Physiological Integrity

1313 soru

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A practical nurse is caring for a client who is 36 hours postoperative following a right above-the-knee amputation. The client has a history of dysphagia and is receiving continuous enteral nutrition via a nasogastric tube. The nursing care plan includes interventions to prevent hip flexion contractures. Which action is most appropriate for the practical nurse to implement?

Pause the continuous enteral feeding, wait 30 to 45 minutes, and then assist the client into a flat prone position for 20 to 30 minutes.

Immediately assist the client into a flat prone position and then pause the continuous enteral feeding.

Maintain the head of the bed at 45 degrees and elevate the right residual limb on a soft pillow.

Position the client supine with the head of the bed elevated 30 degrees and place a rolled towel under the right knee.

Cevabı ve açıklamayı göster

Cevap: Pause the continuous enteral feeding, wait 30 to 45 minutes, and then assist the client into a flat prone position for 20 to 30 minutes.

Cevap

The most appropriate action is to pause the continuous enteral feeding, wait 30 to 45 minutes, and then assist the client into a flat prone position for 20 to 30 minutes.

The correct action demonstrates safe synthesis of two critical basic care protocols. To prevent hip flexion contractures following an above-the-knee amputation, the client should lie prone for 20 to 30 minutes multiple times a day. However, because the client is receiving continuous enteral feedings, laying them flat immediately poses a severe aspiration risk. The nurse must first pause the feeding and wait 30 to 45 minutes to allow for gastric emptying before safely lowering the head of the bed and turning the client prone.

Adım Adım Çözüm

Identify the primary positioning requirement for a client post-above-the-knee amputation.

The client should be placed in a prone position for 20 to 30 minutes several times a day to prevent hip flexion contractures. Elevating the limb on pillows after 24 hours is contraindicated.

Prolonged hip flexion leads to contractures, which can severely impede future prosthesis fitting and mobility.

Identify the safety requirements for a client receiving continuous enteral nutrition.

The head of the bed must remain elevated at least 30 to 45 degrees during the feeding and for 30 to 45 minutes after pausing the feeding.

Maintaining elevation prevents regurgitation and aspiration of gastric contents into the lungs.

Synthesize the conflicting requirements to determine the safest sequence of actions.

The feeding must be paused and sufficient time allowed for gastric emptying before the client can be safely laid flat for the required prone positioning.

Airway protection (preventing aspiration) takes immediate priority, but contracture prevention must still be implemented safely.

Anahtar Kavram

Synthesizing postoperative contracture prevention positioning with aspiration precautions for enteral feedings.

Soru 682Soru →

A practical nurse is providing basic care for a client who returned to the medical unit 2 hours ago following an esophagogastroduodenoscopy (EGD) performed with a topical anesthetic throat spray. The client reports feeling hungry, and their family has brought a culturally specific, home-cooked meal. Which of the following actions should the nurse take first?

Verify the return of the client's gag reflex before permitting the consumption of any food or liquids.

Assist the client into a supine position in bed to promote abdominal relaxation while they eat the meal.

Prioritize arranging the meal tray and documenting the family's cultural food preferences in the medical record.

Withhold the culturally specific food and instead serve the hospital's standard post-procedure clear liquid diet.

Cevabı ve açıklamayı göster

Cevap: Verify the return of the client's gag reflex before permitting the consumption of any food or liquids.

Cevap

The nurse must verify the return of the client's gag reflex before allowing any oral intake to prevent aspiration.

Following an EGD with topical throat anesthesia, the client's gag and swallow reflexes are temporarily suppressed. The absolute priority action in basic care is to ensure airway safety by verifying that the gag reflex has fully returned before allowing the client to consume any food or liquids, thereby preventing aspiration.

Adım Adım Çözüm

Analyze the client's recent procedure and its physiological effects.

The client received a topical anesthetic throat spray for an EGD.

Local anesthesia to the throat impairs the gag and swallow reflexes, creating a temporary but high risk for aspiration.

Evaluate the requested intervention (eating a meal).

The client wants to eat a solid meal brought by the family.

Introducing oral intake before protective airway reflexes have returned can lead to choking or aspiration pneumonia.

Determine the priority nursing action based on ABCs (Airway, Breathing, Circulation).

Airway protection is the absolute highest priority.

The nurse must formally assess the return of the gag reflex before permitting any food or liquids, regardless of cultural preferences or the client's current hunger.

Anahtar Kavram

Airway protection and aspiration precautions during basic care and feeding

Tahmini Süre:1m 15s

Soru 683Soru →

During morning medication rounds, a client examines a newly provided pill and tells the practical nurse, "This does not look like my usual blood pressure medicine. Mine is always white, not blue." What is the safest response by the nurse?

Withhold the medication and verify the prescription with the medication administration record.

Reassure the client that generic substitutions often result in different pill colors.

Administer the medication immediately and document the client's statement in the chart.

Place the pill on the overbed table so the client can take it later in the shift.

Cevabı ve açıklamayı göster

Cevap: Withhold the medication and verify the prescription with the medication administration record.

Cevap

Withhold the medication and verify the prescription with the medication administration record.

When a client questions a medication's appearance, the nurse must always trust the client's observation, withhold the dose, and verify the order. This confirms the 'Right Medication' and is a direct, simple application of medication safety principles.

Adım Adım Çözüm

Listen to the client's concern regarding the medication's appearance.

A potential discrepancy is identified.

Clients are often familiar with their daily medications and serve as an important final check before administration.

Temporarily withhold the questioned medication.

The medication is not administered to the client.

Preventing immediate administration eliminates the risk of an adverse event if the medication is indeed incorrect.

Cross-check the physical medication against the original prescription and pharmacy label.

The accuracy of the drug and dosage is confirmed.

This guarantees the 'Right Medication' principle of safe administration is upheld before any drug is given.

