Physiological Integrity

Three hours after a percutaneous liver biopsy, a client reports feeling mildly anxious and complains of a steady ache in the right upper quadrant. When collecting data, the practical nurse notes the client has cool, clammy skin. Current vital signs are heart rate 108 bpm, respirations 22/min, and blood pressure 102/66 mm Hg. Baseline vital signs prior to the procedure were heart rate 74 bpm, respirations 14/min, and blood pressure 134/80 mm Hg. What is the priority action for the practical nurse to take?

Following a diagnostic cardiac catheterization via the right femoral artery, a client is recovering on the telemetry unit. Later in the shift, the client activates the call light and complains of a new, constant, dull ache in the lower back. The practical nurse assesses the client and compares current vital signs with previous documentation:

Which action should the practical nurse take first?

During morning medication rounds, a practical nurse (PN) assesses a client with heart failure prior to administering a scheduled dose of oral digoxin. The client's current apical pulse is $56 \text{ beats/min}$, and the most recent laboratory report reveals a serum potassium level of $3.1 \text{ mEq/L}$. Based on these findings, which action should the PN take?

A client who recently returned to the clinical unit following an open appendectomy begins to actively vomit. The client is currently resting in bed in a semi-Fowler's position. Which immediate action should the practical nurse take to ensure the client's safety and comfort?

A practical nurse (PN) and a registered nurse (RN) are co-assigned to care for a client with acute heart failure. The primary healthcare provider prescribes furosemide $40\text{ mg}$ intravenous (IV) push stat. The RN prepares the medication in a syringe, hands it to the PN, and says, "The client's potassium is $3.8\text{ mEq/L}$. Can you push this while I admit a new client?" What is the most appropriate action by the PN?

A practical nurse (PN) is providing care for an older adult client admitted with severe community-acquired pneumonia. During the morning assessment, the client appears increasingly lethargic. The PN obtains the following vital signs: Temperature 100.4°F (38.0°C), Heart rate 116 bpm, Respiratory rate 24 breaths/min, and Blood pressure 86/54 mmHg. The morning laboratory results reveal a white blood cell (WBC) count of $18,000/\text{mm}^3$ ($18 \times 10^9/\text{L}$) and a serum lactate level of $4.2\text{ mmol/L}$ (normal: $0.5$ to $1.0\text{ mmol/L}$). Which of the following actions should the PN take? Select all that apply.

A practical nurse (PN) is providing care for an older adult client who suddenly develops a moist cough, increased work of breathing, and new-onset confusion while receiving a continuous intravenous fluid infusion. Which of the following actions should the PN take? Select all that apply.

A client with a mechanical bowel obstruction has been receiving continuous gastric decompression via a nasogastric (NG) tube for three days. During morning data collection, the client reports generalized muscle weakness, severe calf cramps, and a "skipping" sensation in the chest. Which action should the practical nurse take first?

A client with chronic stable angina is scheduled to receive a new transdermal nitroglycerin patch. What is the correct sequence of actions the practical nurse (PN) must take to safely administer this medication? Arrange the following steps in the correct chronological order.

A licensed practical nurse is assigned to care for a client recovering from a right total hip arthroplasty (posterior approach) performed yesterday. The client requires assistance with hygiene, mobility, and comfort. Which actions are appropriate for the nurse to include in the plan of care? Select all that apply.

An 82-year-old client is 8 hours post-operative following the surgical repair of a fractured femur. During the evening rounds, the practical nurse notes the client has become suddenly restless, slightly confused, and is picking at the bedsheets. Current vital signs are a blood pressure of 106/64 mm Hg, a heart rate of 118 beats/min, and a respiratory rate of 24 breaths/min. The client's baseline preoperative vital signs were a blood pressure of 138/76 mm Hg and a heart rate of 82 beats/min. Which action should the practical nurse take first?

An adult client is receiving treatment for a fluid and electrolyte imbalance. The client's medication administration record includes a scheduled daily dose of oral potassium chloride 20 mEq. Upon reviewing the morning electronic health record, the nurse notes a serum potassium level of $5.8 \text{ mEq/L}$. Based on these findings, what is the appropriate action for the practical nurse (PN) to take?

A client is recovering on the surgical unit 4 hours after undergoing a laparoscopic cholecystectomy. The client reports right shoulder discomfort and a feeling of tightness in the abdomen. The most recent vital signs reveal a temperature of 99.2°F (37.3°C), a heart rate of 106/min, a blood pressure of 102/64 mm Hg, and a respiratory rate of 20/min. Preoperative baseline vital signs were a heart rate of 74/min and a blood pressure of 136/78 mm Hg. Which action should the practical nurse take first?

A practical nurse (PN) is reviewing the electronic health record (EHR) of a $72$-year-old client prior to morning medication administration.

Based on the provided data, which of the following actions reflect safe pharmacological practice by the PN? Select all that apply.

While monitoring a client admitted with a right leg deep vein thrombosis (DVT), a practical nurse (PN) reviews the client's response to a continuous intravenous heparin infusion. Which assessment findings indicate a high risk for life-threatening complications and require immediate escalation to the registered nurse (RN)? Select all that apply.

A 78-year-old client is recovering on the surgical unit 48 hours after a bowel resection. The practical nurse enters the room and finds the client restless and newly disoriented to place. The client's family member states, "I think the surgical pain is just keeping him awake." The client's current vital signs are a heart rate of 114 beats/min, a blood pressure of 96/54 mm Hg, and a respiratory rate of 22 breaths/min. Which action should the practical nurse prioritize?

During the second postoperative day following a right below-the-knee amputation, a client requires positioning assistance to prevent musculoskeletal complications. Which action by the practical nurse best supports the client's physical comfort and mobility goals?

A clinical team is managing a client who was admitted with a suspected upper gastrointestinal hemorrhage. A practical nurse (PN) is providing care during the day shift. Which of the following actions by the PN demonstrate appropriate risk reduction and safe clinical practice? (Select all that apply.)

A school-aged child who weighs $33\text{ lbs}$ requires antipyretic therapy. The healthcare provider prescribes oral ibuprofen at $10\text{ mg/kg/dose}$ every $6\text{ hours}$. The pharmacy dispenses an ibuprofen oral suspension with a concentration of $100\text{ mg}$ per $5\text{ mL}$. Calculate the volume, in milliliters ($\text{mL}$), the practical nurse should administer for a single dose. Record the answer to the nearest tenth. Do not include units in your answer.

A practical nurse (PN) is inserting a nasogastric (NG) tube for a client with a bowel obstruction. To reduce the risk of respiratory trauma and aspiration, arrange the following procedural steps in the correct chronological order.