Medical-Surgical Assignment Exam

A client who accidentally received an electrical shock at work and temporarily lost consciousness is brought to the emergent care center by his supervisor because the client states that he doesn't feel well. What intervention should the practical nurse implement first?

Attach a cardiac monitor Rationale The major cause of death from electrical injuries is cardiac dysrhythmia. The client's syncopal episode after the electrical shock indicates a possible cardiac complication, so electrodes for cardiac monitoring (B) should be applied first. (A) is not a priority

A client with a vertebral fracture at T3 after falling from a roof is sent for radiological testing. Which assessment is a priority for the practical nurse (PN) to implement when the client returns to the unit?

Bilateral hand grip and strength. Rationale Assessment for T3 neurological deficits due to spinal cord swelling should include evaluation of bilateral hand grip and strength (A). (B, C, and D) may be indicated, but the priority is a focus assessment for spinal cord injury related to the fractured vertebrae.

A client who is 12 hours postoperative for a right total knee replacement (TKR) is receiving epidural pain management. Which finding requires additional follow-up by the practical nurse (PN)?

Right dorsal pedal pulse absent upon palpation. Rationale Absent pedal pulses in the operative leg is indicative of arterial occlusion, a postoperative complication of TKR, and requires further assessment (D). (A, B, and C) are expected findings following knee replacement surgery.

A client who is 12-hours postoperatively for a total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAHBSO) is refusing to turn and perform postoperative leg exercises. What action should the practical nurse take?

Apply bilateral compression stockings (TEDs). Rationale Following major abdominal surgery, such as TAHBSO, prophylactic measures to prevent deep vein thrombosis (DVT) is a priority, so TEDS (A) should be applied to the client's legs. The client is mostly likely not receptive to reinforcement of teaching (B) in the immediate postoperative period. Although the client has the right to refuse to follow instructions (C) and may need to be medicated (D), the routine use of TEDS is valuable in the prevention of blood pooling in the lower extremities.

A 55-year-old male client with an abdominal aortic aneurysm (AAA) presents to the emergent care center reporting abdominal and scrotal pain and feeling dizzy. Which finding should the practical nurse report to the healthcare provider?

Blood pressure of 160/90. Rationale An AAA can manifests as a palpable abdominal mass that pulsates, which can cause pain in the abdomen, lower back, or scrotum as the aneurysm enlarges. To prevent rupture of the AAA, the client's must be maintained normotensive, so the elevated blood pressure (D) should be reported to the healthcare provider. (A, B, and C) are not related to AAA.

Which information should the practical nurse (PN) reinforce with a female client who has a history of frequent urinary tract infections (UTI)?

Drink a glass of cranberry juice daily. Rationale Drinking cranberry juice (A) has been demonstrated to decrease the risk for UTI by preventing bacteria from adhering to the bladder wall. (B, C, and D) do not decrease the risk for developing UTIs.

A client recovering from a gastrojejunostomy (Billroth II) surgery reports dizziness, weakness, palpitations, and an urge to defecate about 20 minutes after eating. What teaching should the practical nurse reinforce with the client?

Eat low-carbohydrate foods 6 times/day. Rationale The client is experiencing the signs and symptoms of dumping syndrome related to the malabsorption of carbohydrates due to a deficiency of digestive enzymes. The client should consume smaller, more frequent meals that are low in carbohydrates and refined sugar (D), moderate in fat, and moderate to high in protein. Fluids should be taken between meals, not (A). Lying down for about 30 minutes after meals is helpful, not (B). (C) is not indicated.

When performing a focused neurological assessment for an adult client, which finding should the practical nurse report to the charge nurse?

Flexion decorticate posturing. Rationale Flexion posturing or decorticate posturing (D) indicates significant intracranial shifting and cerebral damage and should be reported to the charge nurse. (A, B, and C) are normal findings for adults.

A client with a history of epilepsy is admitted for back pain related to the presence of a cyst located at T6. The client has a tonic-clonic (grand mal) seizure and 30 minutes later is incontinent of urine. What is the priority action for the practical nurse to implement?

Have the client push both feet against the nurse's hands. Rationale Incontinence can occur during a seizure, but the delay of incontinence may be related to rupture of the spinal cyst which results in neurological impairment. Assessment of lower extremity function (B) is the priority. (A, C, and D) should be implemented, but the priority is focused assessment for possible complications.

A client returns to the unit after spinal anesthesia for surgical removal of left tibial hardware. Which finding requires further action by the practical nurse?

Left pedal pulses barely palpable. Rationale An abnormal neurovascular assessment, such as a decreased pedal pulse (C), indicates poor distal perfusion to the left foot and requires intervention. Decreased sensation (A) and movement (B) is expected while residual spinal anesthesia is still present. Local edema (D) is an expected finding related to the trauma of surgical removal of orthopedic hardware.

The practical nurse (PN) is preparing a male client for discharge when he begins to complain of dyspnea. The client's vital signs are pulse at 90 beats/minute, respirations 24 breaths/minute, blood pressure 140/70, and oxygen saturation of 91%. After supplemental oxygen is provided, the client's oxygen saturation is 99%. Which assessment provides the best indication that the client is ready for discharge?

Oxygen saturation without oxygen. Rationale Prior to discharge, the client's ability to adequately compensate is best evaluated by measuring oxygen saturation levels without supplemental oxygen (D). (A, B and C) provide other assessment parameters, but (D) provides the best indication that the client is ready for discharge.

The practical nurse (PN) is reviewing the complete blood count results for a male client with a wound infection and determines the results indicate leukocytosis. What intervention should the PN implement?

Recognize this is an indication of the body's response to fighting the infection. Rationale Leukocytosis is the increase in white blood cells in response to pathogens in a wound, which is the normal physiological reaction to an infectious process (B). (A, C, and D) are not indicated at this time.

A female client who is postmenopausal calls the clinic and states that she has been spotting for the last three days. What action should the practical nurse (PN) implement?

Tell the client to come to the clinic today. Rationale Postmenopausal bleeding is an abnormal finding which can be a sign of endometrial cancer, so the PN should tell the client to come to the clinic today (B). (A, C, and D) are not indicated at this time.

The practical nurse (PN) is reinforcing discharge instructions for a client with a concussion. Which client goal should the PN emphasize as the client's highest priority?

The spouse will regularly check on the client's level of responsiveness. Rationale Discharge instructions for a client after a concussion should include the availability of the spouse who can recognize early changes in level of consciousness (D). (A) is not indicated. (B and C) do not ensure that the client will be able to recognize significant changes that require medical follow-up, which is best observed by the client's spouse or another reliable adult.

A client who is positive for human immunodeficiency virus (HIV) comes to the clinic for a routine check up. During the initial interview, the client's partner tells the practical nurse (PN) that the client has had several occasions of mental confusion. The PN should focus questions to determine if the client is developing which opportunistic infection?

