Physiological Integrity

1313 soru

Tüm türler1,313 Çoktan seçmeli672 Çoklu seçim289 Sayısal68 Sıralama284

A practical nurse (PN) is assigned to care for a client who had a total knee arthroplasty $24$ hours ago and is receiving subcutaneous enoxaparin. While reviewing morning data and preparing for care, which of the following findings should the PN prioritize and report immediately to the registered nurse (RN)?

A missing client identification band that requires verification using the medical record and a second identifier before medication administration.

A resting blood pressure of

114/72\text{ mm Hg}

and a heart rate of

84

beats per minute.

A morning hemoglobin level of

7.4\text{ g/dL}

(

74\text{ g/L}

), a significant decrease from the previous day's result of

12.8\text{ g/dL}

(

128\text{ g/L}

A client request to modify their customized discharge mobility care plan to better suit their home environment.

Cevabı ve açıklamayı göster

Cevap: A morning hemoglobin level of $7.4\text{ g/dL}$ ( $74\text{ g/L}$ ), a significant decrease from the previous day's result of $12.8\text{ g/dL}$ ( $128\text{ g/L}$ ).

Cevap

The significant decrease in the hemoglobin level must be reported immediately.

The correct answer identifies a severe drop in hemoglobin, which is a critical laboratory finding indicating potential internal hemorrhage. Because the client had major surgery and is on an anticoagulant, the practical nurse must immediately escalate this finding to the registered nurse so that the anticoagulant can be held and treatments (such as a blood transfusion) can be initiated.

Adım Adım Çözüm

Analyze the client's clinical scenario and associated risks.

The client recently underwent major orthopedic surgery and is receiving an anticoagulant (enoxaparin), placing them at a high risk for postoperative bleeding.

Identifying the client's primary physiological risks directs the nurse to look for specific complications.

Evaluate each assessment finding against expected baseline data and LPN scope of practice.

The vital signs are normal, the ID band issue is a routine safety hurdle, and the care plan modification is a non-urgent RN task. The hemoglobin drop is the only critical, life-threatening finding.

Prioritization requires distinguishing between stable/expected findings, procedural tasks, and acute physiological deterioration.

Anahtar Kavram

Prioritizing Critical Laboratory Values in Postoperative Care

Soru 1202Soru →

A practical nurse (PN) is caring for an older adult client who is receiving treatment for a urinary tract infection (UTI). Which assessment findings indicate a potential systemic complication that requires immediate reporting to the registered nurse (RN)? Select all that apply.

Geçerli olan tümünü seçin

Blood pressure decreasing from 134/82 mm Hg to 90/58 mm Hg

Heart rate increasing from 78 to 116 beats/minute

New onset of acute confusion and agitation

Client reports of a burning sensation during urination

Collection of cloudy, dark yellow urine

Cevabı ve açıklamayı göster

Cevap: Blood pressure decreasing from 134/82 mm Hg to 90/58 mm Hg; Heart rate increasing from 78 to 116 beats/minute; New onset of acute confusion and agitation

Cevap

The findings that require immediate reporting are a blood pressure drop to 90/58 mm Hg, a heart rate increase to 116 beats/minute, and a new onset of acute confusion.

A significant drop in blood pressure, an increasing heart rate, and new onset of confusion are clinical indicators of physiological decompensation, specifically systemic infection (sepsis) and poor tissue perfusion. These acute changes represent a direct threat to circulation and require immediate escalation to the registered nurse for emergency intervention.

Adım Adım Çözüm

Analyze the client's current diagnosis and baseline status.

The client has a UTI, which can progress to a severe systemic infection (sepsis) if it worsens or is left untreated.

Understanding the primary diagnosis helps the nurse anticipate potential complications.

Evaluate each assessment finding to distinguish between expected localized symptoms and unexpected systemic complications.

Burning during urination and cloudy urine are expected localized symptoms. The changes in vital signs and mental status are unexpected systemic changes.

Nurses must be able to differentiate normal disease manifestations from acute physiological deterioration.

Apply prioritization principles, specifically looking for airway, breathing, or circulation (ABC) threats.

The systemic changes (hypotension, tachycardia, altered mental status) threaten circulation and tissue perfusion, requiring immediate reporting.

Life-threatening circulatory issues always take precedence over localized, expected symptoms.

Anahtar Kavram

Prioritization of systemic signs of infection and hypoperfusion over expected localized symptoms

Soru 1203Soru →

A client with a history of epilepsy is sitting in a chair at the bedside when they suddenly lose consciousness and begin experiencing generalized tonic-clonic muscle jerking. In what order should the practical nurse (PN) implement the following interventions? Arrange the actions in the correct sequential order.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence prioritizes immediate physical safety (moving to the floor), followed by airway management (turning to the side), breathing support (loosening clothing), continuous observation, and final reporting.

The correct order follows the foundational nursing principles of safety and the ABCs (Airway, Breathing, Circulation). When a client begins seizing in a chair, the most imminent threat is a traumatic fall; therefore, easing them to the floor and padding the head is the absolute first step. Once on the floor, the airway becomes the primary concern, requiring the nurse to turn the client to the side to prevent aspiration. Loosening tight clothing further supports breathing. After safety and ABCs are managed, the nurse observes the seizure's duration and characteristics. Finally, reporting and documentation occur after the acute phase has resolved.

Adım Adım Çözüm

Ease the client to the floor and place a soft pad under their head.

The client is protected from sustaining blunt force trauma or fractures from falling out of the chair.

Immediate physical safety is the primary concern when a client loses consciousness in an upright position.

