Physiological Integrity

A practical nurse is caring for a client who is 12 hours postoperative following a total thyroidectomy. The client reports neck discomfort and requests assistance with repositioning. Which action is most appropriate for the nurse to take?

A practical nurse is providing basic care and comfort measures for a client who had a cardiac catheterization via the right femoral artery 2 hours ago. The client is on strict bed rest and reports mild lower back ache. Which of the following actions should the nurse include in the client's care? Select all that apply.

A practical nurse is providing care for an adult client who is receiving intravenous (IV) fluids for the treatment of an acute gastrointestinal bleed. Which of the following actions should the nurse take to reduce the risk of complications and ensure client safety? Select all that apply.

While rounding on a medical unit, the practical nurse (PN) encounters a conscious client with a history of diabetes mellitus who is trembling and visibly diaphoretic. Place the following nursing interventions in the correct chronological sequence to appropriately manage this acute situation.

A practical nurse is assisting with the care of a client who is 1 day postoperative following a right total knee arthroplasty. The client reports discomfort in the right leg and asks the nurse to place a pillow directly under their right knee for support. Which of the following is the most appropriate nursing action?

A practical nurse is assigned to care for a 78-year-old client who had a partial colectomy 3 days ago. During the morning data collection, which of the following findings should the nurse recognize as early indicators of systemic physiological decompensation requiring immediate escalation? Select all that apply.

A 76-year-old client, who is on strict bed rest recovering from an ischemic stroke, has been calm and oriented. The client abruptly becomes highly agitated, attempts to pull off their gown, and reports a feeling of impending doom. Current vital signs show a heart rate of 112 beats/minute, a respiratory rate of 24 breaths/minute, and a blood pressure of 118/74 mm Hg. Which action should the practical nurse take first?

A client is resting in bed 3 hours after a cardiac catheterization performed via the right femoral artery. The client presses the call light and reports a new, constant dull ache in the lower back. The practical nurse (PN) obtains the following vital signs: blood pressure 100/62 mm Hg, heart rate 108 beats/min, and respiratory rate 18 breaths/min. Which of the following is the priority action for the PN?

While conducting evening rounds on a medical-surgical unit, a licensed practical nurse evaluates an elderly client who underwent an abdominal bowel resection yesterday. The client, who has been cooperative and oriented, is suddenly agitated, disoriented, and repeatedly attempting to remove their intravenous line. The nurse observes that the client's skin is clammy and pale. Current vital signs reveal a temperature of 97.4°F (36.3°C), a heart rate of 116 beats per minute, a blood pressure of 92/54 mm Hg, and a respiratory rate of 28 breaths per minute. Based on these clinical findings, what is the most critical action for the nurse to take?

An older adult client is receiving care on a medical unit for a diagnosed urinary tract infection. During a routine assessment, the practical nurse (PN) observes that the client's skin is flushed and warm to the touch, and the client is unusually drowsy. Current vital signs reveal a blood pressure of $94/56$ mm Hg, a heart rate of $114$ beats/min, and a respiratory rate of $24$ breaths/min. A review of the electronic health record shows a newly resulted serum lactic acid level of $4.6$ mmol/L (reference range: $0.5$ to $2.2$ mmol/L). What is the priority action for the PN?

A practical nurse is changing the abdominal dressing of a client who is four days postoperative from an exploratory laparotomy. When the client forcefully coughs, the nurse observes internal organs protruding through the opened incision line. In which sequential order should the practical nurse prioritize the following interventions? Arrange the actions from first to last.

A practical nurse (PN) is monitoring a client who is receiving a continuous infusion of packed red blood cells (PRBCs). Fifteen minutes after the transfusion begins, the client suddenly reports severe lower back pain, chills, and shortness of breath. Arrange the PN's interventions in the correct order of priority.

After receiving the morning handoff report, a practical nurse reviews the clinical data for four assigned clients. Which client situation presents the greatest risk for a severe complication and requires immediate communication with the registered nurse?

A 68-year-old client is recovering from abdominal surgery. The practical nurse (PN) is reviewing the medication administration record and current client data. The client's vital signs are: blood pressure 88/54 mm Hg, heart rate 118 beats/min, and respiratory rate 20 breaths/min. The provider has prescribed oral lisinopril, subcutaneous enoxaparin, and a continuous intravenous (IV) analgesic infusion. Which of the following actions by the PN are correct? Select all that apply.

While performing afternoon rounds at a skilled nursing facility, the practical nurse observes that a client currently being treated for a urinary tract infection is unusually lethargic and takes several seconds to answer simple questions. The client's baseline mental status is fully alert and oriented. Current vital signs reveal a temperature of 97.2°F (36.2°C), a heart rate of 108 beats/minute, a respiratory rate of 26 breaths/minute, and a blood pressure of 94/56 mm Hg. What is the priority nursing action?

A practical nurse (PN) is assigned to a 68-year-old client who is 4 hours postoperative following a total thyroidectomy. The client's current vital signs are: blood pressure 94/58 mm Hg (baseline 132/82 mm Hg), heart rate 116 beats/minute, and respiratory rate 24 breaths/minute. The client is also experiencing new-onset restlessness and confusion. Which of the following actions should the PN take? (Select all that apply.)

A practical nurse (PN) is reviewing the medication administration record and morning laboratory results for a client with end-stage renal disease. The client is scheduled to receive oral sevelamer, subcutaneous epoetin alfa, and oral lisinopril. The laboratory results indicate a serum potassium of 5.8 mEq/L, hemoglobin of 11.5 g/dL, and serum phosphorus of 6.5 mg/dL. The client's blood pressure is 148/88 mm Hg. Which of the following actions should the PN take? Select all that apply.

During morning rounds, a practical nurse (PN) evaluates an octogenarian client who has a known history of gastric ulcers. The client's baseline mental status is alert and oriented; however, the client is now displaying acute confusion and restlessness along with vague complaints of a stomach ache. The client's current heart rate is 114 beats/minute with a blood pressure of 102/64 mm Hg, representing a drop from a baseline blood pressure of 144/82 mm Hg. Which action should the PN take first?

An 82-year-old client is receiving care on the medical-surgical unit 12 hours after an open bowel resection. Which assessment findings should the practical nurse (PN) recognize as early indicators of potential hypovolemic shock that must be reported to the registered nurse (RN) immediately? (Select all that apply.)

An adult client admitted with a severe gastrointestinal infection is prescribed metronidazole oral suspension. The prescription directs the administration of $7.5 \text{ mg/kg}$ every $6 \text{ hours}$. The client's documented weight is $154 \text{ lb}$. The pharmacy supplies the medication with a label reading $250 \text{ mg}/5 \text{ mL}$. How many $\text{mL}$ should the practical nurse administer for a single dose? Record your answer to the nearest tenth. Do not include units in your answer.