Anahtar Kavram

Medication Administration Safety and Client Verification

Soru 684Soru →

While reviewing morning laboratory reports, a practical nurse (PN) notes that a client receiving a daily subcutaneous dose of enoxaparin has a platelet count of $65,000/\text{mm}^3$ ( $65 \times 10^9/\text{L}$ ). Which action should the PN take first?

Withhold the enoxaparin and notify the registered nurse of the laboratory results.

Administer the enoxaparin as prescribed and monitor the client for bruising or bleeding.

Assess the client for mild tachycardia and hypotension before administering the medication.

Ask the registered nurse to administer the medication because it is a high-alert drug.

Cevabı ve açıklamayı göster

Cevap: Withhold the enoxaparin and notify the registered nurse of the laboratory results.

Cevap

The practical nurse should withhold the scheduled enoxaparin and notify the registered nurse of the critically low platelet count.

The correct action is to withhold the scheduled medication and immediately notify the registered nurse. Enoxaparin is an anticoagulant that increases the risk of bleeding. A normal platelet count ranges from

150,000

400,000/\text{mm}^3

. A count of

65,000/\text{mm}^3

is critically low (thrombocytopenia). Administering an anticoagulant to a client who already has a compromised ability to clot severely increases the risk of spontaneous hemorrhage. The practical nurse must recognize this critical value and intervene to prevent harm.

Adım Adım Çözüm

Identify the purpose and physiological risks of the prescribed medication.

Enoxaparin is a low-molecular-weight heparin (anticoagulant) that prevents clot formation and inherently increases the risk of bleeding.

Understanding the medication's mechanism is required to evaluate safety parameters prior to administration.

Evaluate the client's laboratory results against normal reference ranges.

The client's platelet count is

65,000/\text{mm}^3

, which is significantly below the normal range of

150,000

400,000/\text{mm}^3

Platelets are essential for normal blood clotting, and low levels (thrombocytopenia) indicate an existing high bleeding risk.

Synthesize the findings to determine the appropriate nursing intervention.

Combining an anticoagulant with a critically low platelet count is unsafe. The medication must be withheld and the clinical finding escalated to the registered nurse.

The practical nurse must take immediate, proactive action to reduce the client's risk of severe hemorrhage.

Anahtar Kavram

Recognizing critical laboratory values (such as severe thrombocytopenia) and appropriately withholding contraindicated medications to reduce the risk of client injury.

Soru 685Soru →

An older adult client recovering from a stroke has residual left-sided weakness. The licensed practical nurse is preparing to help the client move from the bed into a wheelchair. Arrange the following actions in the correct chronological sequence to ensure a safe transfer.

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Cevabı ve açıklamayı göster

Cevap

The correct sequence is to first position the wheelchair on the strong side, lock all brakes, assist the client to a dangling position, apply the transfer belt, and finally have the client pivot using their strong arm.

Safe transfer of a client with hemiplegia requires systematic preparation and execution. First, the environment must be prepared by placing the wheelchair on the client's strong side and locking all wheels. Next, the client's physiological readiness is ensured by allowing them to dangle and stabilize their blood pressure. Then, safety equipment (a transfer belt) is applied before any weight-bearing begins. Finally, the client uses their strong side to pivot and safely lower themselves into the chair.

Adım Adım Çözüm

Position the wheelchair on the client's right side.

The equipment is properly aligned on the client's unaffected side.

Transferring toward the strong side allows the client to bear weight and pull themselves safely into the chair.

Engage the locking mechanisms on the bed and wheelchair.

Both the bed and the wheelchair are completely immobilized.

This prevents accidental movement of equipment that could lead to unexpected falls.

Assist the client to sit on the edge of the bed.

The client is upright with their legs dangling over the side of the mattress.

Promotes equilibrium and prevents a sudden drop in blood pressure (orthostatic hypotension) prior to standing.

Apply a transfer belt around the client's waist.

The nurse has a secure and safe point of contact.

Provides a designated handhold to control the client's center of gravity and protect both the client and nurse from injury.

Instruct the client to grasp the armrest with their right arm and pivot.

The client safely transitions from a standing position into the wheelchair.

Utilizes the client's remaining strength on the unaffected side to control the descent and stabilize the body.

Anahtar Kavram

Safe client transfer techniques for unilateral weakness

Soru 686Soru →

An adult client who underwent an open partial gastrectomy earlier in the day activates the call bell. The client states, "I feel incredibly thirsty and my heart is racing," while repeatedly pulling at the bed linens. Data collection reveals a temperature of 98.9°F (37.2°C), heart rate of 118 beats/minute, respiratory rate of 24 breaths/minute, and blood pressure of 102/82 mm Hg. Which of the following interventions should the practical nurse implement? Select all that apply.

Geçerli olan tümünü seçin

Apply a continuous pulse oximeter and verify the patency of the intravenous line.

Position the client flat in bed with the lower extremities elevated.

Provide small sips of water or ice chips to address the client's severe thirst.

Administer the prescribed as-needed opioid analgesic to decrease the client's restlessness.

Immediately report the data collection findings to the supervising registered nurse.

Reassess the vital signs in two hours, as these are expected early postoperative values.

Cevabı ve açıklamayı göster

Cevap: Apply a continuous pulse oximeter and verify the patency of the intravenous line.; Position the client flat in bed with the lower extremities elevated.; Immediately report the data collection findings to the supervising registered nurse.

Cevap

The correct actions are to apply continuous pulse oximetry while verifying intravenous access, position the client flat with elevated legs, and immediately report the findings to the registered nurse.

The client is demonstrating classic signs of early compensatory hypovolemic shock, likely secondary to internal hemorrhage following major abdominal surgery. The dangerously narrow pulse pressure (102 - 82 = 20 mm Hg), tachycardia, tachypnea, intense thirst, and restlessness (cerebral hypoperfusion) demand immediate action. The practical nurse must prioritize oxygenation and circulatory support by applying pulse oximetry, ensuring a patent IV line for imminent fluid resuscitation, positioning the client to maximize venous return to vital organs (flat with legs elevated), and immediately escalating the situation to the registered nurse.