Turn the client onto their side.

The airway is protected from obstruction by the tongue, and oral secretions can drain freely.

Following the ABCs (Airway, Breathing, Circulation), securing a patent airway prevents aspiration and hypoxia.

Loosen any restrictive clothing around the client's neck and chest.

Chest expansion is optimized, and venous return from the head is unhindered.

Removing mechanical restrictions supports the 'Breathing' and 'Circulation' components of emergency care.

Note the exact time the seizure began and observe the characteristics of the movements.

Accurate clinical data regarding the seizure is collected for later medical evaluation.

Careful observation dictates future pharmacological interventions, but it must not delay life-saving safety measures.

Document the seizure event and report the findings to the registered nurse (RN).

The healthcare team is informed, and the legal medical record is updated.

Reporting and charting are vital administrative and collaborative steps performed after the client is stabilized.

Anahtar Kavram

During a seizure, nursing priorities are strictly ordered: immediate physical safety (preventing falls/trauma), airway maintenance (side-lying position), breathing support (loosening clothing), continuous assessment, and post-event documentation.

Soru 1204Soru →

An adult client is receiving care on the orthopedic unit 48 hours after undergoing a right total hip arthroplasty. The client is prescribed prophylactic subcutaneous enoxaparin and scheduled oral analgesics. While the practical nurse (PN) collects morning data, several findings are noted. Which specific assessment finding indicates a life-threatening complication that requires the PN to immediately escalate care to the registered nurse?

The client develops sudden-onset pleuritic chest pain, tachypnea, and an oxygen saturation of 88% on room air.

The client's morning laboratory report indicates a hemoglobin level of 10.6 g/dL and a hematocrit of 32%.

The client exhibits a temperature of 99.6°F (37.6°C), a heart rate of 92 beats/min, and a blood pressure of 130/82 mmHg.

The client's hospital identification wristband has been removed from their arm and is placed on the bedside table.

Cevabı ve açıklamayı göster

Cevap: The client develops sudden-onset pleuritic chest pain, tachypnea, and an oxygen saturation of 88% on room air.

Cevap

The correct finding is the development of sudden-onset pleuritic chest pain, tachypnea, and an oxygen saturation of 88% on room air.

The finding of sudden-onset pleuritic chest pain, tachypnea (rapid breathing), and hypoxia (oxygen saturation of 88%) strongly indicates a pulmonary embolism. Clients recovering from total hip arthroplasty are at high risk for blood clots. A pulmonary embolism compromises pulmonary circulation and oxygenation, creating an immediate, life-threatening airway and breathing emergency that requires rapid escalation to the registered nurse and medical team for oxygen therapy and anticoagulation.

Adım Adım Çözüm

Analyze the client's clinical context and risk factors.

The client is 48 hours post-operative following a total hip arthroplasty.

Major lower extremity orthopedic surgeries place clients at a significantly elevated risk for venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE).

Evaluate each assessment finding using the ABC (Airway, Breathing, Circulation) prioritization framework.

The respiratory symptoms (hypoxia, tachypnea, chest pain) indicate an acute compromise of airway and breathing.

Physiological emergencies that threaten oxygenation must always be prioritized over routine post-operative findings or administrative safety protocols.

Differentiate between expected post-operative findings and critical complications.

Mild anemia (Hgb 10.6 g/dL) and low-grade inflammatory vitals (Temp 99.6°F) are expected 48 hours post-surgery. The missing ID band is a safety issue but not an immediate physiological threat.

Understanding normal post-operative physiological responses prevents the nurse from falsely escalating expected findings while missing a true life-threatening event.

Anahtar Kavram

Prioritization of Post-operative Complications and ABCs

Soru 1205Soru →

During morning rounds at an extended care facility, a resident with a history of hypertension and chronic kidney disease reports a new onset of muscle weakness and palpitations. The client's medication administration record includes scheduled oral doses of valsartan, hydrochlorothiazide, and a potassium chloride supplement. A basic metabolic panel drawn earlier this morning reveals a serum potassium level of $6.8\text{ mEq/L}$ ( $6.8\text{ mmol/L}$ ). Based on the practical nurse's scope of practice, which action is the priority?

Administer the medications as prescribed and document the laboratory value, as elevated potassium is an expected finding in chronic kidney disease.

Initiate an intravenous push of calcium gluconate to protect the myocardium from dysrhythmias.

Withhold the valsartan and potassium chloride, remain with the client, and immediately alert the registered nurse.

Elevate the client's legs and encourage deep breathing exercises to manage the palpitations before rechecking the pulse.

Cevabı ve açıklamayı göster

Cevap: Withhold the valsartan and potassium chloride, remain with the client, and immediately alert the registered nurse.

Cevap

Withhold the valsartan and potassium chloride, remain with the client, and immediately alert the registered nurse.

The client is exhibiting signs of severe hyperkalemia (potassium of 6.8 mEq/L), which can cause fatal cardiac dysrhythmias, manifested by the client's palpitations. Valsartan is an angiotensin II receptor blocker (ARB) that can increase serum potassium, and the potassium chloride supplement will further elevate the level. The practical nurse must recognize this critical laboratory value, withhold the contributing medications, stay with the unstable client, and immediately escalate the situation to the registered nurse for emergency intervention.

Adım Adım Çözüm

Analyze the client's laboratory results and presenting symptoms.

The serum potassium level of 6.8 mEq/L is critically high (normal 3.5-5.0 mEq/L), and palpitations indicate a potential cardiac dysrhythmia.

