Physiological Integrity

A practical nurse (PN) is reviewing the electronic health record of a client scheduled to receive a routine dose of oral warfarin. The client's morning International Normalized Ratio (INR) is 5.2. Current vital signs reveal a heart rate of 108 beats/min and a blood pressure of 96/58 mm Hg. Which action should the PN take to reduce the client's risk of complications?

A 4-year-old pediatric client is admitted to the pediatric unit with a high fever. The healthcare provider prescribes ibuprofen $8\text{ mg/kg}$ orally every 6 hours as needed for temperature greater than $101.5^\circ\text{F}$ ($38.6^\circ\text{C}$). The client's current weight is documented as $41.8\text{ lbs}$. The unit stocks ibuprofen oral suspension at a concentration of $100\text{ mg}/5\text{ mL}$. How many mL should be administered for one dose? Record the answer to the nearest tenth. Do not include units in the answer.

An 80-year-old client is admitted to the medical-surgical unit with melena and a suspected upper gastrointestinal bleed. The practical nurse (PN) observes that the client has become suddenly restless, is attempting to get out of bed, and states, 'I have to go to work now.' The client's resting apical pulse is 114 beats/minute. Which action should the PN take first?

During morning care at a rehabilitation center, a practical nurse is providing care for a resident who underwent a right above-the-knee amputation three days ago. To prevent the development of a hip flexion contracture, which positioning strategy is most appropriate for the nurse to implement?

A practical nurse is preparing to administer a scheduled fentanyl transdermal patch to a client managing chronic pain. The client has an existing patch on their right upper chest that was applied 72 hours ago. Which sequence of actions by the nurse demonstrates the safest medication administration technique?

Morning rounds are being conducted on a medical unit for a client undergoing treatment for a deep vein thrombosis. The client is currently receiving a continuous infusion of unfractionated heparin. The client's most recent laboratory results reveal an activated partial thromboplastin time (aPTT) of 115 seconds. During data collection, the client's heart rate is noted at 102 beats per minute with a blood pressure of 98/60 mm Hg. What is the priority action for the practical nurse in this situation?

A client is receiving care on an orthopedic unit following a closed pelvic fracture sustained in a fall. During evening rounds, the licensed practical nurse notes the following vital signs: blood pressure 96/62 mm Hg, heart rate 118 beats/min, respiratory rate 18 breaths/min, and oral temperature 98.8°F (37.1°C). Which nursing action is the most appropriate next step?

An inpatient psychiatric unit receives morning laboratory results for a client managed on oral clozapine therapy. The report shows a white blood cell (WBC) count of $1,800/\text{mm}^3$ and an absolute neutrophil count (ANC) of $400/\text{mm}^3$. Upon entering the room for morning care, the client complains of a painful sore throat and has an oral temperature of $100.8^\circ\text{F}$ ($38.2^\circ\text{C}$). Based on these findings, which action is most appropriate for the practical nurse to perform?

A practical nurse is providing basic care for a client who is on strict bed rest following a carotid endarterectomy complicated by an ischemic stroke with left-sided hemiparesis. Which of the following actions should the nurse include in the client's daily care? Select all that apply.

While conducting hourly rounds, a practical nurse (PN) responds to a call light from the spouse of an 84-year-old client being treated for pneumonia. The spouse reports the client has suddenly become disoriented and is trying to remove their intravenous line. The PN notes the client is extremely restless, with a heart rate of 110 bpm and a blood pressure of 98/60 mm Hg. Which action should the PN take first?

A practical nurse (PN) is preparing to administer a scheduled hepatitis B vaccine intramuscularly to a 6-month-old infant. The infant's parent reports that the child started taking a prescribed oral antibiotic yesterday for a mild ear infection, although the infant currently has no fever. What is the most appropriate action by the PN?

A client recovering from an ischemic stroke is receiving a continuous enteral tube feeding. The client suddenly develops a forceful cough, perioral cyanosis, and audible wheezing. In what order should the practical nurse (PN) perform the following actions? (Arrange the items in the correct chronological sequence from first to last.)

Two hours after a right femoral cardiac catheterization, a client reports a new onset of dull lower back pain. The practical nurse notes the right groin dressing is dry and intact with no visible hematoma, and distal pulses remain equal bilaterally. The client's vital signs are: temperature 98.6°F (37°C), heart rate 108/min, respirations 18/min, and blood pressure 104/62 mm Hg. Baseline vital signs prior to the procedure were heart rate 74/min and blood pressure 128/78 mm Hg. What is the most appropriate next action for the practical nurse?

A practical nurse (PN) is preparing to administer a scheduled dose of oral furosemide to a client admitted with heart failure exacerbation. The client's morning vital signs include a blood pressure of 94/56 mm Hg and a heart rate of 112 beats/min. A recent laboratory report indicates a serum potassium level of 2.6 mEq/L. Which action is the priority for the PN?

A practical nurse (PN) is caring for a 78-year-old client who is prescribed daily oral digoxin and furosemide for the management of heart failure. During the morning assessment, the PN notes the client has become acutely restless and reports seeing "yellow halos" around the room lights. The client's morning laboratory results reveal a serum potassium level of 3.1 mEq/L (3.1 mmol/L), and the current apical pulse is 56 beats/minute. Which of the following is the priority action for the PN to take?

An unlicensed assistive personnel informs the registered nurse (RN) that a postoperative client is experiencing severe pain. The RN, who is occupied with a new admission, hands a filled syringe to the practical nurse (PN) and asks the PN to administer the intravenous (IV) push morphine to the client. Which statement by the PN is the most appropriate response?

A practical nurse (PN) is observing a client who is receiving a transfusion of packed red blood cells. Ten minutes into the transfusion, the client reports sudden lower back pain, chills, and shortness of breath. In what order should the PN perform the following actions to minimize client risk?

A 74-year-old client is admitted with an exacerbation of chronic obstructive pulmonary disease (COPD) and is receiving oxygen at 2 L/min via nasal cannula. During a routine check, the practical nurse (PN) observes that the client is newly agitated, attempting to pull off the oxygen tubing, and confused about their location. The client's heart rate is 108 beats/min and blood pressure is 102/64 mm Hg. Which action should the PN take first?

A licensed practical nurse (LPN) is assisting with the care of a client who is 6 hours postoperative following a subtotal thyroidectomy. Which of the following nursing actions are appropriate to reduce the client's risk for complications? Select all that apply.

An older adult client is recovering in the surgical unit 4 hours after an exploratory laparotomy. The practical nurse (PN) reviews the client's current clinical status. Which of the following findings indicate an expected post-operative progression? Select all that apply.