Adım Adım Çözüm

Analyze the vital signs and physical cues.

The blood pressure of 102/82 mm Hg reveals a narrow pulse pressure of 20 mm Hg. This, combined with tachycardia (118 beats/min), tachypnea, severe thirst, and restlessness, indicates early compensatory hypovolemic shock.

Recognizing subtle signs of shock is required before appropriate interventions can be selected.

Evaluate the clinical context of the symptoms.

The client recently underwent major abdominal surgery (partial gastrectomy), making internal hemorrhage the most likely cause of the hypovolemia.

Connecting the surgical history to the vital signs prevents misinterpreting the restlessness as simply postoperative pain or anxiety.

Select interventions within the practical nursing scope of practice.

Appropriate actions include promoting venous return (supine with legs elevated), preparing for fluid resuscitation (verifying IV patency), monitoring oxygenation, and rapid escalation to the RN.

The PN must protect airway/breathing/circulation (ABC) and collaborate with the RN for advanced interventions.

Anahtar Kavram

Early Recognition and Prioritization in Compensatory Hypovolemic Shock

Soru 687Soru →

A practical nurse is caring for a conscious client with diabetes mellitus who suddenly reports feeling shaky and weak. The client's skin is cool and clammy, and their capillary blood glucose is 58 mg/dL. In what order should the practical nurse implement the following actions?

Öğeleri doğru sıraya koymak için sürükleyin

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Cevap

The correct sequence is to administer a simple carbohydrate, wait 15 minutes, reassess the blood glucose, and finally provide a complex carbohydrate and protein snack.

The standard protocol for treating a conscious client with hypoglycemia is the 'Rule of 15'. The sequence begins with administering 15 grams of a fast-acting simple carbohydrate to rapidly raise the blood glucose. The nurse then waits 15 minutes for the sugar to absorb before reassessing the capillary blood glucose. Once the blood glucose is stabilized above 70 mg/dL, a snack containing a complex carbohydrate and protein is provided to sustain the blood glucose level and prevent a rebound hypoglycemic event.

Adım Adım Çözüm

Administer 15 grams of a fast-acting simple carbohydrate.

Provides an immediate source of glucose to treat the hypoglycemia.

The client is symptomatic with a blood glucose of 58 mg/dL; immediate intervention is required to prevent neurological deterioration.

Wait 15 minutes to allow the body to absorb the sugar.

Allows time for the simple carbohydrate to enter the bloodstream.

Checking the blood glucose too soon will not accurately reflect the effect of the intervention.

Reassess the client's capillary blood glucose level.

Evaluates the effectiveness of the simple carbohydrate administration.

The nurse must verify that the blood glucose has risen to a safe level (typically above 70 mg/dL) or determine if another 15 grams of carbohydrate is needed.

Provide a complex carbohydrate and protein snack.

Maintains the blood glucose level.

Simple carbohydrates are metabolized quickly. Providing a complex carbohydrate and protein prevents a subsequent drop in blood sugar.

Anahtar Kavram

Hypoglycemia Management (Rule of 15)

Soru 688Soru →

A practical nurse (PN) is reviewing assessment data for a group of assigned clients. Which of the following findings indicate a developing complication and require the PN to immediately escalate care to the registered nurse (RN)? Select all that apply.

Geçerli olan tümünü seçin

A client 4 hours post-thyroidectomy who is observed frequently swallowing and clearing their throat.

A client receiving a continuous enteral tube feeding who suddenly begins coughing forcefully and expelling frothy sputum.

A client 2 days post-appendectomy who has an oral temperature of

99.4^\circ\text{F}

(

37.4^\circ\text{C}

) and reports incisional pain as 3 on a 0-to-10 scale.

A client receiving intravenous (IV) furosemide whose morning serum potassium level is

2.8\text{ mEq/L}

(

2.8\text{ mmol/L}

A client receiving subcutaneous enoxaparin who has a morning platelet count of

185,000/\text{mm}^3

(

185 \times 10^9/\text{L}

A client 2 hours post-cardiac catheterization whose heart rate increases from 78 to 114 beats/minute and blood pressure drops from 122/76 to 96/60 mm Hg.

Cevabı ve açıklamayı göster

Cevap: A client 4 hours post-thyroidectomy who is observed frequently swallowing and clearing their throat.; A client receiving a continuous enteral tube feeding who suddenly begins coughing forcefully and expelling frothy sputum.; A client receiving intravenous (IV) furosemide whose morning serum potassium level is $2.8\text{ mEq/L}$ ( $2.8\text{ mmol/L}$ ).; A client 2 hours post-cardiac catheterization whose heart rate increases from 78 to 114 beats/minute and blood pressure drops from 122/76 to 96/60 mm Hg.

Cevap

The findings requiring immediate escalation are: the client frequently swallowing post-thyroidectomy, the client forcefully coughing during enteral feeding, the critically low potassium level of

2.8\text{ mEq/L}

, and the client developing tachycardia with hypotension post-cardiac catheterization.

Complications that compromise Airway, Breathing, and Circulation (ABCs) or pose an immediate risk to life require immediate escalation. Frequent swallowing post-thyroidectomy is a classic sign of hemorrhage causing hematoma formation and airway compression. Forceful coughing with frothy sputum in a client with an enteral feeding tube strongly suggests displacement into the airway and aspiration. A serum potassium level of

2.8\text{ mEq/L}

is critically low (normal

3.5-5.0\text{ mEq/L}

) and can cause fatal cardiac arrhythmias, especially when exacerbated by loop diuretics like furosemide. Finally, a sudden shift toward tachycardia and hypotension following an invasive arterial procedure like a cardiac catheterization is a primary indicator of hemorrhagic shock.

