Physiological Integrity

A client is recuperating on the medical unit after a diagnostic lumbar puncture. The individual complains of a mild throbbing headache. Which interventions should the practical nurse implement to promote comfort and safety? Select all that apply.

An adult client is recovering on the medical-surgical unit 4 hours after an ultrasound-guided percutaneous liver biopsy. The client is currently positioned on their right side and reports new-onset right shoulder pain along with feeling 'anxious.' The practical nurse assesses the client and notes a heart rate of 112 bpm, blood pressure of 104/62 mm Hg, and a respiratory rate of 22 breaths per minute. Baseline vitals before the procedure were a heart rate of 76 bpm, blood pressure of 136/78 mm Hg, and a respiratory rate of 14 breaths per minute. Based on these findings, which action is the priority for the practical nurse?

During an outpatient clinic visit, a client who has been taking the monoamine oxidase inhibitor (MAOI) tranylcypromine for depression reports experiencing a sudden, throbbing headache and a "racing heart." The practical nurse obtains a blood pressure reading of $218/124 \text{ mmHg}$ and a heart rate of $112 \text{ beats/min}$. Which of the following actions should the practical nurse take? (Select all that apply.)

A practical nurse (PN) is reviewing the electronic health record of an older adult client who is scheduled to receive a daily dose of oral warfarin. The client's morning international normalized ratio (INR) is $4.8$. Upon entering the room, the client reports a new, severe headache. Which action should the PN take first?

Following a scheduled bowel resection, a 76-year-old client is recovering on the medical-surgical unit. Five hours post-procedure, the client becomes increasingly restless and reports severe, diffuse abdominal pain. The practical nurse (PN) obtains the following vital signs: heart rate 115 beats per minute, blood pressure 92/64 mm Hg, and respiratory rate 24 breaths per minute. Which actions should the PN prioritize? Select all that apply.

A practical nurse (PN) is monitoring a 68-year-old client who had a left total hip arthroplasty earlier today. The client suddenly becomes restless and confused. The PN observes a widening circle of bright red sanguineous drainage on the surgical dressing. The client's heart rate has increased from 84 to 108 bpm, and blood pressure has changed from 122/76 to 104/88 mmHg. Identify the immediate actions the PN must include in the care of this client. Select all that apply.

A practical nurse is preparing to administer a prescribed transdermal nitroglycerin patch to a client with a history of angina. Arrange the following steps for applying the patch in the correct chronological order.

A practical nurse (PN) is assessing an adult client who is $6$ hours postoperative following a subtotal thyroidectomy. Which of the following assessment findings should the PN identify as indicating a potential life-threatening complication that requires immediate escalation to the registered nurse (RN)? Select all that apply.

A client is transferred to the medical-surgical unit immediately after undergoing a diagnostic lumbar puncture. Which interventions should the practical nurse implement to ensure safety and promote comfort? Select all that apply.

A practical nurse (PN) is caring for a 72-year-old client admitted with an acute exacerbation of heart failure and a suspected lower respiratory tract infection. The client's current vital signs are: temperature 102.4°F (39.1°C), heart rate 108 bpm, respiratory rate 26 breaths/min, and blood pressure 110/70 mm Hg. The client's admission weight is documented as 75 kg. The provider's prescriptions include oral digoxin, intravenous push bumetanide, a weight-based dose of oral amoxicillin, and an influenza immunization. Which of the following actions should the PN take? Select all that apply.

An older adult resident recently diagnosed with a urinary tract infection has a new prescription for oral amoxicillin. The client's medical record prominently lists a severe anaphylactic allergy to penicillin. The pharmacy has just delivered the amoxicillin to the unit. What is the most appropriate action for the practical nurse to take?

A client diagnosed with heart failure is scheduled to receive an oral dose of digoxin. During the pre-administration data collection, which of the following findings should prompt the practical nurse to withhold the medication and notify the registered nurse? Select all that apply.

A client is recovering on the surgical floor one day after undergoing an open laparotomy. Which interventions should the nurse include to promote comfort and prevent complications? Select all that apply.

A practical nurse is caring for a client who is two days post-operative following a total hip arthroplasty. The client is prescribed subcutaneous enoxaparin $40\text{ mg}$ once daily. While reviewing the client's electronic health record prior to the morning medication administration, the nurse notes the following data:

- Hemoglobin: $11.5\text{ g/dL}$
- Hematocrit: $34\%$
- Platelet count: $78,000/\text{mm}^3$ (baseline on admission: $225,000/\text{mm}^3$)

Which action should the practical nurse take first?

A practical nurse is preparing to administer an intramuscular injection of iron dextran to a client with iron-deficiency anemia using the Z-track method. Arrange the following steps of the administration procedure in the correct chronological sequence.

During morning care, a practical nurse reviews the electronic health record of a client receiving chemotherapy. The latest complete blood count reveals a white blood cell (WBC) count of $1,200/\text{mm}^3$ ($1.2 \times 10^9/\text{L}$). What is the priority nursing action?

A client is resting in bed on the telemetry unit 4 hours after a diagnostic cardiac catheterization performed via the right femoral artery. During routine data collection, the client complains of a new, persistent ache in the lower back. Current vital signs show a blood pressure of 102/64 mm Hg and a pulse of 112 beats per minute, compared to a pre-procedure baseline of 134/78 mm Hg and 76 beats per minute. Which action should the practical nurse (PN) take first?

A client is admitted to the medical unit with severe acute pancreatitis and is experiencing significant third-spacing of fluids. Which of the following data collection findings strongly indicate to the practical nurse that the client is developing hypovolemic shock? Select all that apply.

A client with type 2 diabetes mellitus is prescribed a combined subcutaneous injection of regular and NPH insulin. Place the following actions the nurse must take to draw up the medication in the correct chronological sequence.

A practical nurse is caring for a client who is recovering from a diagnostic cardiac catheterization performed via the right femoral artery approach. The client reports mild lower back discomfort and requests a change in position. Which action should the nurse take to promote comfort while maintaining safety?