Physiological Integrity

A client admitted with an exacerbation of heart failure is scheduled to receive oral digoxin and oral furosemide. The client is also prescribed an annual influenza vaccine. Morning laboratory results indicate a serum potassium level of $2.8\text{ mEq/L}$ ($2.8\text{ mmol/L}$) and a serum digoxin level of $1.0\text{ ng/mL}$ ($1.28\text{ nmol/L}$). The client reports experiencing a new onset of muscle cramps, weakness, and a temperature of $101.2^\circ\text{F}$ ($38.4^\circ\text{C}$). Which actions should the practical nurse take? Select all that apply.

A client with a history of heart failure is receiving a continuous intravenous fluid infusion. Which new assessment findings should the practical nurse identify as indicating an acute physiological complication that requires immediate intervention? Select all that apply.

A practical nurse is providing care for a client who returned to the nursing unit 2 hours ago following a diagnostic cardiac catheterization accessed via the right femoral artery. The client is prescribed strict bed rest and reports mild lower back discomfort. Which interventions are appropriate for the nurse to implement to promote comfort while maintaining safety? Select all that apply.

During morning rounds, a practical nurse observes that a resident with type 1 diabetes mellitus is pale, sweating profusely, and visibly shaking. The resident is conscious, able to follow commands, and has an intact gag reflex. In what sequence should the practical nurse perform the following actions? Arrange them from the highest priority (first action) to the lowest priority (final action).

A practical nurse (PN) is preparing to administer a scheduled transdermal nitroglycerin patch to a client with a history of stable angina. The client currently has an active patch on their right upper chest. In what order should the PN perform the following actions to ensure safe medication administration?

A practical nurse is caring for a client who returned to the medical-surgical unit 2 hours ago following a colonoscopy with multiple polyp removals. The client reports feeling "a bit lightheaded" and excessively thirsty. The client's current vital signs are: blood pressure 102/64 mm Hg, apical heart rate 114 beats/minute, and respiratory rate 20 breaths/minute. The client's pre-procedure baseline vital signs were blood pressure 136/84 mm Hg and heart rate 72 beats/minute. Which action should the nurse take first?

A practical nurse (PN) is caring for a client who is 6 hours postoperative following a total thyroidectomy. Upon entering the room, the PN notes that the client is restless, swallowing frequently, and has a heart rate of 114 beats/min. The client's blood pressure is 98/64 mm Hg. Which of the following immediate actions should the PN take? (Select all that apply.)

During a routine wound assessment, a licensed practical nurse discovers that a postoperative client's abdominal incision has completely opened, and loops of bowel are visible outside the body cavity. Arrange the following emergency interventions in the correct chronological sequence to mitigate physiological risk.

An older adult client has been transferred to the medical-surgical unit following a left total hip arthroplasty via a posterior approach. The practical nurse is assisting with the client's initial positioning in bed. Which action should the nurse take to maintain correct body alignment and prevent joint dislocation?

A practical nurse (PN) is preparing to administer scheduled morning medications to a client who is $24\text{ hours}$ postoperative. The medication administration record includes oral oxycodone for pain management, oral docusate sodium, and subcutaneous heparin. Upon entering the room, the PN observes that the client is somnolent, mumbles incoherently when stimulated, and exhibits shallow breathing. The client's vital signs are: blood pressure $102/68\text{ mmHg}$, heart rate $78\text{ bpm}$, respiratory rate $9\text{ breaths/min}$, and oxygen saturation $88\%$ on room air. Which of the following is the most appropriate action for the PN to take?

An older adult client is recovering on the telemetry unit 2 hours after a cardiac catheterization performed via the right femoral artery approach. During rounding, the client reports the sudden onset of a dull, continuous ache in the lower right back. The insertion site dressing remains clean and dry with no visible hematoma. Current vital signs reveal a blood pressure of 102/58 mmHg and a heart rate of 108 bpm, compared to a baseline of 134/76 mmHg and 72 bpm upon arrival. Based on these findings, what is the priority action for the practical nurse?

A practical nurse is monitoring a client who was recently admitted with a deep vein thrombosis (DVT) in the left lower extremity. Which new clinical finding should the nurse identify as the highest priority to report to the charge nurse immediately?

A practical nurse (PN) is caring for a conscious client with diabetes mellitus who suddenly reports feeling shaky and appears diaphoretic. Arrange the following nursing actions in the correct priority sequence to manage this situation and reduce the risk of severe complications. All options must be used.

A practical nurse is collecting data from a client who is 6 hours postoperative following a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigation (CBI). Which of the following findings indicate a potential complication that requires immediate notification to the registered nurse? (Select all that apply)

A practical nurse is gathering data on an older adult client who returned to the surgical unit 4 hours ago after a colon resection. The client's baseline vital signs were a blood pressure of 136/82 mm Hg and a pulse of 74 beats/min. Currently, the blood pressure is 108/66 mm Hg with a pulse of 102 beats/min. The client is continuously picking at the bed linens and complains of incisional pain. What is the priority nursing action?

An 82-year-old client is admitted to the acute care facility for treatment of a severe urinary tract infection. During the shift assessment, the practical nurse (PN) notes the client is restless and disoriented to place, which is a change from baseline. The client's heart rate is 118 beats per minute, respirations are 26 breaths per minute, blood pressure is 92/54 mm Hg, and oral temperature is 96.4°F (35.8°C). Which actions should the PN take? Select all that apply.

A practical nurse (PN) is preparing to mix and administer 5 units of regular insulin and 15 units of NPH insulin in a single syringe for a client with diabetes mellitus. In what order should the PN perform the following steps to prepare the medication? Arrange the actions from first to last.

While assisting a client who has left-sided hemiparesis to move from the bed to a wheelchair, a practical nurse must ensure proper mechanics and safety. In what order should the nurse perform the following actions? Arrange the steps from first to last.

A 74-year-old client is recovering on the orthopedic unit following surgical fixation of a fractured pelvis. The practical nurse (PN) observes that the client, who was previously calm and oriented, is now highly agitated, picking at their intravenous (IV) tubing, and has a resting apical pulse of 116 beats per minute. Which actions should the PN implement immediately? Select all that apply.

A practical nurse (PN) is preparing to assist a client with their morning meal. The client is 48 hours postoperative following a carotid endarterectomy and has residual dysphagia from a previous cerebrovascular accident (CVA). The client is also reporting mild shoulder pain. Which action is the priority for the PN to ensure safe and comfortable care?