Toxoplasmosis. Rationale Clients with HIV who have toxoplasmosis (C) of the brain are most likely to manifest mental confusion, so questions should focus on this protozoan infection that is hosted in cats and excreted in cat feces. Although Kaposi's sarcoma has been associated as an AIDS-defining opportunistic infection, it is a dermatological sarcoma associated with the herpes virus, not a neurological complication. (B and D) are respiratory acquired opportunistic infections in clients with acquired immunodeficiency syndrome (AIDS).

The practical nurse (PN) is reviewing prescriptions for four clients. Which prescription should the PN question?

Encourage incentive spirometer PRN for wheezing. Rationale Incentive spirometer (C) should be questioned because its use increases inspiratory reserve and prevents atelectasis but is not effective for wheezing, which is most commonly associated with asthma. (A) provides a prescription to ensure the client's safety. The use of continuous passive motion (CPM) (B) is prescribed at incremental angle flexion to ensure joint mobility after surgery. (D) gives constant airway pressure to keep airways opened for a client with sleep apnea.

A client with chronic obstructive pulmonary disease (COPD) is using pursed-lip breathing while he is sitting up in a chair by the bedside. The practical nurse (PN) obtains his respiratory rate at 20 breaths/minute and his pulse oximetry is 91% on room air. What action should the PN implement?

Encourage the client to sit up and lean forward. Rationale To assist with breathing, a client with COPD should sit up and lean forward (A), which is called tripoding. (B) is contraindicated for a client with COPD whose respiratory drive is affected by carbon dioxide levels. COPD causes air trapping from loss of alveoli elasticity, not lack of lung expansion, so (C) is not indicated. (D) is not indicated.

An older client is seen in the clinic for an annual physical exam. Which finding should the practical nurse report to the healthcare provider for follow-up?

Hemoglobin 9.1 grams/dl with positive occult blood in stool. Rationale Anemia and occult blood in the stool (A) are early signs of bleeding related to cancer of the colon cancer in a client over the age of 50 and should be reported to the healthcare provider for follow-up. (B) is not abnormal. (C) are normal sounds of peristalsis. (D) is indicative of gas or flatulence.

A male client with emphysema is using pursed-lip breathing and reports to the practical nurse (PN) that he is having a more difficult time breathing. Which intervention should the PN implement?

Lean the client forward on both forearms while sitting. Rationale The client should lean forward in a "tripod" position (C) to maximize respiratory excursion. (A) is not indicated. (B) is used for maximal inspiration that is commonly prescribed postoperatively to prevent atelectasis. The client is experiencing difficulty breathing, and (D) is not the priority at this time.

The practical nurse (PN) receives shift report about a client whose chest x-ray reveals "free air under the right diaphragm." What action should the PN take?

Maintain the client NPO. Rationale "Free air under the diaphragm" on an upright chest x-ray is most often indicative of a gastrointestinal perforation, and the client will probably need surgery, so the client should be kept NPO (A) until that determination is made. Since the air is outside the colon, hence the term "free air," it will not help to position (B) or ambulate (C) the client. (D) is not indicated.

An older client who is at a health fair goes to the First Aid station and reports feeling tired after a recent screening test revealed a hemoglobin of 10.1 grams. The client asks the practical nurse (PN) what could he do to feel better. What information should the PN offer?

Make appointment with healthcare provider. Rationale A common cause of anemia in the elderly is blood loss from the gastrointestinal or genitourinary tracts, so the PN should recommend that the client visit to the healthcare provider for further assessment (D). The cause of the anemia must first be determined before attempting to treat it as iron-deficiency anemia through diet (A) or supplements (B). Stress-relieving measures (C) are always a healthful option, but the etiology and proper treatment of the known problem is a priority.

An older client is manifesting third-degree heart block on the telemetry monitor. The client's vital signs are apical pulse 30 beats/minute, respirations 12 breaths/minute, and blood pressure 70/50. Which initial intervention should the practical nurse anticipate?

Obtain the external pacer and crash cart. Rationale In third-degree block, electrical impulses can not reach the ventricles to illicit contractions that sustain adequate cardiac output. Direct stimulation with an external pacer and emergency cardiopulmonary support equipment on the crash cart (C) are needed to provide circulation until the healthcare provider can insert a temporary transvenous pacemaker. (A, B, and D) are not indicated in third-degree heart block.

A client who is experiencing an acute asthma attack is receiving rescue medication. The practical nurse (PN) reviews the client's history to determine the client's respiratory function over the past few months. Which device results should the practical nurse review to obtain data that measures the client's personal best respiratory function?

Peak flow meter. Rationale A peak flow meter (D) measures the client's ability to breathe air out and provides information regarding the client's personal best respiratory status. (A, B, and C) do not indicate air flow volumes that indicate the client's respiratory function. (A) measures current oxygenation. (B) shows lung fields. (C) is used to help clients expand their lungs to prevent atelectasis.

An adult male arrives in the clinic an hour after he was hit on the right side of the head in a golfing accident. The client is taking warfarin (Coumadin) for atrial fibrillation. Which finding should the practical nurse report to the healthcare provider immediately?

Pupil size, right 7 mm and left 5 mm. Rationale The client is at risk for prolonged bleeding due to Coumadin. Unequal pupil size (C) is indicative of increased intracranial pressure due to a possible epidural hematoma and should be reported to the healthcare provider immediately. Periorbital swelling (A) is an expected finding after facial trauma, and the client's Snellen test is within normal. (B) is likely related to pain and stress of the traumatic injury and should be monitored for changes, but the most significant finding is ipsilateral pupil dilatation. Facial structures are highly vascular, so (D) is an expected finding.

After attending a class on testicular self-examination (TSE), a client reviews the examination's components with the practical nurse (PN). Which comment should the PN confirm with the client as correct self-examination technique?

Roll each testis between thumb and fingers. Rationale Proper TSE includes rolling each testis individually between the thumb and fingers (C). Although (A) may be associated with prostatic inflammation or hypertrophy, it is not a component of the examination technique. The most common recommendation includes performing the examination while taking a shower, not (B). The testes should normally feel smooth, like a "hard boiled egg," which does not need to be reported (D).

An adult male presents in the Emergency Center with "tearing" chest pain that has moved into his back. Which finding by the practical nurse in the client's history is relevant to the client's chest pain?

Smokes three packs of cigarettes a day Rationale Cigarette smoking (A) is the common risk factor associated with hypertension that contributes to dissecting aneurysms of the aortic arch, which is manifested by "tearing chest" that radiates to the back. Alcohol consumption (B) does not have a direct correlation with dissecting aneurysms. Although (C) increases the client's risk for diabetes, the most relevant client behavior that contributes to arterial disease is cigarette smoking. (D) is not related to these symptoms.

