Physiological Integrity

A practical nurse is collecting data on a client who is receiving continuous intravenous heparin therapy for a deep vein thrombosis. Which of the following findings indicate a potential complication and must be reported to the registered nurse immediately? (Select all that apply)

A practical nurse (PN) receives a telephone call from the laboratory reporting a critical serum potassium level of $6.2$ mEq/L for a client. The client's morning medications, which include the potassium-sparing diuretic spironolactone, are currently due. In what order should the PN perform the following actions to minimize the risk of complications? (Arrange the steps in the correct order of priority.)

An adult client on a telemetry unit is prescribed oral metoprolol for hypertension. When implementing safe medication practices for this client, which actions should the practical nurse include? Select all that apply.

A client is admitted to the progressive care unit following a cardiac catheterization utilizing a right femoral artery approach. Four hours after the procedure, the practical nurse obtains a blood pressure of $92/58 \text{ mmHg}$ and a heart rate of $114 \text{ beats per minute}$. The client exhibits mild pallor and reports feeling dizzy, but denies any localized groin pain or chest pressure. What is the priority nursing action?

An adult client is transferred to the medical-surgical unit immediately following a diagnostic cardiac catheterization performed via a right femoral artery approach. The client reports mild lower back pain and requests a change in position to relieve the discomfort. Which action by the practical nurse is the most appropriate to ensure the client's safety and comfort?

A practical nurse is assisting a client who is postoperative from abdominal surgery to transfer from the bed to a chair for the first time. Arrange the following actions in the correct sequence to ensure a safe transfer.

During the evening shift on a surgical unit, a practical nurse receives handoff report on a client recovering from a subtotal thyroidectomy performed earlier that day. The client reports mild incisional pain, is permitted a clear liquid diet, and strictly follows cultural dietary practices that prohibit consuming beef and pork products. Which care measures should the nurse implement? Select all that apply.

A practical nurse is preparing to assist a client with their lunch. The client is 48 hours postoperative following a right carotid endarterectomy and experienced a perioperative right-hemisphere ischemic stroke. This complication resulted in left-sided hemiplegia, left homonymous hemianopsia, and mild dysphagia. Which sequence of basic care and positioning actions should the nurse implement?

While reviewing a client's health record prior to medication administration, a practical nurse (PN) observes a newly written prescription for oral cephalexin. The client's admission history indicates a severe anaphylactic reaction to amoxicillin. What is the safest course of action for the PN?

A practical nurse is caring for a client admitted with an acute asthma exacerbation. The client is receiving continuous oxygen therapy and is scheduled for a nebulized albuterol treatment. Upon assessment, the client's vital signs are: blood pressure $142/88\text{ mmHg}$, heart rate $116\text{ beats/min}$, respiratory rate $26\text{ breaths/min}$, and oxygen saturation $90\%$ on $2\text{ L/min}$ via nasal cannula. The client reports feeling anxious with a "racing heart," and the nurse observes fine bilateral hand tremors. Which action should the practical nurse take?

An 81-year-old client is receiving a continuous intravenous heparin infusion for a recent pulmonary embolism. During morning care, the client becomes restless, repeatedly asks where they are, and reports a new, dull ache in the lower back and flank. Current vital signs are blood pressure 104/64 mmHg (baseline 142/82 mmHg), heart rate 116 beats/minute, and respiratory rate 22 breaths/minute. Which action should the practical nurse (PN) take FIRST?

A practical nurse (PN) is reviewing the morning laboratory results for a client who was admitted 48 hours ago with a left deep vein thrombosis (DVT). The client has a prescription for a scheduled dose of subcutaneous heparin.

During the morning data collection, the client reports new, sudden swelling and severe tenderness in the right leg. Based on these findings, which action is the priority for the PN?

A practical nurse is caring for a client admitted with a gastrointestinal bleed. The client is restless, and their skin is slightly cool to the touch. The client's resting heart rate is 106 beats per minute, and their blood pressure is 108/72 mm Hg. Which of the following is the most appropriate action for the practical nurse to take?

During rounds, a practical nurse evaluates the comfort of a client who underwent a thyroidectomy earlier in the shift. Which position should the nurse ensure the client maintains to reduce swelling and support the incision?

While conducting a postoperative assessment, a practical nurse evaluates a client who returned to the surgical unit four hours ago following a vaginal hysterectomy. The client reports feeling unusually thirsty and mildly dizzy. The nurse notes moderate bright red drainage on the perineal pad. The client's current vital signs show a blood pressure of 106/74 mm Hg (baseline 132/84 mm Hg) and a heart rate of 98 beats/minute. Which of the following is the priority action for the practical nurse?

An older adult client is receiving care in a skilled nursing facility three days after undergoing a right above-the-knee amputation. While organizing the client's daily basic care routine, which action is the most appropriate for the practical nurse to implement?

A practical nurse (PN) is preparing to administer a prescribed transdermal nitroglycerin patch to a client. In what order should the PN perform the following steps? (Arrange the steps in the correct sequence, from first to last.)

A practical nurse is preparing to obtain a capillary blood glucose measurement for a client with diabetes mellitus. In which order should the nurse perform the following actions to ensure an accurate result and reduce the risk of complications? Arrange the steps from first to last.

A practical nurse is preparing to administer an intramuscular injection of iron dextran to an adult client diagnosed with severe iron deficiency anemia (hemoglobin 7.2 g/dL). To prevent medication leakage and permanent skin staining, the nurse must use the Z-track method. Arrange the following steps of the Z-track administration technique in the correct chronological order.

During morning rounds on the orthopedic unit, a practical nurse evaluates a client who underwent a right total knee arthroplasty (TKA) earlier today. To promote safety and optimal joint recovery, which basic care and comfort measures must the nurse incorporate into the plan of care? Select all that apply.