Physiological Integrity

A client receiving continuous enteral nutrition via a nasogastric tube suddenly begins to cough forcefully. The practical nurse observes that the client is experiencing severe dyspnea and has developed circumoral cyanosis. In what order should the practical nurse prioritize the following immediate actions? Arrange the actions in chronological order from first to last.

A practical nurse (PN) is caring for an older adult client who is being treated for pneumonia. The client suddenly becomes restless, reports feeling short of breath, and has an oxygen saturation of 87% on room air. What is the priority action for the PN?

A provider prescribes cefazolin $300\text{ mg}$ deep intramuscularly for a client treating a cellulitis infection. The supply on hand is a $500\text{ mg}$ vial of powdered cefazolin. The label instructions read: 'Reconstitute by adding $2.0\text{ mL}$ of sterile water for injection. The resulting reconstituted solution contains $225\text{ mg/mL}$ of cefazolin.' Determine the volume in milliliters required for a single dose. (Record answer to the nearest tenth. Do not include units in answer.)

A practical nurse (PN) is assigned to care for a 74-year-old client who receives a daily scheduled dose of oral lithium carbonate. During morning rounds, the client is acutely disoriented, exhibits a coarse bilateral hand tremor, and reports severe nausea. The laboratory report from earlier this morning indicates a serum lithium level of 1.9 mEq/L. Which of the following actions should the PN take first?

While assisting a 78-year-old client who was admitted with severe, acute diarrhea, the practical nurse (PN) notes that the client has become suddenly disoriented. The client's radial pulse is weak at 116 beats/min, and blood pressure is 88/54 mm Hg. Which action is the priority?

While conducting morning medication rounds, a practical nurse brings a dose of oral carvedilol into a client's room. The client is dozing, and a visitor is sitting at the bedside. What is the mandatory action for verifying the client's identity before proceeding with the administration?

A client has just returned to the unit after undergoing a lumbar puncture. To promote comfort and minimize the risk of a post-dural puncture headache, which position should the nurse assist the client into?

A practical nurse is assigned to care for a client who is 3 days postoperative following a partial bowel resection. The client has a scheduled prescription for oral ketorolac for moderate pain. The client's morning laboratory report indicates a hemoglobin level of $8.2\text{ g/dL}$ (a decrease from $10.4\text{ g/dL}$ the previous day). The client's current vital signs are a blood pressure of $102/64\text{ mmHg}$, a heart rate of $114\text{ beats/min}$, and a respiratory rate of $20\text{ breaths/min}$. The client reports abdominal pain and requests the scheduled medication. Which action should the practical nurse take first?

A client is receiving care 72 hours after a right above-the-knee amputation. The client reports a dull ache in the residual limb and asks the practical nurse to place a pillow underneath it for support. Which action should the nurse take?

An unlicensed assistive personnel (UAP) reports the morning vital signs for an older adult client who underwent a right total hip arthroplasty the previous day. The client's heart rate is 114 beats per minute and blood pressure is 98/62 mm Hg. The UAP also mentions that the client is newly disoriented to place. Which action should the practical nurse take first?

A practical nurse (PN) is monitoring a client who is receiving a packed red blood cell (PRBC) transfusion. The client suddenly reports severe lower back pain and begins to experience chills. In what order should the PN perform the following actions? Arrange the actions in the correct sequence from first to last.

Following shift report on a medical-surgical unit, a practical nurse (PN) reviews the data for four assigned clients. Which client's clinical presentation indicates a potential life-threatening complication and requires immediate escalation to the registered nurse (RN)?

A practical nurse is reinforcing teaching with a client who has a right short-leg cast about how to ascend stairs using axillary crutches. In which order should the nurse instruct the client to perform the following actions? Arrange the steps from first to last.

An older adult client is recovering on the orthopedic unit on the first postoperative day following a right total hip arthroplasty via a posterior approach. When assisting the client with morning hygiene and bed repositioning, which action by the practical nurse is most appropriate?

An assigned client has left-sided hemiplegia resulting from a recent cerebrovascular accident. The healthcare provider prescribes out-of-bed activity to a chair for all meals. Arrange the following nursing actions for a safe bed-to-wheelchair transfer in the correct chronological order. (Place the initial action at the top and the final action at the bottom.)

A practical nurse (PN) is providing care for a client who is 12 hours post-operative following a left-sided pneumonectomy for lung cancer. Which basic care and comfort interventions should the PN implement? Select all that apply.

A client with a history of seizure disorder is receiving continuous enteral nutrition via a gastrostomy tube. The healthcare provider prescribes liquid phenytoin to be administered via the gastrostomy tube every $12\text{ hours}$. Which action by the practical nurse (PN) demonstrates safe and effective pharmacological management?

While reviewing morning laboratory data for a client prescribed furosemide, a practical nurse observes a serum potassium level of 2.8 mEq/L (2.8 mmol/L). What is the most appropriate initial action by the nurse?

An older adult client who recently had a percutaneous endoscopic gastrostomy (PEG) tube placed is receiving continuous enteral nutrition. The client has been incontinent of bowel, and the unlicensed assistive personnel (UAP) requests assistance from the practical nurse to clean the client. The UAP states, "I need to lay the bed completely flat so we can roll him safely without injuring our backs." Which instruction should the practical nurse provide to the UAP?

A practical nurse (PN) is providing care for a client who is admitted with heart failure and a respiratory infection. The client's prescriptions include oral furosemide, a weight-based dose of oral amoxicillin, and PRN intravenous (IV) push morphine for severe pain. Which of the following actions should the PN perform to ensure safe medication administration? Select all that apply.