Adım Adım Çözüm

Analyze airway and breathing risks in the provided scenarios.

Frequent swallowing post-thyroidectomy indicates internal bleeding pooling in the neck. Coughing with frothy sputum during enteral feeding indicates aspiration. Both require immediate escalation.

Airway compromise is an acute, life-threatening emergency (prioritization of ABCs).

Evaluate laboratory values against normal reference ranges.

A potassium level of

2.8\text{ mEq/L}

is critically low and requires escalation. A platelet count of

185,000/\text{mm}^3

is completely normal.

Failure to report critical lab values increases risk potential, while escalating normal values wastes clinical resources.

Assess vital signs to distinguish expected postoperative trajectories from hemodynamic instability.

Tachycardia and a dropping blood pressure post-catheterization suggest hemorrhagic shock (escalate). A temperature of

99.4^\circ\text{F}

on postoperative day 2 is a normal inflammatory response (do not escalate).

Accurate interpretation of vital sign trends is essential for early recognition of complications.

Select all findings that represent acute, life-threatening complications outside the expected recovery trajectory.

The correct selections relate to the thyroidectomy, enteral feeding, potassium level, and cardiac catheterization.

These four scenarios demand immediate RN or provider intervention to mitigate severe risk.

Anahtar Kavram

Early Recognition of Post-Procedure Complications and Critical Abnormalities

Soru 689Soru →

An older adult client is admitted to a long-term care facility after undergoing a total right hip replacement (posterior approach). When turning and repositioning the client in bed, which action should the practical nurse take?

Keep an abductor wedge or pillow between the client's legs.

Instruct the client to cross their ankles while lying in a supine position.

Elevate the head of the bed to a full 90-degree angle during meals.

Place the client in a side-lying position with the operative leg dropping forward.

Cevabı ve açıklamayı göster

Cevap: Keep an abductor wedge or pillow between the client's legs.

Cevap

Keep an abductor wedge or pillow between the client's legs.

Following a posterior total hip replacement, the client's legs must remain abducted to prevent the hip prosthesis from dislocating. Using an abductor wedge or pillow between the legs maintains proper alignment, prevents adduction (crossing the midline), and limits internal rotation while the client is resting or being turned in bed.

Adım Adım Çözüm

Identify the surgical procedure and its specific postoperative risks.

The client had a total hip replacement (posterior approach), meaning the primary risk is prosthesis dislocation from adduction, internal rotation, or severe flexion.

Understanding prescribed surgical precautions is necessary to determine safe basic care and positioning.

Select the positioning strategy that prevents dislocation.

An abductor pillow keeps the legs separated (abducted) and prevents the operative leg from crossing the midline of the body.

Maintaining proper anatomical alignment ensures joint stability during the healing process.

Anahtar Kavram

Postoperative Positioning and Hip Precautions

Soru 690Soru →

A practical nurse is changing a dressing for a client who is 3 days postoperative following abdominal surgery. The client coughs forcefully, and the nurse observes loops of intestine protruding through the surgical incision. In what order should the nurse perform the following actions? (Arrange the actions from first priority to last priority.)

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Cevap

The correct sequence is: 1) Remain with the client and call for immediate assistance, 2) Place the client in a low Fowler's position with the knees flexed, 3) Cover the protruding bowel with sterile, saline-moistened dressings, 4) Measure the client's vital signs, and 5) Document the evisceration event.

In an acute wound evisceration, the primary goal is to prevent further injury and stabilize the client. The practical nurse must first call for help while staying with the client to ensure continuous monitoring. Next, placing the client in a low Fowler's position with flexed knees immediately reduces intra-abdominal pressure. Once supplies arrive, the nurse covers the wound with sterile, moist dressings to preserve tissue viability. Only after the organs are protected from necrosis should the nurse assess vital signs to monitor for shock. Documentation is always the final administrative step, completed once the client is safe.

Adım Adım Çözüm

Remain with the client and call for immediate assistance.

Assistance is secured without compromising client safety.

The client must never be left alone during an acute surgical emergency. Calling for help allows others to bring required sterile supplies and notify the provider.

Place the client in a low Fowler's position with the knees flexed.

Intra-abdominal pressure is reduced.

This specific positioning relaxes the abdominal muscles, reducing tension on the incision and preventing further protrusion of the internal organs.

Cover the protruding bowel with sterile, saline-moistened dressings.

The exposed intestinal tissue is protected.

Exposed bowel can quickly dry out, leading to tissue necrosis. Sterile, moist dressings preserve the tissue and reduce the risk of severe infection.

Measure the client's vital signs to assess for shock.

The client's hemodynamic status is evaluated.

Evisceration can precipitate hypovolemic shock. Once the physical site is protected, assessing vital signs guides further emergency medical interventions.

Document the evisceration event and the nursing interventions provided.

An accurate medical record is maintained.

Administrative tasks and documentation must always occur after the client is physically stabilized and the immediate life threat is managed.

Anahtar Kavram

Prioritization of nursing care during wound evisceration requires immediate protection of the client, reduction of abdominal tension, and preservation of the exposed organs, followed by physiological monitoring.

Soru 691Soru →

A practical nurse (PN) is assisting an older adult client with morning hygiene and elimination. The client is 2 days postoperative following a right total hip arthroplasty (posterior approach) and requires strict adherence to hip precautions. Which of the following actions by the PN are appropriate? (Select all that apply.)

Geçerli olan tümünü seçin

Roll the client toward the unaffected side with an abduction wedge securely in place between the legs to wash the back.

Instruct the client to flex the right hip to 110 degrees to allow for easier placement of a standard bedpan.

Place a fracture pan under the buttocks while the client uses an overhead trapeze bar to assist with lifting.

Maintain the bed in a completely flat, supine position while assisting the client with their morning meal to avoid hip flexion.

Wash the client's eyes from the inner canthus to the outer canthus, using a different section of the washcloth for each wipe.