The practical nurse (PN) determines that a female client who is returning to the clinic with urinary urgency, frequency, and burning on urination has been in the clinic several times in the past few months with urinary tract infections (UTIs). The client asks the PN how to prevent these infections from reoccurring. What information should the PN give to this client? (Choose all that apply.)

Take all of the prescribed antibiotic. Void before and after sexual intercourse. Wipe from front to back after voiding. Rationale (A, B, and E) are correct. Information that should help the client minimize recurrent UTI includes reinforcing the need to complete all of a prescribed antibiotic (A) even if symptoms resolve after 1 to 2 days of therapy. Hygienic practices, such as emptying the bladder before and after sexual intercourse (B) and wiping from front to back after urinating (E) reduce bacteria introduction into the urethra. Drinking plenty of fluids is often recommended, and avoiding (C) does not necessarily reduce the risk for UTIs. Vaginal douches, harsh soaps, bubble baths, powders, and sprays in the perineal area (D) can irritate the meatus and facilitate bacterial entrance and should be avoided.

The practical nurse (PN) is discussing cancer screening for a group of women who attend a healthy living seminar at the clinic. What information should the PN review?

The Pap smear test is recommended when sexual activity begins. Rationale The human papilloma virus (HPV) is a sexually transmitted infection that causes slow-growing cervical cancer. The Pap smear identifies early cervical cell changes and should be recommended when sexual intercourse begins (D). Adults should have a screening colonoscopy at age 50, not (A). Baseline mammograms (B) are recommended usually at age 40. (C) is recommended for vaginal bleeding in postmenopausal women, not as a screening test for other menstrual irregularities.

A male client arrives at the clinic for a routine physical examination and states he suddenly does not feel well. The practical nurse (PN) obtains the client's vital signs. Which assessment finding has the highest priority?

The oxygen saturation of 88%. Rationale The priority finding is the client's low oxygenation saturation (A). Although the client's blood pressure (B) and cool diaphoretic skin are abnormal, the client's poor oxygenation status is of higher priority than (B and C). (D) is not a significant finding.

The practical nurse (PN) is irrigating the eye of a male client who had a known alkaline substance splashed into his eye. Which finding indicates the PN should stop the procedure?

The pH is 7.4 in the affected eye. Rationale Alkali injuries in the eye can penetrate conjunctival tissues more readily than acids, so irrigation with copious amounts of water should continue until the pH of the eye returns to normal (C). Absence of eye pain (A) is not a reliable indicator that treatment should be stopped. Visual acuity should be measured, but it is not a reliable indicator that all of the alkaline substance has been removed (B). A red reflection is usually related to a corneal abrasion (D).

The practical nurse (PN) is transferring a client to the in-patient dialysis unit for hemodialysis scheduled for today. Which information is essential for the PN to report to the receiving nurse?

Today's hemoglobin result of 8.0 grams. Rationale The PN should report the client's recent hemoglobin level (D), which is low and is essential information in planning the client's care for hemodialysis. (A and B) are standards of care for a client who is receiving dialysis. Although routine antihypertensive drugs (C) are withheld before hemodialysis, the priority is the client's need for possible blood transfusion during the next hemodialysis session.

The practical nurse (PN) is caring for a male client who had laparoscopic removal of a kidney tumor this morning. Which priority assessment should the PN include during the immediate postoperative period?

Urinary output. Rationale Bleeding is a common surgical complication that affects renal perfusion. Priority assessments should include vital signs and urine output (A). (B, C, and D) should be determined, but renal perfusion and elimination are priorities after excision of a kidney tumor.

On admission, a client with an acute myocardial infarction receives a thrombolytic, aspirin, and IV heparin. Which finding indicates to the practical nurse (PN) that the client is having a therapeutic response to the medication?

Activated partial thromboplastin time (APTT) results 2 times the control. Rationale Acute Coronary Syndrome (ACS) protocol includes the administration of thrombolytics, aspirin, and IV heparin, which prolongs the activated partial thromboplastin time at the therapeutic range that is two times the control value (C). This protocol of medications has no therapeutic effect on lungs sounds (A), heart rate or peripheral edema (B), or platelet count (normal platelet count is 100,000 to 400,000/mm3) (D).

A client with a headache, fever, and stiff neck is admitted with the diagnosis of bacterial meningitis. Which prescription should the practical nurse administer first?

Ceftriaxone (Rocephin). Rationale Since bacterial meningitis is a severe condition that can be life-threatening and cause neurological sequela, early diagnosis and treatment with antibiotics, such as Rocephin (A), is imperative. The administration of an antibiotic is the priority over codeine (B) for pain, acetaminophen (C) for fever, or ibuprofen for stiffness (D).

A male client who fell from a fire escape staircase has no sensation or movement of his lower extremities. His vital signs are heart rate 54 beats/minute, respirations 20 breaths/minute, blood pressure 86/50, and pulse oximetry 95%. He is admitted with an normal saline IV infusion to maintain perfusion, and his skin is cool, dry, and pink. Which action is most important for the practical nurse to implement?

Monitor hourly urinary output per indwelling catheter. Rationale Neurogenic shock after spinal injury presents as bradycardia and hypotension due to the loss of peripheral vasoconstriction below the level of injury. The skin is dry to the touch because of an inability to sweat and skin temperature takes on the same temperature as the room. The priority is the monitor hourly urinary output (C), which evaluates adequate perfusion. (A, B, and D) do not have the priority of monitoring perfusion and urinary output.

A male client who was recently diagnosed with Guillain-Barr syndrome (GBS) tells the practical nurse (PN) that the paralysis of his lower extremities is climbing. What is the most important intervention for the PN to implement?

Monitor respiration depth. Rationale Guillain-Barr syndrome ascends progressively, starting at the feet, at an unknown rate of paralytic involvement. The most important intervention is to monitor for paralysis that may involve the diaphragm, so the rate and depth of respirations must be monitored (A) to determine adequate ventilation. Breathing takes priority over potential injury to the lower extremities (B). (C) is an expected finding. (D) should be provided if paralysis involves the cranial nerves, but the priority is addressing ABC (airway, breathing, circulation).

What statement by the client should alert the practical nurse that immediate attention by the ophthalmologist is necessary?

"I now see halos around lights." Rationale Acute angle-closure glaucoma is a sudden or rapid increase in pressure inside the eye, which can result in optic nerve damage and vision loss if untreated. Seeing halos around lights (A) is a classic symptom of acute angle-closure glaucoma, an emergency condition. Yellow, water drainage from the eye (B) is a classic symptom of conjunctivitis, central vision loss (C) is a classic symptom of macular degeneration, and increasingly cloudy vision over time (D) is a classic symptom of cataracts. Although (B, C, and D) require medical attention, they are not as critical as (A).