Identifying critical abnormalities is the first step in clinical decision-making.

Evaluate the scheduled medications for potential interactions with the laboratory findings.

Valsartan (an ARB) and potassium chloride supplements both increase serum potassium levels.

Administering these medications would exacerbate the severe hyperkalemia.

Determine the appropriate action based on the practical nurse's scope of practice.

The nurse must withhold the contraindicated medications and escalate to the registered nurse immediately.

A practical nurse cannot independently prescribe treatments or administer IV push medications for hyperkalemia, but is responsible for withholding harmful medications and reporting critical findings.

Anahtar Kavram

Recognizing critical laboratory values and medication contraindications within the practical nursing scope of practice.

Soru 1206Soru →

A practical nurse (PN) is performing a follow-up assessment on a client who underwent a Roux-en-Y gastric bypass 14 hours ago. Which clinical finding represents an acute decompensation that the PN must immediately escalate to the registered nurse?

A resting heart rate of 116 beats/min accompanied by new-onset restlessness.

A reported pulling sensation and pain rated 6 out of 10 at the laparoscopic port sites.

Scattered basilar lung crackles that completely clear after the client coughs deeply.

A documented urine output of 140 mL in the collection bag over the last three hours.

Cevabı ve açıklamayı göster

Cevap: A resting heart rate of 116 beats/min accompanied by new-onset restlessness.

Cevap

A resting heart rate of 116 beats/min accompanied by new-onset restlessness.

After major abdominal or bariatric surgery, an unexplained increase in heart rate (tachycardia) and acute neurological changes (restlessness, anxiety) are classic, early indicators of systemic compromise. These findings strongly suggest severe complications such as hemorrhage, an anastomotic leak, or developing peritonitis. Because this represents an acute threat to the client's circulation and tissue perfusion (ABCs), the PN must escalate this immediately to the RN for rapid medical intervention.

Adım Adım Çözüm

Analyze the client's postoperative timeframe and specific surgical risks.

The client is 14 hours post-Roux-en-Y gastric bypass, placing them at high risk for hemorrhage or an anastomotic leak.

Recognizing procedure-specific risks guides the prioritization of assessment data.

Evaluate the clinical findings in each option for life-threatening complications (ABCs).

A heart rate of 116 beats/min and new restlessness indicate inadequate tissue perfusion or systemic infection.

Tachycardia is often the earliest physiological adaptation to shock, hemorrhage, or peritonitis.

Compare the abnormal systemic findings against expected or stable postoperative symptoms.

Incisional pain (6/10), clearable lung crackles, and adequate urine output (~46 mL/hr) are expected or stable findings.

Expected clinical findings do not take priority over impending cardiovascular or respiratory collapse.

Anahtar Kavram

Prioritization of early shock indicators (tachycardia, restlessness) over expected postoperative findings.

Soru 1207Soru →

An 85-year-old client is admitted with pneumonia and is receiving intravenous antibiotics. While making bedside rounds, the practical nurse discovers the client is suddenly agitated, attempting to climb out of bed, and breathing at a rate of 28 breaths per minute. Which action should the practical nurse take first?

Measure the client's oxygen saturation and current vital signs.

Guide the client back into bed and dim the lights to calm their dementia.

Apply physical safety devices to prevent the client from leaving the bed.

Perform a comprehensive pain assessment using a standardized scale.

Cevabı ve açıklamayı göster

Cevap: Measure the client's oxygen saturation and current vital signs.

Cevap

Measure the client's oxygen saturation and current vital signs.

Sudden onset of agitation and confusion, especially when accompanied by a high respiratory rate, is a classic presentation of hypoxia in older adults. The correct immediate response is to gather focused, objective data regarding the client's respiratory status (oxygen saturation and vital signs) to identify the severity of the physiological compromise.

Adım Adım Çözüm

Recognize the clinical cues.

The client is demonstrating sudden agitation, restlessness, and tachypnea (28 breaths per minute).

Identifying abnormal physiological findings is the first step in clinical judgment.

Prioritize the cues using the ABC framework.

Tachypnea points directly to a potential breathing or oxygenation issue, which takes priority over behavioral or pain concerns.

Airway, Breathing, and Circulation are the most critical physiological needs.

Determine the appropriate initial nursing action.

The nurse must collect focused objective data (oxygen saturation and vital signs) to report to the registered nurse for immediate intervention.

Sudden confusion is often an early sign of hypoxia in older adults, requiring prompt physiological assessment rather than environmental modifications.

Anahtar Kavram

Prioritizing Physiological Assessment in Acute Changes

Soru 1208Soru →

A licensed practical nurse (LPN) is providing care for a client admitted with bilateral pneumonia who is receiving intravenous antibiotics. Which of the following actions by the LPN demonstrate appropriate risk reduction principles and safe practice? Select all that apply.

Geçerli olan tümünü seçin

Verifying the client's identity using their full name and date of birth before administering a scheduled oral antipyretic.

Waiting until the end of the shift to communicate a morning serum potassium level of

2.8

mEq/L (

2.8

mmol/L) to the registered nurse.

Accepting a delegated task from the charge nurse to perform an initial comprehensive admission assessment on a newly arrived client.

Elevating the head of the client's bed to a semi-Fowler's position to promote optimal lung expansion and airway clearance.

Attributing a new resting heart rate of

114

bpm and a blood pressure of

96/54

mm Hg to anxiety without further escalation.

Promptly notifying the registered nurse that the client's oxygen saturation has declined from

96\%

89\%

on room air.

