Physiological Integrity

A practical nurse is providing care for a client who is recovering on the medical-surgical unit two days after abdominal surgery. As part of minimizing risk potential, the nurse monitors clinical data and ongoing care activities. Which of the following findings or observations require immediate escalation or corrective intervention? (Select all that apply.)

A practical nurse (PN) is caring for a client who had a percutaneous liver biopsy 4 hours ago. The client's baseline vital signs were heart rate 76 beats/minute and blood pressure 134/82 mm Hg. The client now reports a new onset of dull right shoulder pain. Current vital signs are heart rate 112 beats/minute, respirations 22 breaths/minute, and blood pressure 102/68 mm Hg. The puncture site dressing is dry and intact. Which action should the PN take first?

A practical nurse in an outpatient orthopedic clinic is reinforcing discharge teaching for a client with a postoperative non-weight-bearing right leg cast. The client needs to learn how to safely ascend stairs at home using standard axillary crutches. Place the following steps in the correct chronological order to ensure safe mobility.

During a morning shift, a nurse reviews the medication administration record for a toddler diagnosed with an ear infection. The provider has ordered amoxicillin $250$ mg by mouth. The liquid suspension available from the pharmacy is labeled $125$ mg per $5$ mL. Which of the following amounts should the nurse administer for a single dose?

A practical nurse (PN) enters the room of a 65-year-old client receiving intravenous fluids and observes that the central venous catheter (CVC) tubing has accidentally disconnected from the injection cap. The client is suddenly grasping their chest, reporting severe shortness of breath, and exhibiting cyanosis. To reduce the risk of a life-threatening complication, in what order should the PN perform the following interventions? (Arrange from first to last)

A practical nurse (PN) is preparing to administer a scheduled dose of amoxicillin/clavulanate to a pediatric client diagnosed with acute otitis media. The client's current weight is $41.8\text{ lbs}$.

The primary health care provider's prescription reads: "Amoxicillin/clavulanate $45\text{ mg/kg/day}$ PO divided in equal doses every 12 hours."

The pharmacy dispenses a bottle of amoxicillin/clavulanate powder for oral suspension. The reconstitution instructions on the label state: "Add $67\text{ mL}$ of purified water to the bottle in two parts to yield $100\text{ mL}$ of suspension. Each $5\text{ mL}$ of the reconstituted suspension contains $250\text{ mg}$ of amoxicillin."

How many mL should the PN administer for the morning dose? (Record your answer to the nearest tenth. Do not include units in your answer.)

A client is receiving care on an inpatient urology unit $24$ hours after undergoing a transurethral resection of the prostate (TURP) with continuous bladder irrigation. The practical nurse (PN) evaluates the client's status during the current shift. Which of the following findings are correct indicators of complications that require immediate escalation to the registered nurse? (Select all that apply.)

A practical nurse (PN) enters the room of a client who is 5 days postoperative following an exploratory laparotomy. The client is coughing forcefully and reports feeling that "my stomach just tore open." The PN observes a loop of intestine protruding through the surgical incision. Arrange the following nursing actions in the correct chronological priority order.

A practical nurse is preparing to transfer a client who had a right total hip arthroplasty (posterior approach) two days ago from the bed to a chair. In which order should the nurse perform the following actions? Arrange the steps in the correct sequence from first to last.

A practical nurse is assisting a client with morning hygiene and lower body dressing on the second postoperative day following a right total hip arthroplasty using a posterior approach. Which action by the nurse demonstrates the correct application of basic care and positioning principles?

An 82-year-old client is hospitalized with a severe urinary tract infection and has been receiving intravenous (IV) hydration and scheduled oral diphenhydramine for a localized rash over the past 48 hours. During morning rounds, the practical nurse (PN) finds the client newly agitated, disoriented to place, and actively pulling at the IV catheter. The next scheduled dose of diphenhydramine is currently due. Which action should the PN take first?

An older adult client is recovering from an ischemic stroke and has right-sided weakness. Following a bedside swallow evaluation, the client is permitted to consume a pureed diet. Which of the following basic care measures should the practical nurse implement during and after mealtime to promote comfort and safety? Select all that apply.

An 80-year-old client with a history of heart failure is prescribed a daily oral dose of digoxin. The morning laboratory results indicate a serum potassium level of 3.1 mEq/L (3.1 mmol/L). Upon assessment, the practical nurse (PN) notes the client is experiencing new-onset acute confusion and nausea. Which action should the PN take?

A practical nurse is caring for a client who recently returned to the unit following a subtotal thyroidectomy. To promote comfort, minimize neck swelling, and support the airway, which of the following positions should the nurse assist the client into?

A 68-year-old client is recovering on the orthopedic unit 24 hours after a right total hip arthroplasty. The assigned practical nurse enters the room and notes the client is highly restless, reporting severe incisional pain rated as 8 on a 0-to-10 scale. Assessment reveals the following vital signs: blood pressure 88/54 mm Hg, heart rate 118 beats/minute, and respiratory rate 22 breaths/minute. The morning laboratory profile shows a hemoglobin level of 7.8 g/dL, which is a significant decrease from the preoperative baseline of 12.1 g/dL.

The client's current medication administration record includes the following PRN orders for pain management:
* Hydromorphone 0.5 mg intravenous (IV) push every 3 hours
* Ketorolac 15 mg intramuscularly (IM) every 6 hours
* Tramadol 50 mg orally every 4 hours

Based on the clinical assessment and the practical nursing scope of practice, which action is the priority?

A practical nurse is preparing to administer a scheduled dose of potassium chloride oral solution to a client who is receiving diuretic therapy. The provider has prescribed $30\text{ mEq}$ of potassium chloride by mouth daily. The pharmacy provides the medication in a bulk bottle labeled $20\text{ mEq}/15\text{ mL}$.

How many $\text{mL}$ should the nurse administer per dose? (Record the answer to the nearest tenth. Do not include units in the answer.)

A client is receiving care on a medical unit for fluid volume deficit caused by severe gastroenteritis. During afternoon rounds, the practical nurse notes that the client has voided a total of $55\text{ mL}$ of concentrated urine over the past three hours. The client's current heart rate is $104$ beats per minute and blood pressure is $102/68\text{ mm Hg}$, compared to a baseline of $122/78\text{ mm Hg}$. Which action should the nurse prioritize?

During hourly rounds, a practical nurse evaluates a client who underwent a percutaneous coronary intervention via the right femoral approach 3 hours ago. The client's current vital signs are blood pressure 108/62 mm Hg, heart rate 112 beats/min, and respirations 20 breaths/min. Baseline vital signs obtained immediately post-procedure were blood pressure 135/78 mm Hg, heart rate 78 beats/min, and respirations 16 breaths/min. The client reports a new onset of dull, aching back pain. The right groin dressing appears dry and intact. Which action should the nurse take next?

An older adult resident at a skilled nursing facility experienced an unwitnessed ground-level fall earlier in the shift. During a follow-up evaluation, the licensed practical nurse observes a blood pressure of $94/58\text{ mmHg}$ (baseline $136/82\text{ mmHg}$) and a heart rate of $114\text{ beats/min}$ (baseline $72\text{ beats/min}$). The resident appears pale and reports feeling unusually fatigued. Which action is the priority for the nurse?

An older adult resident in a long-term care facility requires a bed linen change and perineal care. The resident is currently receiving continuous enteral nutrition via a gastrostomy tube. What is the most important action for the nurse to perform before adjusting the bed to a flat position?