Physiological Integrity

A 78-year-old client is recovering in the surgical unit six hours after a transurethral resection of the prostate (TURP). The practical nurse (PN) observes that the client is newly restless and asking repetitive questions about his location. Vital signs reveal a heart rate of 112 beats/min and a blood pressure of 98/62 mm Hg. The client's preoperative vital signs were a heart rate of 76 beats/min and a blood pressure of 138/82 mm Hg. Which action is the priority for the PN?

A licensed practical nurse is evaluating an adolescent client who arrived on the surgical unit three hours ago following a tonsillectomy. The client is observed to be swallowing continuously. The current vital signs reveal a heart rate of $118$ beats per minute and a blood pressure of $102/64$ mm Hg. Which action is the priority for the nurse to take?

A practical nurse is providing basic care for an older adult client who had a left-sided mastectomy with axillary lymph node dissection 24 hours ago. The client reports aching, a feeling of heaviness, and stiffness in the left arm. Which nonpharmacological action should the nurse take to promote comfort and reduce these symptoms?

A practical nurse (PN) is caring for a client who is receiving a continuous intravenous (IV) infusion of Lactated Ringer's for fluid replacement. The healthcare provider's prescription is for $1,000 \text{ mL}$ to infuse over 12 hours. The primary IV tubing has a drop factor of $15 \text{ gtt/mL}$. The registered nurse (RN) has initiated the infusion. At what rate, in drops per minute (gtt/min), should the PN verify the IV is infusing?

*Record your answer to the nearest whole number. Do not include units in your answer.*

A client is resting in bed recovering from a total abdominal hysterectomy performed earlier today. While providing routine comfort and hygiene measures, which actions should the nurse take? (Select all that apply)

During evening rounds at a skilled nursing facility, a practical nurse (PN) evaluates a resident who is currently undergoing oral antibiotic treatment for bacterial pneumonia. Which clinical observation requires the most immediate escalation to the registered nurse?

A practical nurse (PN) is caring for a client who is 4 hours postoperative following an open reduction and internal fixation (ORIF) of a fractured right femur. The client reports increasing incisional pain. The PN obtains the following vital signs: temperature 98.8°F (37.1°C), heart rate 110 beats/min, respiratory rate 20 breaths/min, and blood pressure 102/64 mm Hg. Which action should the PN take first?

A practical nurse is assessing a client who returned from an esophagogastroduodenoscopy (EGD) with a biopsy 2 hours ago. The client reports a mild sore throat but now states, "My stomach feels really tight and painful." The nurse notes the client's abdomen is firm and distended. The current vital signs are: blood pressure $104/58\text{ mmHg}$, heart rate $112\text{ beats/min}$, respiratory rate $22\text{ breaths/min}$, and temperature $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$). Which action should the practical nurse take first?

A pediatric client weighing $33$ lb is prescribed ibuprofen oral suspension $250$ mg every $6$ hours for a fever. The established safe pediatric dosage range for this medication is $5$ to $10$ mg/kg/dose. The pharmacy provides ibuprofen in a concentration of $100$ mg/$5$ mL. Based on this information, which action should the nurse perform?

A practical nurse (PN) is preparing to remove an indwelling urinary catheter from an adult female client. Arrange the following actions in the correct sequence to reduce the risk of trauma and potential complications.

A practical nurse (PN) and an unlicensed assistive personnel (UAP) are preparing to move a partially dependent client up in bed using a draw sheet. In what order should the nurse direct these actions? Arrange the steps from first to last.

A practical nurse (PN) is caring for an older adult client who was admitted with a severe urinary tract infection. The client suddenly becomes highly restless, exhibits a respiratory rate of 28 breaths/min, and has a blood pressure that decreased from 132/80 mm Hg to 96/58 mm Hg. Which actions should the PN take in this situation? Select all that apply.

An older adult client is hospitalized for the medical management of a bleeding gastric ulcer. The client is receiving a continuous intravenous infusion of normal saline. During morning rounds, the practical nurse assesses a heart rate of 118 beats per minute, a blood pressure of 92/58 mm Hg, and notes that the client appears pale and reports feeling dizzy. Which action should the practical nurse take first?

An 81-year-old client is recuperating on the surgical unit 48 hours after a pelvic fracture repair. The client's visiting family member alerts the nursing staff, stating the client is suddenly acting agitated and asking when the train is arriving. The client's current vital signs show a heart rate of 106 beats/min, a respiratory rate of 22 breaths/min, a blood pressure of 104/64 mmHg, and an oxygen saturation of 91% on room air. Which action should the practical nurse (PN) take first?

A female client is transferred to the medical-surgical floor immediately after undergoing a percutaneous liver biopsy in the radiology department. As the practical nurse helps the client settle into bed for the mandatory recovery phase, which position is most appropriate to implement?

A practical nurse is providing care for a client with hepatic cirrhosis who underwent a therapeutic paracentesis for severe ascites three hours prior. The nurse reviews the client's current clinical data compared to baseline:

Based on these findings, which action is the priority for the nurse to perform?

A practical nurse (PN) is caring for an adult client with a history of a seizure disorder. The client has no known allergies and their morning vital signs are stable. The provider's prescription states: "phenytoin $300$ mg, PO, every $12$ hours." The pharmacy supplies the medication in a liquid suspension labeled "phenytoin $250$ mg / $5$ mL." Which of the following actions should the PN take to safely administer this medication?

A practical nurse (PN) is assessing a client who is 12 hours postoperative following an open cholecystectomy. Which of the following assessment findings should the PN recognize as expected at this stage of recovery? Select all that apply.

A practical nurse (PN) is preparing to draw up a prescribed medication from a single-dose glass ampule for an intramuscular injection. Arrange the following actions in the correct chronological order to ensure safe medication preparation.

A practical nurse is planning care for an adult client who underwent a right above-the-knee amputation two days ago. Which actions should the nurse implement to promote optimal healing and basic comfort? Select all that apply.