Physiological Integrity

A licensed practical nurse (LPN) is planning daily care activities for a client recovering from a left below-the-knee amputation performed 48 hours ago. Which basic comfort and mobility interventions are essential to include in the client's care? Select all that apply.

A practical nurse (PN) is reviewing the morning laboratory results and medication administration record for a client being treated for a deep vein thrombosis (DVT). The client has been receiving a continuous intravenous heparin infusion and was recently started on oral warfarin. The morning laboratory results reveal an International Normalized Ratio (INR) of $4.2$ and a platelet count of $145,000/\text{mm}^3$. The provider has prescribed a scheduled dose of oral warfarin $5$ mg and a new, one-time prescription for oral phytonadione $2.5$ mg. The pharmacy has dispensed the phytonadione as a $5$ mg/mL oral liquid.

Based on these findings, what is the priority sequence of actions for the practical nurse to take?

A client diagnosed with schizophrenia is scheduled to receive a morning dose of oral clozapine. Upon reviewing the electronic health record, the practical nurse notes that the client's most recent absolute neutrophil count (ANC) is $800/\text{mm}^3$. Which action should the nurse take first?

A practical nurse (PN) is monitoring a client who had an uncomplicated vaginal delivery 3 hours ago. The client is resting in bed and states, "I feel suddenly very weak and a bit dizzy when I lift my head." The PN notes that the client has saturated one perineal pad over the last 45 minutes. The client's skin is cool and slightly clammy. Vital signs reveal a heart rate of 112 beats/min and a blood pressure of 98/60 mm Hg. Which of the following is the priority action for the PN?

A practical nurse (PN) is preparing to administer a scheduled dose of ampicillin intramuscularly (IM) to a pediatric client who weighs $52.8\text{ lb}$. The healthcare provider's prescription reads: ampicillin $100\text{ mg/kg/day}$ IM divided in equal doses every 6 hours. The pharmacy dispenses a $1\text{ g}$ vial of ampicillin powder. The reconstitution instructions on the vial state: "Add $3.5\text{ mL}$ of sterile water for injection to yield a final volume of $4\text{ mL}$ with a concentration of $250\text{ mg/mL}$."

How many milliliters (mL) should the PN administer per dose?

Record your answer using one decimal place. Do not include units in your answer.

A practical nurse (PN) is reinforcing teaching with a client about how to use a metered-dose inhaler (MDI) without a spacer. In which order should the PN instruct the client to perform the following steps? Arrange the actions in the correct sequence.

A client arrives at the medical-surgical unit shortly after undergoing a right-sided modified radical mastectomy. The practical nurse is initiating immediate postoperative care. Which of the following interventions should the nurse include to promote safety, basic care, and comfort? Select all that apply.

An LPN is preparing to administer morning medications to a client with heart failure. The client's morning laboratory results show a serum potassium level of 2.9 mEq/L (2.9 mmol/L). Which action should the nurse take first?

A practical nurse (PN) is caring for a client admitted with a severe gastrointestinal bleed. The client is restless and reports abdominal cramping rated as 7 on a 0 to 10 scale. Data collection reveals a heart rate of 118 beats/min, a blood pressure of 88/56 mm Hg, and a hemoglobin level of 6.8 g/dL (68 g/L). Which of the following actions should the PN take first?

An older adult client is resting in bed after undergoing an endoscopic swallowing evaluation earlier in the shift. The nursing care plan notes that the client is experiencing intermittent confusion and requires assistance with oral intake and comfort measures. Which actions should the practical nurse select to safely implement basic care? Select all that apply.

A practical nurse is preparing to administer a large-volume tap water cleansing enema to an adult client experiencing constipation. In what order should the nurse perform the following actions? Arrange the steps in the correct chronological sequence from first to last.

A practical nurse is assessing a client who is 3 days postoperative following an abdominal laparotomy. The client experiences a vigorous coughing fit and suddenly reports a sensation of something "giving way" in their abdomen. Upon inspection, the nurse observes that the surgical incision has separated and a loop of intestine is protruding. In which order should the nurse perform the following actions? Arrange the steps from first priority to last.

A client who underwent a total hip arthroplasty 24 hours ago is found pulling at their intravenous tubing. The client, who was fully oriented during the morning assessment, is now highly restless and disoriented to place. The current heart rate is 112 beats per minute and the respiratory rate is 26 breaths per minute. What is the priority action for the practical nurse in this situation?

A 78-year-old client is on the surgical unit recovering from a femur repair performed this morning. The client is continuously restless and repeatedly asks the practical nurse about their current location. The latest vital signs show a heart rate of 114 beats per minute and a blood pressure of 94/56 mm Hg. Which action should the nurse take first?

A practical nurse (PN) is caring for a client with chronic bronchitis who is receiving scheduled oral theophylline. The client was also started on oral ciprofloxacin $48\text{ hours}$ ago for a respiratory infection. The client now reports feeling unusually restless and nauseous. Current vital signs are blood pressure $138/82\text{ mm Hg}$, heart rate $118\text{ bpm}$, and respiratory rate $20\text{ breaths/min}$. The morning serum theophylline level is reported as $23\text{ mcg/mL}$. Based on these findings, which of the following is the most appropriate action for the PN to take?

While conducting evening rounds on a medical-surgical unit, a practical nurse evaluates a client who is 12 hours post-thyroidectomy. The client states, 'My lips and fingers feel like they are vibrating.' The nurse observes a respiratory rate of 22 breaths/min, a heart rate of 108 beats/min, and a blood pressure of 102/64 mm Hg. The most recent serum calcium level is reported as 7.2 mg/dL (1.80 mmol/L). Which action should the practical nurse take immediately?

A pediatric client weighing $44\text{ lb}$ ($20\text{ kg}$) has a new prescription for phenytoin oral suspension at $5\text{ mg/kg/day}$ divided into two equal doses. The unit's medication supply contains phenytoin at a concentration of $125\text{ mg}/5\text{ mL}$. When retrieving and delivering this medication, which action by the practical nurse (PN) represents safe pharmacological practice?

A practical nurse is caring for a client who is 24 hours postoperative following a right total knee arthroplasty. The client reports leg swelling and asks the nurse to place a pillow directly under the right knee for comfort. Which action should the nurse take?

A practical nurse (PN) is providing care for a client who is receiving a continuous enteral feeding via a nasogastric (NG) tube. The client suddenly develops a severe coughing spell, becomes tachypneic, and appears highly restless.

In what order should the PN perform the following actions? Arrange the actions in sequence from first to last.

A client receiving a continuous intravenous infusion of 0.9% sodium chloride for dehydration suddenly develops a bounding pulse, jugular venous distention, and a new onset of dyspnea. Auscultation reveals crackles in the bilateral lung bases. Which immediate action should the practical nurse take?