Physiological Integrity

A practical nurse (PN) is preparing to administer a prescribed dose of inhaled fluticasone via a metered-dose inhaler (MDI) with a spacer to a client with chronic asthma. Arrange the following steps for administering this medication in the correct chronological order.

A practical nurse (PN) is reviewing the medication administration record for a client who is prescribed oral cephalexin for a wound infection. The client's medical history indicates a severe anaphylactic allergy to penicillin. Which of the following actions should the PN take?

During the morning medication pass at a long-term care facility, a practical nurse reviews the electronic health record of a resident diagnosed with heart failure. The resident is scheduled to receive oral doses of digoxin and furosemide. Morning laboratory results indicate a serum potassium of 3.1 mEq/L (3.1 mmol/L) and a serum digoxin level of 1.3 ng/mL (1.66 nmol/L). The resident's current vital signs are blood pressure 102/58 mm Hg, heart rate 94 beats per minute, and respiratory rate 18 breaths per minute. Which action should the nurse prioritize to minimize the risk of complications?

While observing an adolescent client on the surgical unit who had a tonsillectomy earlier in the day, the practical nurse notes that the client is restless and swallowing repeatedly. The continuous monitor shows a current heart rate of $118$ beats per minute, compared to a baseline of $82$ beats per minute. Which action should the practical nurse take FIRST?

A practical nurse is caring for a client who is receiving continuous enteral nutrition via a nasogastric tube. The client suddenly begins coughing vigorously, becomes tachypneic, and appears cyanotic. Arrange the following nursing actions in the correct priority order to reduce the client's risk for further complications. (Place the first action at the top and the last action at the bottom.)

A practical nurse (PN) is monitoring a client who is receiving a transfusion of packed red blood cells. Fifteen minutes into the transfusion, the client reports sudden lower back pain, chills, and dyspnea. Place the following nursing actions in the correct order of priority.

A practical nurse is caring for a client receiving continuous bladder irrigation following a transurethral resection of the prostate. The client suddenly reports severe lower abdominal cramping, and the nurse observes that there is no fluid draining into the urinary collection bag. In what order should the practical nurse perform the following actions? (Arrange from first to last)

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

During morning rounds, a client with a history of a T4 spinal cord injury suddenly reports a severe, pounding headache. The practical nurse observes that the client is experiencing profuse sweating above the level of the chest and exhibits nasal congestion. Which immediate interventions are appropriate for this client? Select all that apply.

A practical nurse (PN) is assigned to care for a client who returned to the medical-surgical unit one hour ago following an esophagogastroduodenoscopy (EGD) with a gastric biopsy. The client is resting quietly and reports mild throat soreness. The PN records the following vital signs: blood pressure 106/62 mm Hg, heart rate 108 beats/minute, and respiratory rate 18 breaths/minute. The client's pre-procedure vital signs were blood pressure 144/82 mm Hg, heart rate 72 beats/minute, and respiratory rate 16 breaths/minute. Which action should the PN take first?

Following a right-sided percutaneous liver biopsy, an adult client is transferred to the medical-surgical floor for ongoing monitoring. Which positioning strategy should the practical nurse implement to minimize the risk of post-procedure complications?

An adult client with a history of severe inflammatory bowel disease is receiving continuous total parenteral nutrition (TPN) through a peripherally inserted central catheter (PICC). The practical nurse evaluates the morning laboratory results and identifies a serum glucose level of 415 mg/dL (23.0 mmol/L). During the morning assessment, the client appears lethargic, and the vital signs reveal a heart rate of 114 beats/minute and a blood pressure of 94/56 mm Hg. Which action must the practical nurse implement first?

A practical nurse (PN) is caring for a 72-year-old client who was admitted two days ago following a motor vehicle collision that resulted in a fractured pelvis. During the evening shift, the client becomes increasingly restless, begins pulling at the bed linens, and exhibits new-onset confusion regarding the current location. The client's vital signs are blood pressure 104/82 mm Hg, heart rate 114 beats per minute, and respiratory rate 24 breaths per minute. Which action should the PN take first?

A client is admitted to the surgical nursing unit immediately after a partial thyroidectomy. A practical nurse is contributing to the client's immediate postoperative care plan. Which of the following positioning and comfort measures should the nurse implement? Select all that apply.

A practical nurse is preparing to administer a scheduled crushed medication via a client's nasogastric (NG) tube. To reduce the risk of complications, arrange the following nursing actions in the correct clinical sequence.

A practical nurse (PN) is monitoring a client who underwent a percutaneous coronary intervention via the right femoral artery three hours ago. The client states, "I feel really thirsty and a little dizzy." The PN notes the client's heart rate has gradually increased from a baseline of 74 bpm to 108 bpm, and blood pressure has trended from 132/80 mm Hg to 104/62 mm Hg. Which action should the PN perform first?

A practical nurse is caring for an older adult client with a history of atrial fibrillation who is prescribed daily warfarin. During morning rounds, the client appears suddenly confused and restless. The client's most recent International Normalized Ratio (INR) is 5.5. Which of the following actions should the nurse take first?

A practical nurse is providing basic care for an older adult client who is weak and on prescribed bed rest following a right-sided thoracentesis. The client is receiving continuous oxygen therapy via nasal cannula. Which actions should the nurse include in the plan of care? Select all that apply.

A practical nurse is preparing to administer a mixed dose of intermediate-acting (NPH) and short-acting (Regular) insulin to a client with diabetes mellitus. Arrange the following steps in the correct chronological order for mixing these insulins in a single syringe.

An older adult client in a long-term care facility is receiving a continuous enteral feeding via a nasogastric tube. The practical nurse is preparing to perform a complete bed bath and change the client's bed linens, which requires lowering the head of the bed. Which action is essential for the nurse to take?