Apply bilateral soft wrist restraints immediately if the client becomes disoriented and begins pulling at the surgical dressing.

Cevabı ve açıklamayı göster

Cevap: Roll the client toward the unaffected side with an abduction wedge securely in place between the legs to wash the back.; Place a fracture pan under the buttocks while the client uses an overhead trapeze bar to assist with lifting.; Wash the client's eyes from the inner canthus to the outer canthus, using a different section of the washcloth for each wipe.

Cevap

The appropriate actions are to roll the client toward the unaffected side with an abduction wedge, use a fracture pan combined with an overhead trapeze bar, and wash the eyes from the inner to the outer canthus.

The appropriate actions prioritize joint safety, airway management, and infection control. Using an abduction wedge when turning to the unaffected side prevents dangerous hip adduction. Utilizing a fracture pan with a trapeze bar minimizes hip flexion during elimination. Finally, washing the eyes from the inner to outer canthus adheres to standard hygiene principles to prevent eye infections.

Adım Adım Çözüm

Identify the client's specific physical limitations and safety requirements.

The client is 2 days postoperative for a right total hip arthroplasty (posterior approach) and requires strict adherence to precautions: no hip flexion greater than 90 degrees, no adduction, and no internal rotation.

Understanding surgical precautions is essential before initiating any physical movement or basic care.

Evaluate positioning techniques for hygiene tasks.

Rolling the client toward the unaffected side while utilizing an abduction wedge prevents adduction and internal rotation, making it a safe method to wash the back.

Maintaining neutral alignment of the operative leg prevents dislocation of the new hip joint.

Determine the safest method for assisting with elimination.

Utilizing a fracture pan requires less lifting, and having the client use an overhead trapeze bar allows them to raise their torso without excessive hip flexion.

A standard bedpan usually requires significant hip flexion and rolling, which violates posterior hip precautions.

Recall standard infection control principles for facial hygiene.

Washing the eyes from the inner canthus to the outer canthus using clean sections of the cloth is identified as the correct protocol.

This specific technique prevents the introduction of bacteria or debris into the lacrimal ducts.

Identify and exclude contraindicated or unsafe actions.

Flexing the hip to 110 degrees, feeding the client while completely flat, and immediately applying restraints are all rejected.

Hip flexion past 90 degrees violates orthopedic precautions, feeding while flat prioritizes joint precautions over immediate airway safety (aspiration risk), and applying restraints without alternatives violates safety protocols.

Anahtar Kavram

Safe execution of basic hygiene and elimination care while adhering to posterior total hip arthroplasty precautions and maintaining airway safety.

Soru 692Soru →

A licensed practical nurse is preparing to administer a prescribed large-volume cleansing enema to an adult client who is experiencing constipation. In what order should the nurse perform the following actions? Arrange the steps from first to last.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence is to first position the client in the left lateral Sims position, then lubricate the tip of the tubing, gently insert the tubing into the rectum, and finally open the clamp to allow the solution to flow.

The correct sequential order for administering an enema ensures client safety, promotes comfort, and maximizes the procedure's efficacy. Positioning the client properly in the left lateral Sims position must always come first to physically prepare the client and utilize gravity for the bowel's anatomical curve. Next, lubricating the tube is an essential safety measure that must be completed immediately before any contact is made with the body to prevent mucosal damage. After lubrication, the tube is safely and gently inserted 3 to 4 inches into the rectum. Finally, only once the tube is correctly placed and secured by the nurse's hand, the clamp is opened to begin the instillation of the fluid.

Adım Adım Çözüm

Assist the client into the left lateral Sims position.

The client is positioned appropriately for the procedure.

This position follows the natural curve of the descending colon and sigmoid colon, utilizing gravity to help the fluid flow inward.

Apply a water-soluble lubricant to the tip of the enema tubing.

The tubing tip is slick and ready for insertion.

Lubrication is essential to reduce friction and prevent trauma or tearing of the delicate rectal mucosa during insertion.

Gently insert the tubing 3 to 4 inches (7.5 to 10 cm) into the client's rectum.

The tube is placed at the correct depth within the rectum.

Proper insertion depth ensures the fluid is delivered past the internal and external sphincters without causing injury or perforation.

Open the clamp on the tubing and allow the solution to flow slowly.

The enema solution begins to instill into the colon.

Opening the clamp initiates the actual treatment. Flowing the fluid slowly prevents sudden bowel distension, which can cause severe cramping.

Anahtar Kavram

Basic Care and Comfort: Enema Administration Sequence

Soru 693Soru →

A 78-year-old client is 12 hours postoperative following a laparotomy and bowel resection. The practical nurse (PN) answers the call light and finds the client restless, repeatedly attempting to pull at their intravenous tubing, and stating that they are 'waiting for the bus.' The client's abdominal dressing is dry and intact. Vital signs are temperature 98.4°F (36.9°C), heart rate 114 beats/min, respiratory rate 24 breaths/min, and blood pressure 106/60 mm Hg. The preoperative blood pressure was 148/82 mm Hg. Which action should the PN take first?

Elevate the client's lower extremities and immediately notify the registered nurse (RN).

Administer the prescribed PRN analgesic, as restlessness often indicates uncontrolled pain.

Apply a bed alarm and verbally reorient the client to the hospital room environment.

Record the vital signs in the electronic health record, as they are within normal adult limits.

Cevabı ve açıklamayı göster

Cevap: Elevate the client's lower extremities and immediately notify the registered nurse (RN).

Cevap

Elevate the client's lower extremities and immediately notify the registered nurse (RN).

The client is exhibiting early, classic signs of hypovolemic shock, likely due to internal hemorrhage following the laparotomy. Restlessness and acute confusion are often the earliest indicators of decreased cerebral perfusion. A heart rate of 114 beats/min and a blood pressure of 106/60 mm Hg (a significant drop of 42 mm Hg from the systolic baseline) represent compensatory tachycardia and relative hypotension. Because the abdominal dressing is dry, the bleeding is internal and masked. The priority action is to improve venous return and cardiac output by elevating the client's lower extremities and to immediately alert the registered nurse for collaborative medical interventions.

