Physiological Integrity

An adult client is transferred to the step-down unit after undergoing a diagnostic cardiac catheterization utilizing the right femoral artery approach. When managing the client's basic care and comfort during the immediate recovery phase, which positioning intervention should the practical nurse implement?

Fifteen minutes after receiving an intramuscular injection of ceftriaxone for a respiratory infection, a client suddenly reports feeling dizzy and extremely restless. The practical nurse assesses the client and notes a heart rate of $122$ beats per minute and a blood pressure of $84/50\text{ mmHg}$. Which action should the nurse take first?

A client who underwent a left total knee replacement yesterday requires assistance with morning care and positioning. Which actions by the practical nurse demonstrate correct understanding of postoperative comfort and safety measures? Select all that apply.

A practical nurse is conducting a postoperative assessment on a 76-year-old client who underwent a total abdominal hysterectomy four hours ago. Which assessment findings should the nurse identify as expected physiological responses that can be managed with routine ongoing monitoring? Select all that apply.

An older adult client is recovering in the ambulatory care unit immediately following the surgical removal of a cataract in the right eye. To promote optimal comfort and prevent an increase in intraocular pressure, which positioning intervention should the practical nurse implement?

A practical nurse (PN) is assigned to care for a client who is 24 hours postoperative following abdominal surgery and has a closed-wound drainage system (Jackson-Pratt drain). The PN is preparing to empty the drainage device. Arrange the following actions in the correct sequence to safely perform this procedure.

An adult client is receiving a scheduled course of subcutaneous enoxaparin. During data collection, the client reports passing dark, tarry stools. The practical nurse notes that the client's latest laboratory results show a platelet count of $82,000/\text{mm}^3$, and current vital signs include a heart rate of $112\text{ beats/min}$ and a blood pressure of $94/58\text{ mmHg}$. Which of the following is the priority action for the practical nurse?

A client is recovering in the surgical unit $8$ hours after a right total knee arthroplasty. The practical nurse evaluates the client and records a heart rate of $114$ beats/min, a blood pressure of $94/56$ mm Hg, and a respiratory rate of $18$ breaths/min. The client states their pain is currently manageable. Based on these findings, which of the following actions should the practical nurse take? Select all that apply.

While coordinating care on a busy inpatient unit, a practical nurse performs several medication-related tasks throughout the shift. Which of the following actions reflect adherence to established pharmacological safety standards and the appropriate scope of practice? Select all that apply.

A practical nurse is providing basic care for an adolescent client who is on strict bed rest following a spinal fusion surgery for scoliosis. Which of the following actions should the nurse implement to promote comfort and safety? Select all that apply.

During a shift, a practical nurse reviews the medication administration record for a client being treated for a pulmonary embolism. The client weighs $165\text{ lb}$. The provider has prescribed a subcutaneous injection of enoxaparin sodium at $1\text{ mg/kg}$ every $12\text{ hours}$. The medication is supplied in a prefilled syringe containing $100\text{ mg}/1\text{ mL}$. How many $\text{mL}$ should the nurse administer? Record your answer to the nearest hundredth. Do not include units in your answer.

A practical nurse receives a client who just returned to the nursing unit following a diagnostic lumbar puncture. To prevent a common post-procedure complication and promote client comfort, which positioning action should the nurse implement?

While performing an afternoon assessment on a client who underwent a total thyroidectomy earlier in the day, the licensed practical nurse notes the client has become visibly restless. The client's voice is increasingly hoarse, and they mention a new sensation of tightness in the anterior neck area. Current vital signs show a heart rate of 114 beats/min and a respiratory rate of 24 breaths/min. Which action should the nurse take first?

A client is recovering from a subtotal thyroidectomy performed earlier in the day. During routine data collection, the practical nurse notes the client's heart rate is 108 beats/min and blood pressure is 102/64 mm Hg. The client states, "My neck feels very tight, and it is getting a little hard to swallow." Which action should the practical nurse take immediately?

A client arrives at the medical-surgical unit after undergoing a percutaneous liver biopsy. The registered nurse has completed the initial admission assessment and delegates ongoing care to the licensed practical nurse. Which actions are essential for the practical nurse to perform to minimize the risk of complications? Select all that apply.

A practical nurse is reinforcing teaching for a client who is non-weight-bearing on the right leg and is learning to ascend stairs using crutches without a handrail. In what order should the practical nurse instruct the client to perform the following actions? Arrange the actions in the correct chronological sequence.

During morning rounds, a practical nurse (PN) evaluates a client who had an open appendectomy 6 hours earlier. The baseline vital signs recorded upon transfer from the post-anesthesia care unit were a blood pressure of 122/78 mm Hg and a heart rate of 76 beats/min. The current vital signs show a blood pressure of 100/64 mm Hg and a heart rate of 108 beats/min. The client complains of feeling slightly dizzy. Which action should the PN take first?

A practical nurse (PN) is reviewing the medication administration record for an adult client with a history of heart failure. The client is scheduled to receive oral digoxin and oral furosemide. Additionally, a new prescription for intravenous (IV) push furosemide was just added to the chart. The client's morning vital signs include a heart rate of $56\text{ beats/min}$ and a blood pressure of $118/74\text{ mm Hg}$. The morning serum potassium level is $3.1\text{ mEq/L}$. Which of the following actions should the PN take? Select all that apply.

A practical nurse (PN) is collecting data on an 82-year-old client who is receiving intravenous antibiotics for severe pyelonephritis. Which of the following assessment findings should the PN identify as early indicators of systemic decompensation and potential septic shock that require immediate notification to the registered nurse (RN)? Select all that apply.

A practical nurse is caring for a client with atrial fibrillation who is prescribed a daily dose of oral warfarin. The client is also scheduled to receive a seasonal influenza vaccine. Upon reviewing the morning laboratory results, the nurse notes an international normalized ratio (INR) of $6.5$. Which of the following actions is the priority for the practical nurse?