Cevabı ve açıklamayı göster

Cevap: Verifying the client's identity using their full name and date of birth before administering a scheduled oral antipyretic.; Elevating the head of the client's bed to a semi-Fowler's position to promote optimal lung expansion and airway clearance.; Promptly notifying the registered nurse that the client's oxygen saturation has declined from $96\%$ to $89\%$ on room air.

Cevap

The correct actions are verifying the client's identity using two identifiers, elevating the head of the bed, and promptly notifying the registered nurse about the decreased oxygen saturation.

Verifying identity using two distinct identifiers ensures correct medication administration and prevents errors. Elevating the head of the bed is an independent nursing intervention that facilitates optimal respiratory function for a client with pneumonia. Finally, promptly reporting an oxygen saturation drop from 96% to 89% allows for timely assessment and potential adjustment of respiratory support to prevent further hypoxia.

Adım Adım Çözüm

Evaluate each action for adherence to the LPN scope of practice and risk reduction principles.

Identify actions that promote client safety and correctly escalate abnormal findings.

The LPN is responsible for identifying potential complications, safely administering care, and communicating changes in client status to the RN.

Analyze the laboratory and vital sign data provided in the options.

Determine that a potassium level of 2.8 mEq/L and an oxygen saturation of 89% are critical abnormalities requiring immediate escalation.

Hypokalemia and hypoxia pose immediate risks to the client's physiological stability.

Review the nursing actions for scope of practice and medication safety.

Determine that initial comprehensive assessments are outside the LPN scope, and utilizing two identifiers is required for medication administration.

LPNs perform focused, not initial comprehensive, assessments. Two distinct client identifiers are required for safe medication administration.

Anahtar Kavram

The practical nurse plays a critical role in reducing risk potential by recognizing and escalating abnormal clinical findings, adhering strictly to medication administration rights, and working within their defined scope of practice.

Soru 1209Soru →

The nursing staff is providing care for a 78-year-old client who is receiving continuous intravenous (IV) hydration therapy for severe gastroenteritis. The client has a documented medical history of congestive heart failure. Upon entering the room, the nurse notes the client is increasingly restless, has developed a frequent moist cough, and reports feeling 'like I cannot catch my breath.' Which immediate actions should the practical nurse take? Select all that apply.

Geçerli olan tümünü seçin

Check the client's peripheral oxygen saturation using a pulse oximeter

Assist the client into an upright sitting position in bed

Attribute the client's new onset of restlessness to expected age-related cognitive changes

Listen to the anterior and posterior lung fields for abnormal breath sounds

Complete a comprehensive peripheral vascular assessment before evaluating respiratory status

Administer a rapid intravenous push of a loop diuretic to reduce systemic fluid volume

Cevabı ve açıklamayı göster

Cevap: Check the client's peripheral oxygen saturation using a pulse oximeter; Assist the client into an upright sitting position in bed; Listen to the anterior and posterior lung fields for abnormal breath sounds

Cevap

The correct actions are to assist the client into an upright sitting position, check peripheral oxygen saturation, and listen to the lung fields for abnormal breath sounds.

When a client with heart failure receives IV fluids and develops a moist cough and shortness of breath, it strongly indicates fluid volume overload and pulmonary edema. The immediate priority is to support breathing by sitting the client upright. The practical nurse must also promptly collect essential respiratory data, including oxygen saturation and lung auscultation, so accurate information can be immediately reported to the registered nurse or provider for advanced orders.

Adım Adım Çözüm

Analyze the client's clinical presentation.

The client has a history of heart failure, is receiving IV fluids, and is now showing signs of fluid volume overload and pulmonary edema (moist cough, dyspnea, restlessness).

Identifying the underlying complication directs the priority of nursing care.

Apply the Airway, Breathing, Circulation (ABC) prioritization framework.

Interventions must immediately address the client's breathing difficulties before assessing secondary body systems.

Airway and breathing are always the highest priority in acute status changes.

Determine the actions that fall within the practical nurse's scope of practice.

The PN can reposition the client to ease breathing and collect focused respiratory data (SpO2, lung sounds) to urgently report to the RN.

The PN must act rapidly but safely, avoiding interventions that require RN-level credentials (like IV push medications).

Anahtar Kavram

Prioritization and Scope of Practice during Acute Pulmonary Edema

Tahmini Süre:1m 30s

Soru 1210Soru →

While providing morning hygiene, a practical nurse is evaluating the comfort and body alignment of a client who underwent a left above-the-knee amputation 48 hours ago. To prevent a common joint complication associated with this surgery, which positioning technique is most appropriate for the nurse to implement?

Assisting the client to lie flat on their abdomen for short intervals multiple times a day

Propping the residual limb continuously on a folded blanket while the client rests in bed

Encouraging the client to sit upright in a bedside armchair for prolonged periods

Securing a wedge cushion between the client's thighs to keep the legs spread apart

Cevabı ve açıklamayı göster

Cevap: Assisting the client to lie flat on their abdomen for short intervals multiple times a day

Cevap

The correct action is to assist the client to lie flat on their abdomen for short intervals multiple times a day.

Assisting the client into a prone position (lying flat on the abdomen) for 20 to 30 minutes several times a day is crucial after an above-the-knee amputation. This position fully extends the hip joint, helping to prevent hip flexion contractures that can severely impair future mobility and prosthetic fitting.

Adım Adım Çözüm

Identify the primary complication risk associated with an above-the-knee amputation.

The most common and debilitating positioning complication is a hip flexion contracture.