Adım Adım Çözüm

Analyze the client's vital signs and compare them to the preoperative baseline data.

The heart rate is elevated (114 beats/min) and the blood pressure is significantly decreased from baseline (106/60 mm Hg down from 148/82 mm Hg), indicating relative hypotension.

Identifying relative changes, rather than just relying on absolute parameters, is crucial for recognizing early physiological decompensation.

Evaluate the client's neurological status and behavior in the context of recent surgery.

The client is exhibiting new-onset restlessness, disorientation, and agitation.

Acute changes in mental status are early, critical signs of decreased cerebral tissue perfusion associated with hypovolemic shock.

Synthesize the clinical findings to determine the priority physiological need.

The combined findings of tachycardia, relative hypotension, and acute confusion in a postoperative client indicate impending hypovolemic shock, likely from internal hemorrhage.

According to the ABCs (Airway, Breathing, Circulation) prioritization framework, circulation is severely and acutely compromised.

Select the nursing intervention that immediately addresses the circulation deficit while remaining within the PN scope of practice.

Elevating the client's legs increases venous return, and notifying the RN escalates the situation for rapid medical intervention.

This is the safest and most effective initial response to stabilize a client with suspected hemorrhagic shock.

Anahtar Kavram

Early recognition of hypovolemic shock requires comparing current vital signs to the client's baseline and interpreting acute mental status changes as indicators of poor cerebral perfusion.

Tahmini Süre:1m 30s

Soru 694Soru →

A client who underwent a complete left-sided pneumonectomy three days ago requires routine hygiene and repositioning to prevent skin breakdown. The client is currently resting in a supine position but reports stiffness and back discomfort. Which positioning action by the practical nurse is the safest and most appropriate for this client?

Assist the client into a left lateral position with a pillow providing back support.

Turn the client onto the right lateral position to avoid placing pressure directly on the surgical incision.

Place the client in a prone position for 15 minutes to facilitate the drainage of posterior airway secretions.

Lower the head of the bed to a flat supine position and elevate the client's legs to promote venous return.

Cevabı ve açıklamayı göster

Cevap: Assist the client into a left lateral position with a pillow providing back support.

Cevap

The safest positioning action is to assist the client into a left lateral position with appropriate pillow support.

The correct action is to position the client on their left side. Following a complete pneumonectomy, the client must be positioned on their back or on the operative side (the side where the lung was removed). Because this client had a left-sided pneumonectomy, placing them on the left side ensures that the remaining right lung is positioned uppermost. This allows the healthy lung to expand fully with gravity's assistance and prevents the mediastinum and heart from shifting and compressing the only functional lung.

Adım Adım Çözüm

Identify the specific surgical procedure and the affected anatomical side.

The client had a left-sided pneumonectomy, meaning the left lung was entirely removed, leaving only the right lung functional.

Surgical alterations dictate precise postoperative positioning limitations to ensure client safety.

Determine the primary physiological goal of positioning for this specific surgery.

The goal is to maximize the expansion and ventilation of the remaining right lung while preventing a fluid or tissue shift into the empty pleural space (mediastinal shift).

Proper oxygenation relies entirely on the single unoperative lung, which must not be restricted.

Select the position that fulfills this physiological safety requirement.

Positioning the client on the operative side (the left side) allows the good lung (right side) to remain uppermost and expand fully without compression from abdominal or mediastinal structures.

Lying on the unoperative (good) side would cause the heart and mediastinum to compress the only functional lung, leading to respiratory failure.

Anahtar Kavram

Postoperative Positioning for Pulmonary Surgeries

Soru 695Soru →

A practical nurse (PN) is reviewing the assessment data of an older adult client who is 24 hours postoperative following a partial bowel resection. Which findings indicate a potential complication that requires immediate escalation to the registered nurse? Select all that apply.

Geçerli olan tümünü seçin

A morning serum potassium level of 2.8 mEq/L (2.8 mmol/L)

A resting heart rate of 118 beats per minute with a blood pressure of 90/58 mm Hg

New-onset restlessness with a respiratory rate of 28 breaths per minute

A white blood cell (WBC) count of 11,200/mm³ (11.2 × 10⁹/L)

Serosanguineous drainage totaling 40 mL in the closed-suction surgical drain over 8 hours

An oral temperature of 99.2°F (37.3°C) with mild incisional tenderness

Cevabı ve açıklamayı göster

Cevap: A morning serum potassium level of 2.8 mEq/L (2.8 mmol/L); A resting heart rate of 118 beats per minute with a blood pressure of 90/58 mm Hg; New-onset restlessness with a respiratory rate of 28 breaths per minute

Cevap

The findings that require immediate escalation are the serum potassium level of 2.8 mEq/L, the heart rate of 118 beats per minute with hypotension, and the new-onset restlessness with tachypnea.

A serum potassium level of 2.8 mEq/L is critically low (normal is 3.5-5.0 mEq/L) and places the client at risk for severe cardiac dysrhythmias. A heart rate of 118 beats per minute combined with a blood pressure of 90/58 mm Hg indicates potential hypovolemic shock or internal bleeding. New-onset restlessness and tachypnea are classic early, subtle signs of hypoxia or a pulmonary embolism. All of these findings indicate instability and require immediate RN assessment and provider notification.

Adım Adım Çözüm

Analyze the client's postoperative timeframe and expected physiological responses.

The client is 24 hours postoperative, a period where mild inflammation and mild incisional pain are expected, but fluid shifts, hemorrhage, and electrolyte imbalances pose high risks.

Differentiating normal postoperative healing findings from early signs of shock or metabolic derangement is critical for the practical nurse.

Evaluate the laboratory values and vital signs against critical thresholds.

