Physiological Integrity

A practical nurse is assigned to care for a client who underwent a lumbar laminectomy 24 hours ago. The client has become increasingly restless, is exhibiting new-onset mild confusion, and requires a bed bath with a complete linen change. Which of the following actions should the practical nurse take? Select all that apply.

During morning rounds, the practical nurse (PN) evaluates a client recovering from a severe lower respiratory tract infection. The PN monitors the client for potential respiratory compromise. Which of the following clinical manifestations should the PN recognize as early indicators of hypoxia? Select all that apply.

A client with heart failure is prescribed a scheduled dose of oral furosemide. During the morning data collection, the practical nurse notes that the client's serum potassium level is $2.9\text{ mEq/L}$. The client's vital signs include a heart rate of $108\text{ beats/min}$ and a blood pressure of $96/58\text{ mmHg}$. Which action is the priority for the nurse?

A practical nurse (PN) is assisting a client with evening hygiene and preparing them for sleep. The client had a cataract extraction on the left eye earlier in the day. Which action by the PN is the most appropriate to promote comfort and prevent complications during rest?

A practical nurse is caring for a client who is 24 hours postoperative following a right-sided pneumonectomy for lung cancer. The client is currently in a supine position and states, "My back aches from lying flat. Can you help me turn onto my side?" Which of the following actions should the nurse take?

A licensed practical nurse (LPN) is assessing a client who is 4 hours postoperative following a partial nephrectomy. Which of the following findings indicate a potential complication and should be immediately reported to the registered nurse (RN)? Select all that apply.

An older adult client is receiving treatment for a small bowel obstruction and has a nasogastric tube set to low continuous suction. Over the past six hours, the tube has drained 750 mL of gastric fluid. The assistive personnel reports that the client, who was previously alert and cooperative, is now persistently asking questions about a workplace they retired from two decades ago. The practical nurse enters the room and notes the client has a resting heart rate of 114 beats/min. Which action should the practical nurse take first?

A 77-year-old client is resting in the surgical unit one day after an open cholecystectomy. Previously conversant and calm, the client abruptly becomes restless, fails to recognize visiting family members, and reports intense abdominal aching. The practical nurse evaluates the client and records a blood pressure of 96/60 mm Hg, a pulse of 108 beats per minute, respirations at 24 breaths per minute, and an oxygen saturation of 93% on room air. Which immediate interventions should the practical nurse prioritize? (Select all that apply.)

A practical nurse is preparing to transfer a client who has left-sided hemiparesis following a cerebrovascular accident from the bed to a wheelchair. In what order should the nurse perform the following actions? (Move the steps into the correct chronological order.)

The clinical educator is evaluating a practical nurse (PN) during a medication administration pass on a step-down telemetry unit. The PN is managing multiple clients with complex medication regimens. Which of the following observed actions indicate that the PN is practicing safely and within the legal scope of practice? Select all that apply.

A practical nurse (PN) is preparing to administer a prescribed oral liquid suspension of ibuprofen to an 18-month-old toddler. Which action should the PN take to ensure safe medication administration?

A practical nurse is caring for a client who is 48 hours postoperative following a right above-the-knee amputation. To prevent a common musculoskeletal complication associated with this procedure, which positioning action should the practical nurse implement?

Following a shift handoff report, you are reviewing the clinical data of a client who underwent an open splenectomy 12 hours ago. Which of the following findings requires the most urgent notification of the registered nurse (RN)?

A 72-year-old client is admitted to the medical unit with acute gastroenteritis and frequent watery stools. During the afternoon shift, the practical nurse (PN) observes that the client is restless, has dry oral mucosa, and exhibits new mild confusion. The client's current vital signs are: blood pressure 102/64 mm Hg (admission baseline 130/80 mm Hg) and heart rate 114 beats/min (admission baseline 84 beats/min). Which action should the PN take first?

A practical nurse (PN) is evaluating a 79-year-old client admitted yesterday with an acute exacerbation of peptic ulcer disease. The client's spouse calls the PN to the room, stating the client suddenly seems highly disoriented and is attempting to get out of bed. The PN observes the client's skin is pale and cool to the touch. Current vital signs are: heart rate 108 beats/minute, respirations 22 breaths/minute, and blood pressure 104/66 mm Hg. The client's admission blood pressure was 142/84 mm Hg. Which action should the PN take FIRST?

Following a motor vehicle collision, a client with a confirmed pelvic fracture is admitted to the progressive care unit. During the morning assessment, the practical nurse reviews the client's laboratory results, which reveal a hemoglobin level of 9.2 g/dL (92 g/L). The nurse notes that the client has produced only 80 mL of urine over the previous 4 hours. Current vital signs include a heart rate of 118 beats/minute, blood pressure of 102/64 mm Hg, and respiratory rate of 22 breaths/minute. The client suddenly reports an intense, new sensation of pressure in the pelvic region. Which of the following actions should the practical nurse take first?

An adult client is recovering on the surgical unit on the third day after undergoing a left below-the-knee amputation. As part of routine daily management, which fundamental care and comfort actions should the practical nurse implement? Select all that apply.

A practical nurse is reviewing clinical data for four assigned clients. Which client finding indicates the highest risk for a life-threatening complication and requires immediate communication to the registered nurse?

A practical nurse (PN) is providing morning care to a client who is 3 days postoperative following an exploratory laparotomy. The client coughs forcefully and reports a "popping" sensation. The PN observes that the abdominal incision has completely separated, with a loop of bowel protruding. Arrange the following nursing actions in the correct priority sequence from first to last.

A practical nurse (PN) is preparing to administer morning medications, including digoxin and furosemide. When checking the client's chart, the PN discovers a new serum potassium result of $2.6$ mEq/L. Arrange the following actions in the correct priority sequence.