Physiological Integrity

While planning care for a client who underwent a left below-the-knee amputation 48 hours ago, the practical nurse considers interventions to promote mobility and prevent musculoskeletal complications. Which actions should be included in the client's care plan? Select all that apply.

A practical nurse is assisting with the care of a client who underwent a bedside left-sided thoracentesis $1\text{ hour}$ ago. During the current assessment, the client appears highly restless and reports a sudden increase in shortness of breath. The client's vital signs are: blood pressure $102/64\text{ mm Hg}$ (baseline $138/82\text{ mm Hg}$), heart rate $114\text{ beats/min}$, and respiratory rate $28\text{ breaths/min}$. The nurse notes asymmetrical chest wall expansion and a subtle deviation of the trachea to the right. Which action should the practical nurse take first?

A licensed practical nurse (LPN) is reviewing the electronic health record of a client admitted with a mechanical small bowel obstruction. The client has a nasogastric (NG) tube connected to low continuous wall suction, which has drained 1,800 mL of fluid over the last 24 hours. Which assessment finding represents the greatest potential for a life-threatening complication and requires immediate reporting to the registered nurse?

A practical nurse (PN) is preparing to obtain a capillary blood glucose reading for a client with type 2 diabetes mellitus. To ensure an accurate result and reduce the risk of infection, in what order should the PN perform the following actions? (Arrange the steps in the correct sequence.)

A client is recovering on the surgical unit following an abdominal procedure and receives a prescribed dose of intravenous morphine for severe pain. Shortly after, the practical nurse (PN) finds the client minimally responsive with a respiratory rate of 7 breaths/min. The PN immediately summons the registered nurse (RN), who administers intravenous naloxone. Fifteen minutes later, the client is fully awake and breathing at 16 breaths/min. Which action should the PN prioritize next?

A practical nurse (PN) is caring for a client with a history of heart failure who is receiving a continuous intravenous (IV) infusion of 0.9% sodium chloride at 150 mL/hr for mild dehydration. During data collection, the PN notes the client's heart rate has increased from 80 to 118 bpm, and blood pressure has risen from 110/70 to 160/90 mmHg. The client becomes newly restless and states, "My chest feels tight and I cannot catch my breath." Which action should the PN take first?

A practical nurse (PN) in a pediatric clinic is preparing to administer the first dose of oral amoxicillin to a toddler diagnosed with acute otitis media. The toddler weighs $33\text{ lbs}$. The primary healthcare provider has prescribed $45\text{ mg/kg/day}$ of amoxicillin, to be administered in two equally divided doses every $12\text{ hours}$. The clinic pharmacy dispenses amoxicillin oral suspension at a concentration of $250\text{ mg}/5\text{ mL}$. How many milliliters ($\text{mL}$) should the PN administer for this single dose? Record your answer to the nearest tenth. Do not include units in your answer.

A practical nurse (PN) is preparing to administer an iron dextran intramuscular (IM) injection using the Z-track method to a client with severe iron deficiency anemia. The PN has already identified the client, donned gloves, cleansed the site, and prepared the syringe. In which order should the PN perform the following steps? (Arrange the actions from first to last)

A practical nurse is preparing to transfer a client with left-sided hemiparesis from the bed to a wheelchair. In what order should the nurse perform the following actions? Arrange the steps in the correct sequence.

While working in an endoscopy recovery unit, a practical nurse evaluates a client who underwent a colonoscopy with a polypectomy two hours prior. The client complains of a sudden onset of severe, sharp abdominal pain. During the assessment, the nurse palpates a firm, board-like abdomen and observes that the client's heart rate has increased from a pre-procedure baseline of 74 beats per minute to 118 beats per minute. Which action should the nurse take first?

An assigned client with peripheral edema and a history of heart failure is scheduled to receive a routine morning dose of oral torsemide. Review of the electronic health record reveals a morning serum potassium level of 2.7 mEq/L and a blood pressure of 108/64 mm Hg. What is the priority action for the practical nurse?

An 82-year-old client is admitted to the medical-surgical unit with a severe systemic infection and is prescribed scheduled doses of intravenous (IV) piggyback gentamicin and oral levofloxacin. During the morning assessment, the practical nurse (PN) observes that the client, who was alert and oriented the previous evening, is now highly agitated and disoriented to time and place. The client's morning laboratory results reveal a serum creatinine of 2.8 mg/dL (baseline was 0.9 mg/dL on admission). Which action should the PN take first regarding the client's care and scheduled medications?

A practical nurse (PN) is monitoring a client admitted with acute gastroenteritis and frequent episodes of vomiting. During the most recent data collection, the PN notes the client's blood pressure has decreased from 124/80 mm Hg to 98/62 mm Hg, and the heart rate has increased from 86 beats/min to 118 beats/min. The client's skin is cool and clammy. Which action is the priority for the PN to take?

A licensed practical nurse (LPN) is monitoring a client who underwent a percutaneous liver biopsy $2$ hours ago. The client is resting quietly in the right lateral position. The LPN obtains the following current vital signs: blood pressure $108/66$ mm Hg, heart rate $104$ beats/min, and respiratory rate $20$ breaths/min. The client's pre-procedure vital signs were blood pressure $132/76$ mm Hg, heart rate $74$ beats/min, and respiratory rate $16$ breaths/min. Which action should the LPN take next?

An 8-year-old child weighing $55$ lb is prescribed oral cefdinir. The prescribed dose is $14$ mg/kg/day, to be administered in two divided doses every $12$ hours. The pharmacy dispenses cefdinir oral suspension at a concentration of $250$ mg/$5$ mL. How many milliliters (mL) will the practical nurse administer for a single dose? Record your answer using one decimal place. Do not include units in your answer.

During a morning assessment, a client receiving continuous total parenteral nutrition (TPN) appears diaphoretic and exhibits sudden confusion. The client's capillary blood glucose level is $42$ mg/dL. The client's medication administration record includes a PRN prescription for $50$ mL of $50\%$ dextrose in water (D50W) intravenous (IV) push for severe hypoglycemia. Based on the practical nurse scope of practice, which action is most appropriate?

An outpatient clinic has requested a 24-hour urine collection for a client being evaluated for nephropathy. The client is currently staying in a short-term rehabilitation unit. How should the nurse sequence the steps to ensure an accurate specimen collection? Arrange the actions in the correct chronological order.

A practical nurse (PN) is assisting a client who has a right-sided chest tube to change positions in bed. Suddenly, the chest tube is completely pulled out of the client's chest wall. Arrange the following immediate nursing actions in the correct chronological order.

A newly admitted client experiencing severe constipation is prescribed a warm tap water enema. The equipment has been gathered and the solution is prepared in the enema bag. Arrange the following steps in the correct chronological sequence to safely administer the enema.

A practical nurse is preparing to administer prescribed oral acetaminophen to a pediatric client experiencing a fever. The healthcare provider has prescribed $240$ mg to be given every $6$ hours as needed. The medication is available in a liquid concentration of $160$ mg/$5$ mL. Which action describes the safest and most appropriate procedure for the practical nurse to follow?