Surgical trauma and natural resting positions tend to pull the hip flexor muscles inward and upward.

Evaluate how different body positions affect the hip joint.

Sitting and elevating the limb flex the hip, whereas lying prone fully extends the hip joint.

Extension counteracts the tendency of the flexor muscles to shorten and tighten.

Select the intervention that promotes hip extension.

Lying flat on the abdomen is identified as the correct positioning strategy.

Prone positioning stretches the flexor muscles and maintains proper joint alignment.

Anahtar Kavram

Post-Amputation Positioning and Contracture Prevention

Soru 1211Soru →

An adult client who is immobile and 24 hours post-operative from a gastrostomy tube placement is receiving continuous enteral nutrition. When planning basic care and comfort measures, which actions should the licensed practical nurse (LPN) implement? Select all that apply.

Geçerli olan tümünü seçin

Maintain the head of the bed elevated at 30 to 45 degrees continuously.

Pause the enteral feeding pump prior to lowering the head of the bed for repositioning.

Apply a moisture barrier cream to the perineal skin after cleansing incontinent episodes.

Lower the head of the bed to a flat, supine position for one hour after morning care while the feeding infuses.

Complete the initial comprehensive skin assessment of a newly discovered pressure injury on the sacrum.

Administer a prescribed as-needed analgesic for joint stiffness before clearing loud, gurgling respiratory secretions.

Cevabı ve açıklamayı göster

Cevap: Maintain the head of the bed elevated at 30 to 45 degrees continuously.; Pause the enteral feeding pump prior to lowering the head of the bed for repositioning.; Apply a moisture barrier cream to the perineal skin after cleansing incontinent episodes.

Cevap

The appropriate actions for the LPN to implement are maintaining the head of the bed elevated at 30 to 45 degrees, pausing the feeding pump before lowering the head of the bed, and applying a moisture barrier cream after incontinence care.

Maintaining the head of the bed elevated at 30 to 45 degrees is essential to prevent regurgitation and aspiration during continuous enteral feedings. If the head of the bed must be lowered for turning or repositioning, the feeding pump must be paused first to protect the client's airway. Applying a moisture barrier cream to the perineal area after cleansing is a fundamental comfort measure that protects vulnerable skin from breakdown due to incontinence and immobility.

Adım Adım Çözüm

Analyze the client's clinical presentation.

The client is immobile, post-operative, and receiving continuous enteral nutrition.

Identifying risk factors such as aspiration and skin breakdown guides the selection of safe basic care interventions.

Evaluate basic care and comfort interventions for safety and scope of practice.

Elevating the head of the bed, pausing feeds before repositioning, and applying moisture barrier creams are within the LPN scope and directly promote safety and skin integrity.

These actions prevent aspiration and manage moisture, which are critical basic care elements.

Identify and exclude contraindicated or out-of-scope actions.

Positioning the client flat while feeding, performing initial comprehensive assessments, and delaying airway clearance for pain management are unsafe or outside the LPN scope of practice.

LPNs must adhere to ABC prioritization, proper post-procedure positioning to protect the airway, and scope of practice limitations.

Anahtar Kavram

Basic Care and Comfort for Enteral Nutrition and Immobility

Soru 1212Soru →

A practical nurse (PN) is assisting with the care of a client who is receiving an intermittent intravenous (IV) infusion of vancomycin. The client suddenly reports intense itching, and the PN observes a bright red rash on the client's face, neck, and upper chest. The client's blood pressure has dropped to $88/58\text{ mmHg}$ . Which action should the PN take first?

Continue the infusion and document the rash and blood pressure as an expected reaction.

Elevate the head of the bed for comfort and ask the client to rate the itching on a pain scale.

Stop the vancomycin infusion immediately and alert the registered nurse (RN).

Prepare to administer an intravenous push of epinephrine per the facility's anaphylaxis protocol.

Cevabı ve açıklamayı göster

Cevap: Stop the vancomycin infusion immediately and alert the registered nurse (RN).

Cevap

The correct action is to stop the vancomycin infusion immediately and alert the registered nurse (RN).

The client is exhibiting signs of Red Man Syndrome or a severe hypersensitivity reaction to vancomycin, characterized by flushing, an upper body rash, and significant hypotension. The first and most critical action is to stop the offending infusion to prevent further circulatory compromise. The PN must then immediately notify the RN, as managing an acute, unstable client requires RN-level assessment and intervention.

Adım Adım Çözüm

Assess the client's clinical presentation.

The client has intense itching, a bright red rash on the upper body, and hypotension (

88/58\text{ mmHg}

Identifying these symptoms is crucial for recognizing Red Man Syndrome or a severe hypersensitivity reaction.

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

The hypotension indicates a circulatory threat.

In any emergent drug reaction causing hemodynamic instability, the source must be removed immediately.

Act within the practical nurse (PN) scope of practice.

The PN stops the IV infusion and immediately escalates the situation to the RN.

The PN can independently stop a harmful infusion but must collaborate with the RN for further assessment and emergency IV push interventions.

Anahtar Kavram

Prioritization and Scope of Practice in Adverse Medication Reactions

Soru 1213Soru →

Following a left femoral cardiac catheterization, an older adult client is admitted to the medical-surgical unit with orders for strict bed rest. The practical nurse (PN) is organizing the client's care to ensure safety and comfort. Which actions should the PN incorporate into the daily care plan? Select all that apply.

Geçerli olan tümünü seçin

Ensure the client's left leg remains completely straight and flat against the mattress.

Elevate the head of the bed to a 60-degree angle while the client is eating.

