Physiological Integrity

A practical nurse is providing care for a client who is four hours postoperative following a total abdominal hysterectomy. The client reports incisional pain rated as a 4 on a 0 to 10 scale and mild nausea. Current vital signs reveal a temperature of 99.1°F (37.3°C), a heart rate of 116 beats/minute, a respiratory rate of 20 breaths/minute, and a blood pressure of 92/56 mm Hg. The client's preoperative blood pressure was 122/76 mm Hg. Which action should the nurse take first?

A practical nurse (PN) is prioritizing care for a client who is 6 hours postoperative following a partial bowel resection. The PN reviews the client's current assessment data and laboratory results. Which of the following findings indicate a potential complication requiring immediate escalation to the registered nurse (RN)? Select all that apply.

A practical nurse (PN) is caring for a client with a spinal cord injury at the T4 level. The client suddenly reports a severe, pounding headache and blurred vision. The PN observes profuse diaphoresis and flushing above the level of the injury. Arrange the following actions in the order the PN should perform them, from first to last.

A client recovering from a cerebrovascular accident has documented dysphagia and right-sided facial weakness. The client is currently alert and ready to eat lunch. Which technique is correct for the practical nurse to implement when assisting this client with their meal?

Following a percutaneous coronary intervention (PCI) via the right femoral artery, a client is transferred to the medical-surgical unit. During the $2$-hour post-procedure assessment, the practical nurse evaluates the client's status. Which assessment findings suggest an impending clinical emergency requiring immediate notification of the registered nurse? Select all that apply.

An adult client is prescribed a daily dose of oral diltiazem for the management of hypertension. Prior to providing the morning dose, the practical nurse (PN) obtains a blood pressure reading of $88/54$ mm Hg and an apical heart rate of $58$ beats/min. Which of the following actions should the PN perform?

The practical nurse (PN) is assisting a healthcare provider with a lumbar puncture for an adult client on the medical-surgical unit. In what order should the PN perform the following actions to ensure client safety and reduce the risk of complications? Arrange the actions in the correct chronological sequence.

An assigned client recently underwent a large-volume paracentesis for the management of ascites. Two hours following the procedure, the practical nurse records a blood pressure of 94/56 mmHg and a resting heart rate of 118 beats per minute. The client's pre-procedure baseline demonstrated a blood pressure of 134/82 mmHg and a heart rate of 74 beats per minute. Based on these findings, which action must the nurse take first?

The practical nurse is assigned to care for an older adult client diagnosed with severe community-acquired pneumonia. The client was alert and cooperative during the previous shift. Currently, the client is agitated, actively trying to climb out of bed, and giving disorganized answers to simple questions. Which action represents the most appropriate initial response by the nurse?

A licensed practical nurse is caring for a client who underwent abdominal surgery earlier in the day. The client requests a scheduled as-needed dose of oral hydromorphone, reporting incisional pain as 9 on a 0-to-10 scale. Upon data collection, the nurse observes that the client is extremely drowsy, difficult to arouse, and has a respiratory rate of 8 breaths per minute. Which action should the nurse take first?

A practical nurse (PN) enters the room of a client receiving a continuous enteral tube feeding. The client is coughing forcefully, appears dyspneic, and is clutching their chest. In which order should the PN perform the following actions? (Arrange the actions from first to last.)

A practical nurse is preparing to administer a scheduled dose of cefazolin $750\text{ mg}$ intramuscularly (IM) to a client with a skin infection. The medication is supplied as a $1\text{ gram}$ vial of dry powder. The reconstitution instructions on the vial state: "Add $2.5\text{ mL}$ of sterile water for injection to yield a final concentration of $330\text{ mg/mL}$."

How many $\text{mL}$ should the nurse administer? Record the answer to the nearest tenth. Do not include units in the answer.

A practical nurse (PN) is caring for a client with a T4 spinal cord injury. The client suddenly reports a severe, pounding headache and nasal congestion. The PN observes profuse sweating above the level of the spinal injury. Arrange the following nursing actions in the priority order the PN should perform them.

A practical nurse is preparing a combined subcutaneous injection of regular insulin and NPH insulin for a client whose pre-meal capillary blood glucose level is 185 mg/dL. To ensure safe medication preparation and avoid cross-contamination, arrange the following steps in the correct chronological sequence.

A practical nurse is reviewing the morning laboratory results for an adult client who is prescribed a scheduled dose of oral warfarin. The client's most recent international normalized ratio (INR) is 4.6. Which of the following actions should the practical nurse take first?

An assigned client is recovering on the medical-surgical unit two hours after a percutaneous liver biopsy. The client complains of new-onset right shoulder pain. The current vital signs reveal a heart rate of 104 beats/min and a blood pressure of 102/64 mm Hg, compared to a pre-procedure heart rate of 74 beats/min and a blood pressure of 126/80 mm Hg. What is the most appropriate next step for the practical nurse (PN)?

During the afternoon shift, a client is transferred back to the surgical unit four hours after undergoing a total thyroidectomy. Which interventions must the practical nurse implement to minimize the risk of postoperative complications? Select all that apply.

A client with liver cirrhosis and a recent history of esophageal varices is resting in a medical-surgical unit. Upon assuming care, the practical nurse notes a baseline blood pressure of 106/72 mm Hg and a heart rate of 94 beats per minute. An hour later, the client suddenly becomes restless, begins pulling at the bed linens, and has pale, diaphoretic skin. Which action should the practical nurse take first?

A practical nurse (PN) is walking in the hallway with a client who has a history of seizure disorders. The client suddenly loses consciousness and begins to experience tonic-clonic muscle jerking. In what order should the PN perform the following actions? Arrange the actions in order of priority from first to last.

During a routine morning shift on a general care unit, a practical nurse is tasked with safely administering medications and monitoring clients. Which of the following actions by the nurse indicate proper pharmacological safety and adherence to professional scope? Select all that apply.