The practical nurse (PN) at an extended care facility is called to the unit's activity room where a client has "fainted." Which finding indicates to the PN that the client experienced a syncopal episode?

A sudden experience that everything went black. Rationale In syncope or "fainting", the client experiences a sudden loss of consciousness (A). Incontinence of urine or stool (B) is typical for a seizure disorder, not syncope. A sudden fall in blood pressure (C) is common with syncope, which may rebound as the client gains consciousness. (D) is typical of migraine headaches, not syncope.

A client presents to the clinic complaining of severe stabbing pain in the epigastric region that radiates to the mid-back area. Which finding indicates to the practical nurse that the client should remain NPO?

Amylase and lipase levels are 3 times the normal value. Rationale Pancreatitis is confirmed by amylase and lipase levels that are elevated 2 to 3 times the normal value (A). Clients with pancreatitis should be kept NPO, which allows the pancreas to rest. An elevation in ALT levels (B) is characteristic of liver disease. WBC elevation (C) indicates infection. A low serum potassium level (norm is 3.5 to 5.5 mEq/L) indicates hypokalemia. Although (B, C, and D) require further assessment by the healthcare provider, they do not require an NPO status.

A male client is admitted with encephalitis and hourly neurological assessments are prescribed. At 0300, the client reports a headache rated at "8" on 0 to 10 pain scale. The practical nurse (PN) administers a prescribed PRN analgesic at 0315, and notes the client is asleep and snoring at 0400. What priority action should the PN take?

Awake the client to check response to stimuli. Rationale Neurological assessments for a client with encephalitis include level of consciousness, complaint of headache, vital signs, response to stimuli, and strength and movement of all extremities. Observation of the client with encephalitis is necessary to detect subtle changes, so the client should be awakened every hour (A) as prescribed. Pain assessment should follow medication administration and be documented (B) to reflect the sequence of activities. Although (C and D) are parts of the neurological assessment, changes in level of consciousness and response to stimuli are the priority.

During admission to the medical unit, a client with bacterial meningitis complains that the light is hurting his eyes and he has a headache. The practical nurse (PN) reviews the client's pervious neurological responses and obtains the client's temperature, which is 103.1 F (39.5 C). Which action should the PN implement next?

Begin a secondary infusion of the prescribed antibiotic. Rationale Immediate implementation of the treatment plan for prescribed antibiotics (B) should be initiated to prevent long-term neurological sequela. Once the infusion of antibiotics is started, antipyretics (A) and analgesia (C) should be administered. (D) should be done at regular and frequent intervals during treatment, but administration of the antibiotic is the next action.

A female client arrives at the clinic holding her abdomen and reports diffuse abdominal pain and a frothy greenish vaginal discharge. What intervention is most important for the practical nurse (PN) to implement?

Check urine with early pregnancy test. Rationale Based on the client's symptoms, it is most important to determine if the client has a possible ectopic pregnancy, so the PN should check the client's urine using an early pregnancy test (D). (A, B, and C) should be implemented after (D).

An older male resident of an extended care facility, who had no obvious injuries after a fall a couple of weeks earlier, has become increasingly confusion over the last 4-5 days. Which complication should the practical nurse suspect as a result of the recent fall?

Chronic subdural hematoma. Rationale The elderly are at risk of subdural venous bleeding after a low-impact head injury, resulting in a chronic subdural hematoma (C) that manifests with signs of confusion about 2 weeks after injury. (A, B, and D) occur immediately after an acute injury and are more likely related to arterial flow interruption.

The practical nurse (PN) performs a Glasgow Coma Scale (GCS) assessment for a client who experienced an acute brain attack (stroke) yesterday and obtains a score of "12." What assessment should the PN do next?

Comparison of GCS score with previous checks. Rationale A key element in neurological assessments is the client's trends, which can be subtle changes, so the PN should compare the client's present score to previous scores to determine if the client is better, worse, or the same (D). (A, B, and C) are components of the GCS.

An older female client with heart failure (HF) calls the clinic and tells the practical nurse (PN) that she has been coughing after starting the prescription, captopril (Capoten). Which information by the client requires further investigation by the PN?

Complains her shoes are too snug to wear. Rationale The weakened pumping action of the heart causes excess fluid retention that causes weight gain and edema, which is evidenced by shoes (B) or clothes that become too tight to wear. Fatigue (A) is a common symptom of HF. Seeing floating spots in front of the eye (C) are often vitreous humor debris that occurs with aging. (D) may be used for coughing, a side effect of ACE inhibitors, but increasing fluid retention is indicative of an exacerbation of HF.

When assisting the nurse in the collection of a specimen for arterial blood gases (ABG), which action should the practical nurse (PN) implement?

Compress radial and ulnar arteries and release to evaluate skin color. Rationale To perform the Allen test, the radial and ulnar arteries are occluded until the hand is pale and then released to evaluate hand color, which determines collateral circulation to the radial artery if the artery is injured during the collection of an ABG blood sample. The PN can assist the nurse by performing the Allen test (A), which should be done before each arterial puncture. A tourniquet is not used for arterial puncture (B). The arterial puncture site is compressed for 5 minutes, not (C). The ABG specimen is stored on ice, not (D), during transport for analysis.

The practical nurse (PN) is assisting with the admission of a client with postnecrotic cirrhosis. Which finding is most important for the PN to report to the charge nurse?

Confusion times one (person). Rationale Hepatic encephalopathy is a manifestation of end-stage liver disease caused by the accumulation of ammonia, which is manifested by neurological changes. To ensure client safety, changes in the levels of orientation (person, place, and time) (C) require treatment and should be reported. (A, B, and D) are expected findings of cirrhosis.

A client with myasthenia gravis is admitted in myasthenic crisis. Which priority action should the practical nurse (PN) implement?

Determine client's ability to swallow. Rationale Myasthenia gravis affects the muscles involved in swallowing, respirations, and eyelid movement. The priority action is assessing the client's ability to swallow (A), which influences the client's risk for aspiration. (B, C, and (D) should be implemented, but do not have the priority of (A).

The practical nurse (PN) is caring for client who returned to the unit after a cardiac catheterization. Which finding should the PN report to the nurse?

Faint pedal pulses. Rationale Decreased pedal pulse volume (B) after a cardiac catheterization may indicate of arterial occlusion of the femoral artery used during the procedure and should be reported to the charge nurse. Although (A, C, and D) may be related to the client's underlying cardiac status, these findings are not a complication of cardiac catheterization.

The practical nurse (PN) is caring for a client with cancer who is receiving chemotherapy (CT) and is nauseated. Which intervention should the PN implement to promote adequate nutrition for the client?