The potassium of 2.8 mEq/L is critically low. The vital signs (tachycardia and hypotension) indicate potential shock. The restlessness with tachypnea suggests hypoxia.

These findings are life-threatening and fall outside the scope of independent PN management, requiring immediate RN collaboration.

Eliminate the expected, benign postoperative findings from the choices.

The slightly elevated WBC count, low-grade temperature, and small amount of serosanguineous drainage are normal 24 hours after surgery.

These findings can be safely monitored and documented by the PN without the need for immediate emergency escalation.

Anahtar Kavram

Reduction of Risk Potential: Recognizing Postoperative Complications

Soru 696Soru →

A practical nurse (PN) is reviewing the electronic health records of four assigned clients before beginning morning rounds. Which client should the PN see first?

A client who is 4 hours postoperative following an appendectomy and has a blood pressure of 90/58 mm Hg and a heart rate of 118/min

A client with a fractured femur who is requesting immediate medication for a pain level of 8 on a 0 to 10 scale

A client recovering from a total hip arthroplasty who has an abduction pillow placed between the lower extremities

A client receiving continuous intravenous fluids whose most recent serum potassium level was 4.0 mEq/L (4.0 mmol/L)

Cevabı ve açıklamayı göster

Cevap: A client who is 4 hours postoperative following an appendectomy and has a blood pressure of 90/58 mm Hg and a heart rate of 118/min

Cevap

The client who is 4 hours postoperative following an appendectomy and has a blood pressure of 90/58 mm Hg and a heart rate of 118/min.

The client with a blood pressure of 90/58 mm Hg and a heart rate of 118/min is demonstrating early signs of hypovolemic shock, a critical and potentially life-threatening complication of surgery. This circulatory instability takes the highest priority and requires immediate data collection and reporting to the registered nurse.

Adım Adım Çözüm

Analyze the vital signs of the postoperative client with a blood pressure of 90/58 mm Hg and heart rate of 118/min.

Identified as early signs of hypovolemic shock (hypotension and tachycardia), a critical circulatory complication.

Recognizing signs of shock immediately is essential for preventing rapid clinical deterioration.

Evaluate the condition of the client with a fractured femur reporting severe pain.

Identified as a high-priority comfort need, but not an immediate life-threatening physiological emergency.

Using the ABC (Airway, Breathing, Circulation) framework, circulation takes precedence over pain.

Review the status of the client with a total hip arthroplasty utilizing an abduction pillow.

Identified as an expected and appropriate postoperative positioning intervention.

Abduction pillows are standard care to prevent hip dislocation after arthroplasty and do not require troubleshooting.

Assess the potassium level of the client receiving intravenous fluids.

Identified a laboratory value of 4.0 mEq/L, which is within the normal expected range.

Normal laboratory values do not indicate an acute or unstable physiological problem.

Compare all client scenarios to determine the highest overall priority for the nurse.

The postoperative client with signs of shock is selected as the top priority.

Acute circulatory compromise presents the most immediate risk to client safety and requires the most urgent assessment.

Anahtar Kavram

Prioritization using the ABCs framework and early recognition of hypovolemic shock.

Soru 697Soru →

A client recovering from an ischemic stroke is receiving continuous enteral nutrition via a percutaneous endoscopic gastrostomy (PEG) tube. The client's medication administration record includes scheduled morning doses of extended-release nifedipine and liquid acetaminophen. Which action by the practical nurse demonstrates safe pharmacological practice?

Crush the extended-release nifedipine into a fine powder, dissolve it in 30 mL of sterile water, and administer it via the PEG tube.

Withhold the extended-release nifedipine, administer the liquid acetaminophen, and notify the registered nurse to request an appropriate immediate-release alternative.

Substitute the oral nifedipine with an intravenous push antihypertensive medication to ensure the client receives the scheduled dose on time.

Convert the ordered nifedipine dosage into milligrams per kilogram (mg/kg) to determine if the capsule can be safely divided in half for administration.

Cevabı ve açıklamayı göster

Cevap: Withhold the extended-release nifedipine, administer the liquid acetaminophen, and notify the registered nurse to request an appropriate immediate-release alternative.

Cevap

The safe action is to withhold the extended-release nifedipine, administer the liquid acetaminophen, and collaborate with the registered nurse to request a therapeutically equivalent immediate-release or liquid alternative.

Extended-release (ER) medications are formulated to release their active ingredients slowly over an extended period. They must never be crushed, chewed, or opened. Doing so destroys the delayed-release mechanism, causing a rapid absorption of the entire dose at once (dose dumping), which can lead to severe adverse effects such as profound hypotension. Because intact capsules cannot be given via a percutaneous endoscopic gastrostomy tube, the safest action is to withhold the medication, safely administer the liquid acetaminophen, and collaborate with the registered nurse or healthcare provider to obtain a therapeutically equivalent liquid or immediate-release formulation.

Adım Adım Çözüm

Review the prescribed medication properties against the ordered route of administration.

Nifedipine is prescribed as an extended-release capsule, while acetaminophen is a liquid. The route is a PEG tube, which requires medications to be in liquid form or crushed and dissolved.

To determine if the physical properties of the medications allow for safe administration via the prescribed enteral tube.

Analyze the compatibility of extended-release medications with feeding tube administration.

Extended-release formulations cannot be crushed, chewed, or opened without destroying their time-release mechanism.

Crushing an extended-release antihypertensive causes rapid, uncontrolled absorption known as 'dose dumping,' leading to severe systemic toxicity such as profound hypotension.

Determine the appropriate nursing intervention within the practical nurse scope of practice.

The practical nurse must safely administer the liquid medication (acetaminophen), withhold the contraindicated extended-release medication (nifedipine), and immediately collaborate with the registered nurse.

To ensure client safety and facilitate securing a viable alternative formulation from the healthcare provider or pharmacist.

