11 breaths/min, and oxygen saturation 89% on room air. The client's family requests the next dose of pain medication to calm the client. Which action should the PN take first?
A client is receiving rehabilitation on a medical-surgical unit following a right total knee arthroplasty. The nurse is observing the client use a standard, non-rolling walker for ambulation. Arrange the steps of the walking sequence in the correct order to ensure safe equipment use. All options must be used.
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While checking on a client who underwent a subtotal thyroidectomy earlier in the shift, the practical nurse observes that the client is unusually restless. The client points to the surgical area and whispers, "It feels really tight in my neck." Which action should the nurse take first?
The healthcare team is managing the recovery of a client who underwent a left total knee arthroplasty the previous day. The client is receiving continuous epidural analgesia and requires assistance with daily activities. Which interventions are appropriate for the practical nurse to incorporate into the client's basic care routine? Select all that apply.
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A practical nurse is caring for a client who is 24 hours postoperative following a left-sided modified radical mastectomy with axillary lymph node dissection. Which of the following interventions should the nurse include in the client's care plan? Select all that apply.
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A newly admitted client with a history of severe osteoporosis and bilateral cataracts is starting a prescribed loop diuretic regimen. The client has limited mobility and uses a rolling walker. Which actions are appropriate for the practical nurse (PN) to take regarding this client's safety and care? (Select all that apply.)
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A practical nurse (PN) is employed at an outpatient specialty clinic that heavily utilizes electronic health records (EHR) and digital communication. Which actions by the PN demonstrate correct adherence to client confidentiality and information security standards? Select all that apply.
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A practical nurse (PN) is providing basic care and comfort for an older adult client who returned to the unit 4 hours ago following a right femoral cardiac catheterization. The client has a history of mild dementia and requires assistance with activities of daily living (ADLs). Which actions should the PN include in the plan of care? (Select all that apply.)
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An 18-month-old toddler is brought to the pediatric clinic for a scheduled health maintenance visit. When gathering anthropometric and developmental data, which action should the practical nurse take?
A practical nurse (PN) is preparing to administer scheduled morning medications, including oral pantoprazole and oral metoprolol, to a client admitted ago with an upper gastrointestinal bleed. The client states, "My stomach hurts a little, but I am mostly just very dizzy." The client's current vital signs are: blood pressure , heart rate , respirations , and oxygen saturation on room air. Based on this data, which action should the PN take first?
A practical nurse (PN) is caring for a client with acute mania who is exhibiting escalating psychomotor agitation in the dayroom. The client is pacing rapidly, speaking loudly, and invading the personal space of other clients. Arrange the following behavioral interventions in the order they should be implemented, from the least restrictive to the most restrictive.
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A practical nurse (PN) is preparing to witness the signature on an informed consent form for a planned biopsy on an older adult client who speaks only Mandarin. The client's adult son, who speaks fluent English, approaches the PN and states, "Please do not tell my father this procedure is to check for cancer. In our culture, discussing a serious illness brings bad energy and destroys hope. I will sign the consent form for him." Which response by the PN is most appropriate?
A practical nurse (PN) is caring for an 82-year-old client with moderate-stage dementia who is 2 days post-operative following a hip replacement. The client is currently pacing the room, yelling intermittently, and swatting at staff members who approach. When selecting a data collection technique to evaluate the client's current comfort level, which approach is most appropriate for the PN to take?
A 68-year-old client is on bed rest in skeletal traction after suffering a fractured femur. During mid-afternoon rounding, the client appears anxious, shifts frequently in bed, and expresses intense thirst. Vital signs collected at this time show a heart rate of 112 beats/min, blood pressure of 102/66 mm Hg, and a respiratory rate of 24 breaths/min. The baseline vitals taken upon arrival were a heart rate of 82 beats/min, blood pressure of 130/76 mm Hg, and a respiratory rate of 16 breaths/min. Which action should the practical nurse prioritize?
While conducting a health screening at a community clinic, a practical nurse observes multiple symmetrical, circular burns on the posterior thighs of a 6-year-old client. The child's parent claims the child accidentally sat on a hot metal grate while playing at a park. Which of the following actions is the priority for the nurse to take?
A practical nurse (PN) enters a client's room and finds the client lying on the floor. The client is awake, responsive, and states, 'I tried to walk to the bathroom, but my legs gave out.' In which order should the PN perform the following actions? Arrange the actions from first priority to last.
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