Give an antiemetic prior to the administration of CT. Rationale To ensure that the client is able to tolerate and retain nutritious meals, an antiemetic is often prescribed prior to the administration of CT (D) to minimize nausea and vomiting. (A) is recommended for gastric reflux, but does not minimize nausea so the client can eat and retain foods. Dry foods, like crackers, not clear liquids (B), provide some relief for nausea. Although cold foods do not produce an aroma and are less likely to cause nausea (C), the most effective treatment for CT-induced nausea and vomiting is the use of antiemetics.

A client is found pulseless and unresponsive with the telemetry showing a rapid, wide QRS complex. What should the practical nurse do first?

Initiate cardiac compressions. Rationale Ventricular tachycardia is life-threatening because it does not produce adequate cardiac output and perfusion and will progress to ventricular fibrillation. Basic life support should be initiated because the client is pulseless and unresponsive, so cardiac compressions are given first (B) at 100 times/minute. Once assistance arrives, (A, C, and D) can be given.

A client with type II diabetes mellitus (DM) is admitted with an infected foot ulcer. Which prescription should the practical nurse (PN) implement first?

Intravenous antibiotics. Rationale Initiation of IV antibiotic therapy (A) is the priority and is critical for foot ulcer infections in the client with DM. Glucophage (C), an antidiabetic drug, should be given daily with or shortly after meals. Teaching (B) and treatments (D) can be provided after IV antibiotics are started.

The practical nurse (PN) is caring for an elderly client with a history of heart failure (HF) who suddenly wakes up in the middle of the night complaining of being unable to breathe. What action should the (PN) implement?

Listen to bilateral lung fields. Rationale A client with a history of HF who wakes up suddenly with complaints of difficulty breathing is related to an increased blood volume returning to the heart after lying recumbently, which can result in paroxysmal nocturnal dyspnea. Listening to the client's lung fields (D) provides information about the heart's inability to adequate pump blood that causes fluid to back up into the lungs. (A, B and C) do not address the concept of shortness of breath and oxygenation.

The practical nurse (PN) is caring for a client who had a lumbar laminectomy 4 hours ago. Which finding should the PN report to the healthcare provider?

Leg muscle strength grade 2. Rationale Evaluation of spinal motor nerve innervation of skeletal muscles is based on muscle strength response. A decrease in muscle strength (B) (normal muscle strength is grade 5) indicates spinal nerve impairment, a possible complication of spinal surgery, and should be reported to the healthcare provider. (A, C, and D) are findings within normal limits for a client in the immediate postoperative period.

The practical nurse (PN) is monitoring a client with a comminuted fracture of the left femur. Which finding should the PN report to the healthcare provider immediately?

Leg pain of "10" unrelieved by opioids. Rationale Compartment syndrome, an emergency complication of circulatory impairment, is manifested by severe pain unaffected by opioid analgesics (C), which should be reported immediately. (A and B) are common findings consistent with trauma. Although (D) should be reported, the presence of a pulse point provides some oxygenation to distal tissues.

A male client is admitted to the medical unit after falling off a second story roof to a concrete sidewalk. The client's skin is warm and pink, and his vital signs are heart rate 60 beats/minute, respirations 26 breaths/minute, blood pressure 80/48. Which action is most important for the practical nurse to implement?

Maintain normal saline infusion and IV access. Rationale The client who is experiencing spinal shock after falling from a building should receive IV normal saline to maintain perfusion (B). (A and C) are ongoing assessments that are implemented after emergency interventions are initiated. Mannitol is not indicated at this time (D).

A client who is a competitive athlete returns from the operating room after having an open reduction and internal fixation of the right tibia. The practical nurse (PN) determines the client's apical heart rate is 48 and regular. Which action should the PN perform next?

Observe the clients level of consciousness. Rationale Bradycardia is a common normal heart rate for a physically fit athlete and is not treated unless the client is symptomatic. Monitoring the client's level of consciousness (B) is the priority action to evaluate the client's recovery from anesthesia and adequate cerebral perfusion. (A) is not indicated at this time. (C) helps to reduce postoperative swelling, but the priority is the client's response to the surgical intervention. (D) is not indicated unless the client is experiencing inadequate perfusion.

The practical nurse (PN) recognizes which stool characteristics as typical of a client with acute cholecystitis?

Pale, floating. Rationale In cholecystitis, bile, which emulsifies fat in the duodenum, is impeded by gallbladder irritation, ineffective ejection from the gallbladder, or gallstone obstruction of the common bile duct. Stool with increased fecal fat are characteristically are frothy and float, and clay-colored or pale (A) due to the lack of bile which contains biliruben that colors the stool. (B) is characteristic of gastrointestinal bleeding. Watery diarrhea with a "horse barn odor" is classic of Clostridium difficile infection (C). Bloody, "currant jelly" stool typically occur with intussusception (D).

Which finding is an early indication that a recently applied leg plaster cast is causing compartment syndrome?

Paresthesia. Rationale Nerves are sensitive to excessive pressure which causes a tingling sensation, paresthesia (C). It is an expected finding for a plaster cast to initially feel warm (A), which is due to an exothermic reaction of the wet plaster. Pain after a fracture is common (B), but pain characteristic of compartment syndrome is unrelenting pain despite analgesia or with passive movement. Although obliteration of the pulse (D) is a sign of compromised circulation, this is a late sign occurring after a client experiences a loss of sensation or paresthesia.

Which finding by the practical nurse is the best indication that a client's peristalsis has returned after abdominal surgery?

Passes flatus per rectum. Rationale Passing flatus, or intestinal gas (A), is the best indication that peristalsis is present and moving intestinal contents. (B) is not indicative of the presence of peristalsis. Belching, or burping (C), is the movement of air upward, which can be a symptom of an upper intestinal obstruction. (D) is a positive sign of a returning appetite, but does not indicate the return of peristalsis.

What action should the practical nurse (PN) implement for a client who has a banana allergy?

Place a box of latex-free gloves in the room. Rationale A client with a banana allergy may have a cross-sensitivity to products containing latex, so (D) should be implemented. (A, B, and C) are not indicated for a client with a banana allergy.

A client who is involved in a motor vehicle collision (MVC) is admitted for evaluation. After a chest xray, the practical nurse (PN) reports that the client is dyspneic, has decreased right breath sounds, normal left field breath sounds, and tracheal deviation. After notification of the healthcare provider, what priority action should the PN implement?

Prepare for emergency chest tube insertion. Rationale The client is manifesting signs of a tension pneumothorax as a result of chest trauma, so emergency pleural decompression by the healthcare provider is vital. The PN should prepare for emergency chest tube insertion (A) by the healthcare provider. Although (B and C) should be implemented, the priority is preparation for emergency decompression of the pleural space. (D)

A client who is one-day post-thyroidectomy begins to develop a stridor. Which priority action should the practical nurse implement?