Use a fracture pan instead of a standard bedpan for urinary or bowel elimination.

Assist the client to sit on the edge of the bed with their legs dangling for comfort.

Offer frequent oral fluids and water to assist in flushing out the contrast dye.

Place a wedge cushion under the left knee to promote slight joint flexion.

Cevabı ve açıklamayı göster

Cevap: Ensure the client's left leg remains completely straight and flat against the mattress.; Use a fracture pan instead of a standard bedpan for urinary or bowel elimination.; Offer frequent oral fluids and water to assist in flushing out the contrast dye.

Cevap

The correct actions are to ensure the left leg remains completely straight, use a fracture pan for elimination, and offer frequent oral fluids.

Proper care for a client following a femoral cardiac catheterization prioritizes preventing hemorrhage at the arterial puncture site while meeting basic physiological needs. Keeping the affected leg completely straight prevents dislodging the clot at the femoral artery site. Using a fracture pan minimizes movement of the hips and back, avoiding undue stress on the puncture site during elimination. Finally, encouraging oral fluids is an essential basic care measure to help the kidneys excrete the nephrotoxic contrast medium used during the procedure.

Adım Adım Çözüm

Analyze the client's clinical situation and primary risk factors.

The client had a left femoral cardiac catheterization and is on strict bed rest, placing them at high risk for arterial bleeding at the puncture site.

Identifying the highest risk complication guides the selection of safe positioning and comfort measures.

Evaluate each basic care and mobility intervention for safety regarding the femoral puncture site.

Interventions that keep the hip and leg straight (flat leg, fracture pan) are safe, while interventions that bend the hip or leg (high fowlers, dangling, knee cushions) are dangerous.

Any flexion of the affected hip (bending past 30 degrees) or increased pressure can dislodge the clot at the femoral artery.

Identify interventions that address systemic procedural recovery needs.

Encouraging oral fluids helps clear the contrast dye used during the catheterization.

Contrast dye is nephrotoxic, and maintaining adequate hydration is a fundamental comfort and safety measure for the LPN to implement.

Anahtar Kavram

Post-procedural positioning and basic comfort care following femoral cardiac catheterization.

Soru 1214Soru →

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

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence is to first position the client, lubricate the tubing, insert it into the rectum, elevate the container to start the flow, and monitor the client by clamping the tube if cramping occurs.

Administering a cleansing enema requires a systematic approach to ensure safety and comfort. The client must first be positioned correctly in the left lateral Sims' position to allow gravity to assist the fluid flow into the sigmoid colon. Next, the nurse lubricates the tubing to prevent mucosal injury and gently inserts it safely into the rectum. Once the tube is securely in place, the container is elevated to the proper height to control the fluid's hydrostatic pressure. Finally, the nurse monitors the client continuously during instillation and clamps the tubing if cramping occurs to allow the colon to relax.

Adım Adım Çözüm

Position the client in the left lateral Sims' position.

The client is properly aligned to facilitate fluid flow.

Gravity aids the flow of solution into the sigmoid colon and descending colon.

Lubricate the tip of the rectal tube with water-soluble jelly.

The tube is ready for smooth insertion.

Lubrication minimizes friction, preventing tissue injury and discomfort.

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

The tube passes the internal sphincter and enters the rectum safely.

This depth ensures the fluid is delivered past the sphincter without risking intestinal perforation.

Elevate the enema container 12 to 18 inches (30 to 45 cm) above the anus.

Fluid begins to instill at a safe, controlled rate.

The height determines the fluid pressure. Staying within this range prevents rapid distention and mucosal injury.

Clamp the tubing temporarily if the client reports abdominal cramping.

The flow of fluid stops, relieving client discomfort.

Stopping the flow allows bowel spasms to subside before resuming the enema at a slower rate.

Anahtar Kavram

The procedural steps for administering a large-volume cleansing enema prioritize anatomical alignment, safety, and client comfort.

Soru 1215Soru →

Fifteen minutes after a registered nurse (RN) initiates an intravenous (IV) vancomycin infusion for a client with a severe soft tissue infection, the practical nurse (PN) responds to the client's call light. The client states, "My face and chest feel like they are burning and itching." The PN observes profound erythema over the client's face, neck, and upper torso. The client's blood pressure is $122/78\text{ mmHg}$ , and respirations are unlabored at $16\text{ breaths/min}$ . Which action should the PN take first?

Inform the client that this is an expected reaction to the medication and offer a cool washcloth to soothe the skin.

Recalculate the intravenous drip rate to determine if the medication is infusing too rapidly.

Stop the vancomycin infusion immediately and notify the RN.

Scan the client's identification band and check the electronic health record for undocumented drug allergies.

Cevabı ve açıklamayı göster

Cevap: Stop the vancomycin infusion immediately and notify the RN.

Cevap

The immediate priority action is to stop the vancomycin infusion and notify the registered nurse.

The client is exhibiting signs of Red Man Syndrome, a rate-dependent infusion reaction to vancomycin characterized by intense flushing, erythema, and itching of the face, neck, and upper torso. Although the client's vital signs are currently stable, the immediate priority is to stop the infusion to prevent further histamine release, which could lead to severe hypotension. The practical nurse (PN) must then immediately notify the registered nurse (RN) to assess the client and determine the next steps, which typically involve administering an antihistamine and restarting the infusion at a significantly slower rate.

Adım Adım Çözüm

Assess the client's clinical presentation and vital signs.

The client has intense flushing and itching of the upper body, but stable blood pressure and unlabored respirations.

