Physiological Integrity

A client with a history of stable angina is prescribed a daily nitroglycerin transdermal patch. After gathering the necessary supplies, entering the client's room, and verifying the client using two identifiers, the practical nurse proceeds with the medication administration. Arrange the following actions in the correct sequential order from first to last.

While performing afternoon rounds, a practical nurse evaluates an older adult client who underwent an abdominal bowel resection two days ago. The client's current vital signs reveal a heart rate of 114 beats per minute and a blood pressure of 96/64 mm Hg. The client, who was previously fully oriented, is now restless, repeatedly asking where they are, and picking at the bed linens. Which action should the practical nurse take first?

A practical nurse (PN) is caring for a 16-year-old client who is 4 hours postoperative following a tonsillectomy. The client is awake but quietly and repeatedly swallowing. The client's heart rate has increased from 78 bpm to 110 bpm over the last hour, while blood pressure has decreased slightly from 118/74 mm Hg to 108/66 mm Hg. Which of the following is the most appropriate action for the PN to take?

An older adult client is hospitalized with severe lower extremity cellulitis and is receiving intravenous antibiotic therapy. Over a 4-hour period, the client's urine output totals 55 mL. The client's resting heart rate has trended upward from 78 to 96 beats/min, and blood pressure has trended downward from 132/78 to 106/62 mm Hg. The client now appears unusually agitated and is unsure of their location. Which actions should the practical nurse take? Select all that apply.

A practical nurse is caring for an adult client experiencing an acute asthma exacerbation. The client appears restless, and auscultation of the lungs reveals bilateral expiratory wheezing. The client's current vital signs are blood pressure 134/86 mmHg, heart rate 114 beats per minute, respiratory rate 26 breaths per minute, and oxygen saturation 92% on room air. The healthcare provider has prescribed an immediate albuterol nebulizer treatment and an oral dose of prednisone. Which action should the nurse take first?

An adult client is receiving postpartum care on the maternal-newborn unit following an uncomplicated vaginal birth. During the ongoing evaluation, the practical nurse reviews the client's current clinical data. Which assessment findings indicate a developing complication and require immediate escalation to the registered nurse? Select all that apply.

A practical nurse in a long-term care facility is reviewing a new medication order for a resident diagnosed with a lower respiratory tract infection. The provider's prescription reads: 'Azithromycin $500\text{ mg}$ PO on day 1, followed by $250\text{ mg}$ PO daily on days 2 through 5.' The pharmacy dispenses an azithromycin oral suspension with a concentration of $200\text{ mg}/5\text{ mL}$. How many total milliliters (mL) of this medication will the nurse administer over the entire 5-day treatment course? (Record answer to the nearest tenth. Do not include units in answer.)

A 79-year-old client on a medical-surgical unit is undergoing treatment for a complicated urinary tract infection with intravenous antibiotics. During the night, the client, whose baseline mental status is alert and oriented, becomes highly agitated, attempts to climb out of bed, and pulls at the intravenous line. The practical nurse obtains the following vital signs: temperature 97.2°F (36.2°C), heart rate 118 beats/minute, blood pressure 94/52 mm Hg, and respiratory rate 24 breaths/minute. Which action should the practical nurse take first?

An adult client with a history of type 2 diabetes mellitus and hypertension is assigned to a practical nurse. During the morning assessment, the client is awake and reports feeling slightly shaky. The vital signs are a blood pressure of 142/88 mm Hg, an apical heart rate of 54 beats/minute, and a capillary blood glucose level of 64 mg/dL (3.5 mmol/L). The medication administration record includes scheduled morning doses of oral glipizide, subcutaneous regular insulin, and oral atenolol. Which of the following actions should the practical nurse take? Select all that apply.

A practical nurse (PN) is preparing to obtain an aerobic wound culture from a client's sacral pressure injury. In what order should the PN perform the following actions? (Arrange the steps in the correct sequence from first to last.)

A client is receiving care on the surgical unit 6 hours after an abdominal hysterectomy. During data collection, the practical nurse notes that the client appears restless and pale. The client's vital signs are: blood pressure 88/52 mm Hg, heart rate 116 beats/min, and respiratory rate 24 breaths/min. A recent laboratory report shows a hemoglobin level of 8.1 g/dL (81 g/L). Which action should the practical nurse take first?

During a pediatric clinic visit, a practical nurse prepares to administer a scheduled measles, mumps, and rubella (MMR) vaccine to a 15-month-old child. The client's health record indicates a current prescription for high-dose systemic corticosteroids to manage an autoimmune disorder. What is the most appropriate action for the practical nurse to take?

While observing an 82-year-old client admitted 12 hours ago with severe diarrhea and vomiting, the practical nurse (PN) notes several clinical findings. Which of the following data points strongly suggest the client is developing hypovolemic shock and warrant immediate notification of the registered nurse (RN)? Select all that apply.

Following a right knee arthroplasty, a 74-year-old client is admitted to the orthopedic unit. The client's baseline mental status was alert and oriented. During a routine check, the practical nurse finds the client newly confused and persistently attempting to get out of bed. The client's heart rate is 118 beats/min, respiratory rate is 24 breaths/min, and blood pressure is 106/58 mm Hg. The closed-suction drain has accumulated 260 mL of bright red fluid within the last hour. Which action should the nurse prioritize?

A practical nurse (PN) is prioritizing care for a group of clients on a postoperative medical-surgical unit. Which actions by the PN demonstrate safe clinical judgment and appropriate risk reduction strategies? Select all that apply.

A practical nurse (PN) is assisting a healthcare provider with a bedside thoracentesis for a client diagnosed with a large pleural effusion. In what order should the PN perform the following actions to minimize the risk of complications and ensure client safety? Arrange the actions from first to last.

A client with a history of congestive heart failure is prescribed daily oral furosemide. During morning rounds, the practical nurse gathers data before administering the medication. The electronic health record displays a morning serum potassium level of $2.8 \text{ mEq/L}$. The client's current vital signs are: blood pressure $94/56 \text{ mmHg}$, heart rate $114 \text{ bpm}$, and respiratory rate $18 \text{ breaths/min}$. What is the priority action by the nurse?

A practical nurse is caring for a client with a history of heart failure who is scheduled to receive a routine morning dose of oral furosemide. The client's morning basic metabolic panel reveals a serum potassium level of 2.7 mEq/L (mmol/L). During data collection, the client reports feeling generalized muscle weakness, and the practical nurse notes an irregular apical pulse of 106 beats per minute. What is the most appropriate action for the practical nurse to take?

A practical nurse is assigned to care for a client who is prescribed oral levofloxacin, subcutaneous regular insulin, and an intravenous (IV) push dose of ondansetron. The client's morning laboratory results reveal a serum potassium level of $2.9\text{ mEq/L}$. Which of the following actions are appropriate for the practical nurse to take? Select all that apply.

An older adult client with a history of congestive heart failure and chronic bronchitis is receiving inpatient care. The practical nurse observes that the client, who was alert and oriented two hours prior, has suddenly become highly agitated, is attempting to climb over the bed rails, and is unable to answer simple questions. Which of the following actions should the practical nurse prioritize?