Prepare for emergency tracheotomy at the bedside Rationale A complication after thyroidectomy is laryngeal edema, which is manifested by a stridor, so the client should be prepared for imminent emergency tracheotomy (A). Although (B, C, and D) may be implemented, the priority is alleviation of the client's upper airway obstruction per emergency tracheotomy.

A male client with type 1 diabetes mellitus comes to the clinic because he is feeling bad. He tells the practical nurse (PN) that he stopped taking his prescribed insulin. He has a flushed appearance; a deep, sighing respiratory pattern; and a fruity breath odor. Which action should the PN implement?

Prepare regular insulin dose based on blood glucose results. Rationale The client is experiencing diabetic ketoacidosis (DKA) and needs regular insulin based on serum glucose levels (C) to stop the breakdown of protein with resulting residual ketone bodies as a fuel source. Kussmaul respirations are a compensatory mechanism in an attempt to blow off the excess acid, so oxygenation is not indicated (A). (B) is not indicated because carbon dioxide further aggregates acidosis. Kayexalate (D) is used to treat hyperkalemia, not hypokalemia that occurs with DKA.

A client receives pulmonary resuscitation with an Ambu bag for 10 minutes before being intubated with a endotracheal tube (ET). The practical nurse (PN) notes that the client's stomach is distended. What action should PN implement?

Prepare to insert a nasogastric tube. Rationale Artificial ventilation with a bag-valve-mask, such as an Ambu bag, can inadvertently cause air to enter the stomach, so the PN should prepare for nasogastric tube insertion to alleviate distention and reduce the risk of vomiting (C). Abdominal board-like rigidity is due to intra-abdominal bleeding or peritonitis, not intubation (B). (A and D) are not indicated.

The practical nurse (PN) is caring for a client who has increased intracranial pressure (ICP) and a nursing diagnosis of "Ineffective breathing pattern." Which intervention should the PN use as the best measure for attainment of the goal, "Client will have adequate oxygenation?"

Review current results of arterial blood gas studies. Rationale Adequate client oxygenation is best evaluated by examining blood gas values (D). (A and B) provide indirect evidence of effective oxygenation. (C) may reduce ICP and improve cerebral oxygenation but does not provide evaluative data.

The practical nurse (PN) completes a focused assessment for a client with a possible brain attack (stroke). Which finding requires further assessment by the PN?

Somnolence when questioned. Rationale Somnolence when the client is questioned represents an altered state of consciousness (D) to a verbal stimulus, and further assessment, such as tactile stimulus, is needed. (A, B, and C) are normal findings.

The practical nurse (PN) is assigned to care for a client with a radium implant for cervical cancer. Which intervention should the PN implement while providing care?

Wear the film badge while in the clients room. Rationale The PN should organize procedures and provision of care to the client that limits the amount of time and distance relative to the radioactive source. The PN should wear a film badge (C) that registers the nurse's cumulative radiation exposure. (A) is not indicated. Visitors are allowed at the bedside but should observe the precautions of time and distance maintained from the radiation source (B). Radioactive precautions, not contact isolation (D) are indicated.

A client with chronic kidney disease (CKD) has a serum potassium level of 7.0 mEq/L. Which prescription should the practical nurse administer?

50% dextrose and regular insulin IV. Rationale The client is hyperkalemic (normal range of serum potassium is 3.5 to 5.0 mEq/L) and is at risk for life-threatening cardiac dysrhythmias. An emergency prescription to manage hyperkalemia is the administration of IV glucose and IV insulin (C) to promote ion shifting by driving potassium back into the cells, thereby reducing the serum potassium level. Fluid restriction and diuretics (A) are used to manage hypervolemia. Calcium, vitamin D, and phosphate binders (B) are used to treat hypocalcemia. Synthetic erythropoietin (D) is used to treat anemia.

A client presents to the clinic reporting a new onset of blurred vision. Which assessment should the practical nurse implement to evaluate the client's central vision acuity?

A Snellen chart. Rationale The most commonly used assessment tool to test central visual acuity is the Snellen eye chart (A), which determines the client's ability to clearly read variably sized alphabet letters at 20 feet. Peripheral vision can be estimated with the confrontation test (B). In accommodation (C), the pupils should constrict as the eyes focus on a near object. Pupillary light reflexes (D) indicate an intact lower visual apparatus in response to light.

The practical nurse (PN) is caring for a client who is 2 days postoperatively for a total colectomy. Which finding requires immediate intervention by the PN?

A board-like abdomen. Rationale A rigid, board-like abdomen (A) is a probable sign of peritonitis, which requires immediate intervention. (B, C, and D) are expected findings 2 days post-colectomy.

The practical nurse (PN) is caring for a group of clients on a telemetry unit. Which client requires immediate follow-up by the PN?

A client with multiple premature ventricular contractions (PVC)/minute after receiving atropine. Rationale A client who is experiencing multiple PVCs/minute (C) is at risk for ventricular fibrillation (VF) and requires immediate follow-up and treatment. Digoxin slows the heart rate by decreasing the rate impulse conduction through the AV node, which is contraindicated in heart block (A), but the client who is at risk for impending VF is the priority. The PN should continue monitoring (B and D) for other side effects of glucocorticosteroids and epinephrine, such as trembling (D), which are not life threatening.

A male client with pancreatic cancer who received morphine and midazalom (Versed) during an endoscopic retrograde cholangiopancreatography (ERCP) returns to the unit. His vital signs are pulse 80 beats/minute, 16 breaths/minute, blood pressure 120/80, and pulse oximeter 98%. Which action should the practical nurse (PN) implement?

Determine client's fingerstick glucose level. Rationale A client with pancreatic involvement is likely to experience inadequate insulin secretion, which places the client at risk for abnormal serum glucose, so the client fingerstick glucose level (C) should be checked. Based on the client's vital signs, (A and D) are not indicated at this time. The client's gag reflex is suppressed due to medication administered during the procedure, so fluids or food should be withheld (B) until the gag reflex returns.

After a client reports having frothy, floating stools with a foul odor, what area of the client's history should the practical nurse review?

Dietary fat intake. Rationale The client's dietary fat intake (C) should be investigated since steatorrhea, or fat in the stool, results from undigested fat in the diet, which is a classic symptom of cholecystitis, an inflammation of the gall bladder. A bleeding gastric ulcer (A) produces dark, tarry stools. Celiac disease, or an intolerance to gluten (B), is likely to causes gastric upset and malnourishment. Alcohol consumption (D) is often related to gastritis.

