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A client recovering from surgery has an established diagnosis of post-traumatic stress disorder. Suddenly, a heavy equipment cart crashes loudly in the adjacent hallway. The client immediately drops to the floor, curls into a tight position, and begins hyperventilating. Which action is the priority for the practical nurse (PN) to take?
During a follow-up visit at an outpatient pediatric clinic, a mother brings in her 4-day-old neonate who was delivered at 37 weeks gestation. The mother states, "My baby is so sleepy, I have a hard time waking him up to breastfeed, and he has only had two wet diapers since yesterday." The practical nurse notes a yellowish tint to the neonate's sclera and chest, and a slightly depressed anterior fontanelle. Which of the following actions should the practical nurse take? Select all that apply.
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During a routine wellness visit, a practical nurse observes a 12-month-old client interacting with various objects on the examination table. Which specific behavior demonstrates that the infant has achieved an expected developmental milestone for this age?
A practical nurse is providing basic care for a client who is on strict bed rest following a right femoral cardiac catheterization. Which of the following actions should the nurse include in the client's care? Select all that apply.
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A client is transferred to the surgical unit following a right modified radical mastectomy that included an axillary lymph node dissection. When implementing basic care and comfort measures, which action should the practical nurse take regarding the client's right arm?
A practical nurse is preparing 0900 medications for a client with stage 4 chronic kidney disease. The electronic health record indicates the client is prescribed oral carvedilol, lisinopril, and calcium acetate. Morning laboratory results reveal a serum potassium level of and a serum calcium level of . The client's vital signs are blood pressure , heart rate , and respiratory rate . Which action is most appropriate for the practical nurse to take?
During a morning medication pass on a medical-surgical unit, a client with heart failure is scheduled to receive oral digoxin and oral furosemide . The client reports experiencing new-onset nausea and states, 'I have not had any appetite since yesterday.' The morning laboratory report indicates a serum potassium level of , and the current apical pulse is 62 beats per minute. Which action should the practical nurse take?
A practical nurse (PN) at a community clinic is caring for a 19-year-old client who discloses frequently mixing large amounts of alcohol with highly caffeinated energy drinks at weekend parties, which recently resulted in a blackout. Which of the following actions by the PN are appropriate? Select all that apply.
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A client receives a new diagnosis of advanced pancreatic cancer from the healthcare provider. Later that afternoon, the client presents the practical nurse (PN) with a binder of medical research articles and spends the interaction calmly asking highly technical questions about the cellular mechanisms of various chemotherapy agents. Which of the following is the most appropriate action by the PN?
A practical nurse (PN) enters the room of a client who was recently admitted to a hospice facility. The client's sibling is sitting at the bedside crying and states, "I do not know what I am going to do without them. We have lived together for over 60 years." Arrange the PN's actions in the most appropriate therapeutic sequence. All options must be used.
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Following a total knee arthroplasty, an older adult client's baseline preoperative vital signs were a blood pressure of mm Hg and a resting heart rate of beats per minute. Four hours postoperatively, the practical nurse assesses the client and notes a blood pressure of mm Hg, a heart rate of beats per minute, and a respiratory rate of breaths per minute. The surgical dressing has a moderate amount of sanguineous drainage. Which action should the nurse take next?
Staff members at an assisted living center report that an older adult resident, who is typically cooperative and oriented, has spent the morning pacing the hallways, acting aggressively toward peers, and speaking in disorganized sentences. An unlicensed assistive personnel remarks, "I guess age is finally catching up to her mind." Which action is the priority for the practical nurse to take?
A client with advanced diabetic retinopathy is hospitalized for a systemic infection. In the middle of the night, while the hospital room is entirely dark, the client becomes intensely agitated, attempts to climb over the side rails, and shouts, 'The room is flooding with water, I need to swim out!' Which action should the practical nurse (PN) take first?
A practical nurse is providing care for a client who recently returned to the unit following an esophagogastroduodenoscopy (EGD) with moderate sedation. Which of the following nursing actions should the nurse take to reduce the risk of potential complications? (Select all that apply)
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A client admitted to a medical-surgical unit with pneumonia informs the nurse that they want to cancel their scheduled bronchoscopy and go home. Shortly after, the client's sibling approaches the nurses' station asking for an update on the client's condition. Which actions should the practical nurse take to uphold client rights and maintain confidentiality? (Select all that apply)
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A practical nurse (PN) is co-leading a group activity on an inpatient psychiatric unit. A client suddenly stands up, begins hyperventilating, grips their chest, and says, "I am having a heart attack and I am going to die!" Medical causes have been previously ruled out, and the PN recognizes an acute panic attack. In what order should the PN perform the following actions? Arrange the interventions in the correct sequence from first to last.
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A practical nurse is reinforcing teaching for a client who has a right fractured tibia and is prescribed strict non-weight-bearing status. The client is using axillary crutches and needs to ascend a flight of stairs. In what order should the nurse instruct the client to perform these actions? (Arrange the steps from first to last.)
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A practical nurse is preparing to administer a combination of regular insulin and neutral protamine Hagedorn (NPH) insulin to a client with diabetes mellitus. Arrange the following steps for preparing the mixed insulin injection in the correct chronological order.
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A practical nurse at a community clinic is participating in a health education session for preadolescent females and their caregivers. When reinforcing teaching about the expected physiological transitions of female puberty, the nurse describes the sequence of developmental milestones. Place the following physiological milestones in the chronological order in which they typically occur. (Arrange from first to last)
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A practical nurse (PN) is reviewing the morning data for a 72-year-old client who is 24 hours post-operative following a right total hip arthroplasty. The client is scheduled to receive a morning dose of subcutaneous enoxaparin.
| Assessment Parameter | Preoperative Baseline | Current Morning Data |
|---|---|---|
| Blood Pressure | 138/82 mm Hg | 104/62 mm Hg |
| Heart Rate | 76 beats/min | 98 beats/min |
| Hemoglobin | 13.5 g/dL | 10.1 g/dL |
The client reports feeling dizzy when sitting on the edge of the bed and rates incisional pain as a 4 on a 0 to 10 scale. Based on these findings, which action represents the most appropriate risk reduction strategy for the PN to take?