To differentiate between true anaphylaxis (which typically involves respiratory distress or severe hypotension) and a rate-related infusion reaction.

Identify the complication.

The findings indicate Red Man Syndrome, an adverse reaction caused by rapid infusion of vancomycin.

Recognizing the specific adverse effect dictates the appropriate nursing intervention.

Determine the priority nursing intervention within the PN scope of practice.

The PN must stop the infusion immediately.

Removing the causative agent prevents the reaction from progressing to severe hypotension or shock. The PN has the authority and responsibility to stop a harmful infusion.

Escalate the situation.

Notify the RN immediately.

The RN is required to perform a comprehensive assessment, notify the provider if necessary, and manage the restart of the infusion at a slower rate.

Anahtar Kavram

Vancomycin Infusion Reactions (Red Man Syndrome)

Soru 1216Soru →

A practical nurse (PN) enters a client's room and observes the client coughing forcefully and clutching their chest. The client is receiving continuous enteral nutrition via a nasogastric (NG) tube. The client appears cyanotic around the lips, and the pulse oximeter reads 86% on room air. In what order should the PN perform the following actions? (Arrange the actions from first to last.)

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence is: Turn off the continuous enteral feeding pump, Elevate the head of the bed to a high-Fowler's position, Apply supplemental oxygen, Auscultate the client's bilateral lung sounds, and Notify the supervising registered nurse (RN).

In any acute respiratory emergency involving enteral feeding, the first step is to remove the noxious stimulus by stopping the pump to prevent further aspiration. Following the ABCs (Airway, Breathing, Circulation), the nurse should then position the client to maximize lung expansion and apply oxygen to treat the hypoxia. Once these immediate life-saving measures are applied, the PN should collect focused data (lung sounds) so that a complete and accurate report can be given when notifying the supervising RN.

Adım Adım Çözüm

Turn off the continuous enteral feeding pump.

The flow of enteral formula is halted immediately.

This is the most critical action to prevent further aspiration of formula into the airway.

Elevate the head of the bed to a high-Fowler's position.

The client is placed in an upright position.

This maximizes lung expansion and utilizes gravity to minimize the risk of further reflux.

Apply supplemental oxygen per facility emergency protocol.

Oxygen delivery to the lungs is increased.

This treats the immediate hypoxia evidenced by cyanosis and a pulse oximetry reading of 86%.

Auscultate the client's bilateral lung sounds.

Clinical data regarding the respiratory status is collected.

The PN must gather baseline data on the extent of the complication (e.g., presence of crackles) before calling for assistance.

Notify the supervising registered nurse (RN) of the status change.

The healthcare team is alerted to the client's deterioration.

With the client stabilized and initial data collected, the RN and healthcare provider can evaluate the client for further interventions like chest x-rays or suctioning.

Anahtar Kavram

Prioritization of care during an acute aspiration event focuses on airway protection first (stopping the cause), followed by breathing support (positioning and oxygen), data collection, and then escalation.

Soru 1217Soru →

A pediatric client with a respiratory tract infection has an order for amoxicillin suspension. The medical record indicates the child weighs $16\text{ kg}$ . The prescribed dose is $45\text{ mg/kg/day}$ , divided equally and given every $12\text{ hours}$ . The dispensed bottle contains a concentration of $250\text{ mg}/5\text{ mL}$ . How many mL should be prepared for a single administration?

Record your answer to the nearest tenth. Do not include units in your answer.

Cevabı ve açıklamayı göster

Cevap: 7.2

Cevap

7.2

The correct volume is calculated by first determining the total daily dose based on the client's weight (

16\text{ kg} \times 45\text{ mg/kg/day} = 720\text{ mg/day}

). This total is then divided into two doses because the medication is scheduled every

12

hours, resulting in

360\text{ mg}

per dose. Using the available concentration of

250\text{ mg}/5\text{ mL}

, the required volume is (

\frac{360}{250} \times 5 = 7.2\text{ mL}

Adım Adım Çözüm

Calculate the total daily dose in milligrams.

16\text{ kg} \times 45\text{ mg/kg/day} = 720\text{ mg/day}

The prescription provides a weight-based rate for a full 24-hour period, which must be determined first.

Determine the amount of medication required for a single dose.

720\text{ mg} \div 2\text{ doses} = 360\text{ mg/dose}

The medication is ordered every

12

hours, meaning it is administered

2

times per day.

Calculate the liquid volume needed to deliver the single dose.

\frac{360\text{ mg}}{250\text{ mg}} \times 5\text{ mL} = 7.2\text{ mL}

This determines the required milliliter volume of the supplied suspension that contains the target dose of

360\text{ mg}

Anahtar Kavram

Weight-based pediatric dosage calculation and liquid volume conversion

Tahmini Süre:2m 0s

Soru 1218Soru →

A practical nurse is providing care for a client who had a right total hip arthroplasty using a posterior approach the previous day. The nurse is preparing to assist the client with repositioning and comfort measures in bed. Which of the following actions is the most appropriate to maintain proper alignment and prevent joint dislocation?

Place an abduction wedge or pillow between the client's legs while turning them.

Elevate the head of the bed to a 90-degree angle while the client eats their meals.

Support the right leg with a trochanter roll to encourage internal rotation of the hip.

Allow the client to cross their legs at the ankles while resting in a supine position.

Cevabı ve açıklamayı göster

Cevap: Place an abduction wedge or pillow between the client's legs while turning them.

Cevap

Place an abduction wedge or pillow between the client's legs while turning them.