A client who had an abdominal cholecystectomy today has a T-tube that has drained 200 ml of greenish-brown fluid in the past 12 hours. What action should the practical nurse (PN) take?

Document the findings in the electronic medical record. Rationale This is an expected amount and color of biliary drainage from a T-tube, which may drain between 250 to 500 ml during the first 24 hours (B) after a cholecystectomy. The T-tube should not be irrigated (A) nor clamped (C). There is no indication that the client is in shock (D).

A client is brought to the emergent care center for chest pain and receives morphine, oxygen, nitroglycerin, and aspirin per acute coronary syndrome (ACS) protocol. Which additional protocol prescriptions should the practical nurse obtain from the emergency medication cart?

Eptifibatide (Integrilin), a glycoprotein (IIb/IIIA) inhibitor. Rationale Integrilin a common thrombolytic agent used to prevent a coronary artery clot from extending (A). Heparin, not Coumadin (B), is used in the treatment of ACS. Beta blockers, not calcium channel blockers (C), are the recommended cardiac drug used in ACS. Lasix is not used in the ACS protocol unless the client manifests additional complications.

A client with a ventriculoperitoneal shunt has large bruises on the forehead and arm. The practical nurse (PN) at the outpatient clinic determines that the client received the bruises accidentally while walking through the doorways at home. What action should the PN take?

Evaluate the client's pupillary response to light. Rationale A malfunctioning ventriculoperitoneal shunt can cause increased intracranial pressure (ICP) that results in neurological changes, such as poor depth perception that cause self injury while walking through doorways. Assessing for pupil equality, shape, reactivity to light (A), and other neurological assessments should be implemented. Although (B) may be encouraged for clients with a shunt or who have frequent seizures, the priority is to assess for signs of ICP. The client is most likely experiencing a shunt malfunction, not physical abuse (C). Ringing in the ears (D) is not a classic neurological symptom finding of ICP.

The practical nurse (PN) obtains an oral temperature of 100F (37.8C) for a female client who is one day postoperatively after a total abdominal hysterectomy. What action should the PN implement?

Evaluate the client's temperature in 4 hours. Rationale An oral temperature of 100 F (37.8 C) on the first postoperative day is not indicative of infection and should be monitored every 4 hours (A). (B, C, and D) are implemented for postoperative prevention of infections, which are more likely to manifest in 48 to 72 hours postoperatively.

The practical nurse (PN) notes an irregular radial pulse for a client who has an implanted pacemaker. What action should the PN do first?

Measure the apical-radial pulse with another nurse. Rationale An apical-radial pulse measurement should be implemented simultaneously by two nurses (B) to validate an irregular radial pulse. (A, C, and D) are implemented after (B).

Which action should the practical nurse (PN) implement for a client who is having a liver biopsy?

Monitor for signs of dyspnea after return from biopsy. Rationale Biopsy of the liver may cause a pneumothorax due to the liver's proximity to the lung. After the biopsy, the client should be monitored for signs of dyspnea (D). (A and B) are not required before the biopsy. The liver is located in the upper hypochondriac region, so the client should be placed on the right side, not (C), to facilitate external compression to the puncture site.

A client who is hit on the head with a baseball bat is admitted for observation. The practical nurse (PN) notes clear liquid leaking from the client's ear. What action should the PN take?

Observe the collected fluid for blood surrounded by a yellow ring. Rationale Basal skull fractures that tear the dura are associated with leakage of cerebrospinal fluid (CSF) from the ear or the nose. The presence of the "halo" sign (fluid leakage that includes blood coalesces in the center and outlined by a yellow ring) is consistent with CSF leakage (B). (A, C, and D) are not indicated.

A male client who arrives at the clinic for an eye examination tells the practical nurse (PN) that he has recently experienced blurred vision. Which finding is most important for the PN to report to the healthcare provider?

Small rapid, rhythmic, oscillating movements of eyeballs. Rationale Nystagmus, an abnormal, involuntary and rapid twitching or oscillation of the eyeball (C), requires further assessment and should be reported to the healthcare provider. (A) most likely indicates color blindness, which requires no further action. A consensual response to light stimulus (B) and pupillary responses during accommodation for near vision (D) are normal findings

The practical nurse (PN) observes that the dressing of a client with a gunshot wound to the groin is saturated with bright red blood. Which is the PN's priority action?

Apply direct pressure to the area. Rationale The priority action is to stop the bleeding by applying direct pressure to the area (D). Although determining the client's level of pain (A), taking the client's temperature (B), and documenting the extent of bruising (C) are all important actions, the saturated dressing is indicative of active bleeding, which needs immediate action.

The practical nurse (PN) is reviewing the admission data for an older male with benign prostatic hyperplasia (BPH). Which finding should the PN report to the healthcare provider?

Blood urea nitrogen (BUN) is 50 mg/dl. Rationale If left untreated, BPH can cause lower urinary tract symptoms (LUTS), urinary tract infection (UTI), hematuria, or compromised upper urinary tract function, which is reflected by an elevated BUN level (C) (norm 10 to 20 mg/dl) that indicates the kidney is unable to clear nitrogenous waste from the blood. Frequent nocturnal voiding (A) and a weak urinary stream (B) are common symptoms of BPH, which impact a client's quality of life, but these findings are not as important as an elevated BUN. (D) is not significant and may indicate a contaminated specimen.

A male client calls the clinic and reports he is having heavy chest pressure after exercising. He tells the practical nurse (PN) that he took three nitroglycerin sublingual (SL) tablets without relief. What instruction should the PN provide?

Call 911 immediately. Rationale If three nitroglycerin SL tablets are ineffective, the client should call 911 immediately (A) to activate the emergency medical system (EMS) (A). (B) places the client at risk for a potentially life threatening event without immediate medical assistance. (C) may be indicated if the client has developed a tolerance to nitroglycerin. (D) should be implemented once EMS is in place.

An adult client presents to the emergent care center with hives and laryngeal edema after being stung by a bee. Following successful treatment, what information is most important for the practical nurse to reinforce with the client upon discharge?

Carry an epinephrine pen. Rationale A client who experiences a severe, life-threatening allergic reaction to a bee sting is at risk for anaphylaxsis 12 hours after the initial symptoms subside, a biphasic reaction that occurs in about 20% of these reactions. The client should carry an epinephrine auto-injector, such as an EpiPen (C), for emergency treatment of anaphalytic shock. The client should avoid bees (A), but an EpiPen should be available for immediate use if exposed again. Although oral benadryl (B) is used to treat allergic reactions, its onset is ineffective in responding to anaphylaxis. Wearing a medical alert bracelet (D) is advisable, but it is not as important as carrying an EpiPen

The practical nurse (PN) is caring for a client who returns to the room after a bronchoscopy with a local anesthetic. What action should the PN take prior to giving the client a lunch tray?