Anahtar Kavram

Safe Administration of Enteral Tube Medications and Formulation Limitations

Tahmini Süre:1m 30s

Soru 698Soru →

During routine hourly rounds, a practical nurse evaluates a 42-year-old client who returned from a total abdominal hysterectomy 4 hours ago. The client appears very restless and requests water, stating they are extremely thirsty. The client's heart rate has increased from 82 to 110 beats per minute over the past hour, while the blood pressure is currently 108/68 mm Hg. What is the most appropriate initial action for the nurse to take?

Inspect the surgical dressing and perineal pad for evidence of excessive bleeding

Provide a small amount of ice chips to alleviate the client's severe thirst

Document the current vital signs as an expected early postoperative response

Assist the client into a high-Fowler's position to promote optimal comfort

Cevabı ve açıklamayı göster

Cevap: Inspect the surgical dressing and perineal pad for evidence of excessive bleeding

Cevap

Inspect the surgical dressing and perineal pad for evidence of excessive bleeding

The correct action is to inspect the surgical dressing and perineal pad. The client's restlessness, severe thirst, and increasing heart rate (tachycardia) are classic early compensatory signs of hypovolemic shock, often caused by internal or external hemorrhage following major surgery. Even though the blood pressure is currently maintained, the nurse must immediately assess for the source of potential bleeding to gather critical data before notifying the registered nurse or provider.

Adım Adım Çözüm

Analyze the client's new clinical signs: restlessness, extreme thirst, and an increasing heart rate.

Identify that these are classic early compensatory signs of hypovolemic shock.

Recognizing early shock is critical before the blood pressure begins to drop.

Determine the most likely cause of hypovolemia in a client 4 hours post-hysterectomy.

The most likely cause is postoperative hemorrhage.

Surgical patients are at high risk for internal or external bleeding in the immediate postoperative period.

Select the nursing action that prioritizes assessing the circulatory status.

The nurse must inspect the operative site and perineum for bleeding.

Direct assessment of the surgical site provides critical data about potential hemorrhage to report to the registered nurse.

Anahtar Kavram

Early recognition and assessment of hypovolemic shock

Tahmini Süre:1m 0s

Soru 699Soru →

A school-aged child with a superficial skin infection is prescribed oral cephalexin 500 mg every 12 hours. The pharmacy dispenses cephalexin oral suspension with a concentration of 250 mg/5 mL.

How many mL should the practical nurse administer for a single dose? Record the answer as a whole number. Do not include units in the answer.

Cevabı ve açıklamayı göster

Cevap: 10

Cevap

To determine the correct volume to administer, use the formula

\frac{\text{Desired}}{\text{Have}} \times \text{Volume}

. The desired single dose is 500 mg, and the medication on hand is 250 mg per 5 mL. Plugging these values into the formula yields

\frac{500}{250} \times 5 = 10

mL.

Adım Adım Çözüm

Identify the desired single dose from the provider's prescription.

500 mg

This is the target amount of medication the client needs to receive at one time.

Identify the concentration of the medication available from the pharmacy.

250 mg in 5 mL

This determines how much liquid contains the required medication.

Apply the dosage calculation formula:

\frac{\text{Desired}}{\text{Have}} \times \text{Volume}

\frac{500}{250} \times 5

This standard formula safely converts the prescribed mass into the volume to be administered.

Perform the arithmetic to find the final volume.

Simplifying the fraction

\frac{500}{250}

equals 2. Multiplying

2 \times 5

yields 10.

Anahtar Kavram

Basic Liquid Dosage Calculation

Soru 700Soru →

Following an ultrasound-guided percutaneous liver biopsy, an adult client is brought to the medical unit for recovery. The client is drowsy from mild conscious sedation, reports mild procedural discomfort, and needs assistance finding a resting position. Which positioning action should the practical nurse implement to ensure client safety?

Assist the client into a right lateral side-lying position with a small rolled blanket placed beneath the lower right rib cage.

Position the client in a left lateral side-lying position to promote venous return and avoid placing pressure on the puncture site.

Elevate the head of the bed to 45 degrees while keeping the client supine to facilitate optimal diaphragmatic excursion.

Assist the client into a prone position to provide counter-pressure to the abdomen and alleviate procedural discomfort.

Cevabı ve açıklamayı göster

Cevap: Assist the client into a right lateral side-lying position with a small rolled blanket placed beneath the lower right rib cage.

Cevap

The correct action is to assist the client into a right lateral side-lying position with a small rolled blanket placed beneath the lower right rib cage.

The correct positioning intervention is to place the client on their right side with a rolled blanket under the lower right rib cage. The liver is a highly vascular organ located in the right upper quadrant. Following a percutaneous liver biopsy, the primary clinical risk is internal hemorrhage. Placing the client in a right lateral position utilizes the client's own body weight to provide direct, continuous mechanical compression to the puncture site against the chest wall. This external pressure promotes hemostasis and minimizes the risk of severe bleeding.

Adım Adım Çözüm

Analyze the client's recent medical procedure (percutaneous liver biopsy) and identify the primary physiological risk.

The liver is a highly vascular organ, making internal hemorrhage the most significant immediate post-procedure complication.

Understanding the primary complication risk determines the appropriate basic care and comfort measures needed for safety.

Determine the anatomical location of the organ and the corresponding puncture site.

The liver is located in the right upper quadrant of the abdomen, and the biopsy is performed through the right lower rib cage.

Nursing positioning must specifically target the correct anatomical side to be effective.

Select the nursing intervention that physically mitigates the risk of hemorrhage.

The right lateral side-lying position is selected.

Lying on the right side with a rolled blanket applies direct mechanical compression to the liver capsule against the chest wall, promoting hemostasis and preventing bleeding.

Anahtar Kavram

Post-procedure positioning following a percutaneous liver biopsy to prevent internal hemorrhage.

ÖncekiSayfa 35 / 66Sonraki

Physiological Integrity

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