Following a total hip arthroplasty with a posterior approach, maintaining abduction is a critical priority. Using an abduction wedge or pillow between the legs during turning prevents the affected leg from crossing the body's midline (adduction). This maintains the proper alignment of the femur in the acetabulum and prevents posterior dislocation of the prosthesis.

Adım Adım Çözüm

Identify the type of surgery and the associated movement precautions.

The client had a right total hip arthroplasty via a posterior approach. Precautions include avoiding hip flexion greater than 90 degrees, avoiding internal rotation, and avoiding adduction (crossing the midline).

Understanding surgical precautions is essential for planning safe basic care and positioning.

Evaluate each nursing action against the established hip precautions.

Using an abduction pillow prevents adduction and is the correct action. Sitting at 90 degrees causes excessive flexion. Encouraging internal rotation or crossing legs (adduction) directly violates precautions and risks dislocation.

Applying the precautions to routine comfort measures ensures the prosthesis remains stable during recovery.

Anahtar Kavram

Postoperative Positioning and Hip Precautions

Soru 1219Soru →

A practical nurse (PN) is assigned to care for a group of clients on a medical-surgical unit. When preparing and administering pharmacological therapies, which of the following actions are appropriate and within the PN's scope of practice? Select all that apply.

Geçerli olan tümünü seçin

Administering a scheduled dose of subcutaneous heparin to a client with deep vein thrombosis.

Administering an intravenous (IV) push dose of furosemide to a client experiencing an acute exacerbation of heart failure.

Reinforcing previous education about dietary potassium intake for a client who is newly prescribed oral spironolactone.

Administering the live-attenuated intranasal influenza vaccine to a client who is currently in their second trimester of pregnancy.

Auscultating the client's apical pulse for 60 seconds before administering a scheduled dose of oral digoxin.

Confirming a client's identity by asking them to state their first name only, bypassing the barcode scanner due to a damaged identification band.

Cevabı ve açıklamayı göster

Cevap: Administering a scheduled dose of subcutaneous heparin to a client with deep vein thrombosis.; Reinforcing previous education about dietary potassium intake for a client who is newly prescribed oral spironolactone.; Auscultating the client's apical pulse for 60 seconds before administering a scheduled dose of oral digoxin.

Cevap

The appropriate actions are administering subcutaneous heparin, reinforcing dietary education for spironolactone, and auscultating the apical pulse prior to digoxin administration.

The correct actions align with the practical nurse's scope of practice, which includes administering non-intravenous medications (such as subcutaneous heparin), collecting focused data (such as an apical pulse before digoxin), and reinforcing teaching initially provided by the registered nurse (such as dietary restrictions for spironolactone).

Adım Adım Çözüm

Evaluate each action against the practical nurse (PN) scope of practice.

Subcutaneous injections, reinforcing established teaching, and pre-administration data collection (vital signs) are within the PN scope.

The PN safely cares for stable clients with predictable outcomes and supports RN interventions.

Identify actions that require registered nurse (RN) level assessment or are out of scope.

Intravenous (IV) push medications require RN licensure.

IV push medications have immediate effects and require continuous advanced clinical judgment.

Review the remaining actions for strict adherence to pharmacological safety guidelines.

Giving a live vaccine to a pregnant client and using only one identifier are safety violations.

Live vaccines are contraindicated in pregnancy, and safety protocols mandate two unique client identifiers for medication administration.

Anahtar Kavram

Practical Nurse Scope of Practice and Medication Safety

Soru 1220Soru →

A client on a medical-surgical unit is scheduled to receive a routine dose of oral furosemide. Prior to administration, the practical nurse (PN) notes that the client's most recent serum potassium level is $2.9\text{ mEq/L}$ . Which action should the PN take first?

Administer the medication as prescribed and document the laboratory result in the client's chart.

Administer a prescribed intravenous push dose of potassium chloride to correct the deficit.

Withhold the furosemide and immediately notify the supervising registered nurse (RN).

Verify the client's identity using the barcode scanner and proceed with administration.

Cevabı ve açıklamayı göster

Cevap: Withhold the furosemide and immediately notify the supervising registered nurse (RN).

Cevap

The correct action is to withhold the furosemide and notify the registered nurse (RN).

The correct action is to withhold the medication and notify the RN. Furosemide is a loop diuretic that causes potassium depletion. A serum potassium level of

2.9\text{ mEq/L}

indicates severe hypokalemia (normal range is typically

3.5

5.0\text{ mEq/L}

). Administering the medication could lower the potassium level further, leading to life-threatening cardiac dysrhythmias. The PN must withhold the dose and escalate this critical finding.

Adım Adım Çözüm

Evaluate the client's serum potassium laboratory result.

Identify that a potassium level of

2.9\text{ mEq/L}

is significantly below the normal range (typically

3.5

5.0\text{ mEq/L}

To determine if the client's current physiological status is safe for the prescribed therapy.

Determine the pharmacological effect of furosemide.

Recognize that furosemide is a loop diuretic that causes the kidneys to excrete potassium.

To predict how the medication will impact the client's already compromised electrolyte balance.

Select the appropriate nursing intervention within the PN scope of practice.

Decide to withhold the medication and escalate the critical finding to the RN or healthcare provider.

To prevent severe hypokalemia, which can lead to life-threatening cardiac dysrhythmias, while operating safely within the PN scope of practice.

Anahtar Kavram

Furosemide Administration and Hypokalemia Management

ÖncekiSayfa 61 / 66Sonraki

Physiological Integrity

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Cevap

Adım Adım Çözüm

Anahtar Kavram