Check presence of a gag reflex. Rationale A local anesthetic to the oropharynx for bronchoscopy inhibits the gag reflex, so the client's gag reflex should be present before giving the client with anything to eat or drink. Although a high Fowler's position is preferred for meals, (B) is not essential. (C and D) are not indicated.

The practical nurse (PN) is assessing breath sounds of a client who has spontaneous respirations after an endotracheal tube (ET) insertion. The breath sounds are absent on the left side. What action should the PN do?

Contact the nurse in charge immediately. Rationale A complication of endotracheal intubation is advancement of the tube into the right main stem bronchus, which does not aerate the left lobes. The PN should contact the nurse (C) so the ET can be repositioned. (B) is ineffective in aerating the left lung fields if the ET has been advanced into the right stem bronchus. (A and D) can be implemented after the ET is repositioned.

A male client is admitted after being hit on the head with a tire iron. In the change-of-shift report, the client's Glasgow Coma Scale (GCS) score is 14, and pulse (P) 90 beats/minute (bpm), respirations (R) 18 breaths/minute, and blood pressure (BP) 104/60. Which finding is most important for the practical nurse to follow-up when checking the client after the shift change?

Current GCS score is 12. Rationale Neurological changes are subtle and need aggressive follow-up, so the most important finding that indicates a change in the client's status is the decrease in the GCS (D). (A) is expected after blunt head trauma, but the most important finding is a deterioration in mental status. (B) is an expected question on admission that should be re-evaluated after the client has been re-oriented to "place." (C) should be continued but does not provide sufficient vital sign trends at this time.

Two days after a small bowel resection, a male client reports tingling of fingers and toes and feels dizzy. The client's nasogastric tube (NGT) is draining per low intermittent suction, and the practical nurse (PN) suspects the client has a fluid and electrolyte imbalance because he has been taking oral ice chips PRN. Which assessment finding should the PN report when monitoring the client?

Elevated pulse and dysrhythmia noted on telemetry. Rationale Nasogastric suctioning that increases the loss of gastric secretions that are diluted by the client's oral intake of ice chips contributes to fluid and electrolyte imbalances and can cause a metabolic alkalosis. The client's cardiovascular function should be monitored for signs an elevated pulse and cardiac dysrhythmias (B) related to fluid loss and potassium imbalances. (A) describes symptoms of fluid volume excess, not loss. Deep vein thrombosis typically causes heaviness in the leg and unilateral pain (C). (D) are signs related to metabolic acidosis, not alkalosis.

The practical nurse (PN) is caring for a client with trigeminal neuralgia associated with Cranial Nerve V pathology. While reinforcing the discharge teaching instructions, the PN should include which information?

Encourage a soft diet to minimize chewing. Rationale Trigeminal neuralgia causes intense facial pain that is worsened by movement, such as chewing, talking, or tactile stimulation. The client should understand that a soft diet (A) is helpful in reducing stimuli of the cranial nerve. (B, C, and D) are not indicated for the client with trigeminal neuralgia.

A female client who is currently receiving chemotherapy (CT) for colon cancer tells the practical nurse (PN) that she plans to become pregnant in case CT is not successful. What action should the PN take?

Encourage her to wait until the completion of chemotherapy. Rationale CT is teratogenic and causes birth defects in the first trimester, so the client should be encouraged to wait until CT is completed (D) and talk with her healthcare providers about the treatment risks in pregnancy. (A, B, and C) do not address the risk of CT in pregnancy.

A client presents to the emergent care center with symptoms on an acute brain attack and right sided facial drooping. Which action should the practical nurse (PN) implement first?

Maintain the client NPO. Rationale An acute brain attack, or cerebrovascular accident (CVA), is commonly manifested with facial drooping and dysphagia, so the client should be maintained NPO (A) to minimize the risk of aspiration. Although (B, C, and D) should be implemented, first the client should not have anything by mouth.

A male client with a chest tube and a three-chamber water seal drainage system calls the practical nurse (PN) to the bedside and says his chest tube (CT) is not working. The PN observes that the client's respiratory effort and breath sounds are normal. Which action should the PN implement?

Observe the water-seal chamber for bubbling. Rationale Assessment of the water-seal drainage system should be implement to determine if normal fluctuation of the water level in the water-seal chamber is occurring or if continuous bubbling is present (D), which is indicative of an air leak. Clamping the CT is not recommended (A) but may be necessary if the water seal drainage system is damaged. Chest tubes should not be milked (B) or stripped because this action increases intrapleural pressure. (C) is implemented if the chest tube becomes dislodged, which is not evident at this time.

A client with a peptic ulcer develops severe upper abdominal pain. Which finding is most important for the practical nurse (PN) to report to the charge nurse?

Rigid, board-like abdomen. Rationale A rigid, board-like abdomen indicates perforation of a bleeding peptic ulcer (B) and possible peritonitis. (A, C, and D) should be reported, but a rigid, board-like abdomen is a surgical emergency.

When making morning assessments, the practical nurse finds a client who is exhibiting a new finding of right-sided facial drooping. Which assessment is most important for the PN to implement first?

Test all four extremities for movement and strength Rationale Unilateral facial droop may be a symptom of an acute brain attack (stroke) or Bell's Palsy. Unilateral motor deficits are the most obvious effects of a stroke (B) and should be assessed for first. If ruled out, other assessments can be performed for the possibility of Bell's Palsy (A, C and D).

A client presents to the urgent care clinic with a sudden onset of left upper quadrant pain radiating to the back. Based on which laboratory values should the practical nurse (PN) ensure the client remains NPO? (Select all that apply.)

Amylase is 660 units/L. Lipase is 1600 units/L. Rationale Elevation of amylase (D) and lipase (E) indicates the probability of pancreatitis, and the client should be NPO to prevent stimulation of pancreatic activity. Although (A and B) are elevated, they do not require the client to be NPO. (C and F) are elevated and indicative of possible liver disease, but the client does not need to be NPO.

An adult male arrives at the emergent care clinic complaining of a high fever and a severe sore throat. The practical nurse (PN) observes that the client is irritable, breathing with his mouth open, and drooling. What action should the PN take?

Assemble supplies for endotracheal intubation. Rationale Drooling with concurrent upper respiratory distress is common in epiglottis, which causes rapid edema of the epiglottis. Securing an airway is a priority, and intubation supplies should be readily available (C) for the healthcare provider. Nothing should be placed in the mouth, not even a thermometer (A). IV access (B) should be obtained for emergency medications, but preparing for emergency intubation is the first priority. The tripod position, not (D), eases the client's effort to breath with respiratory distress due to swelling of the epiglottal structures.

Which technique should the practical nurse implement for a male client who does not response to nail bed pressure during a focused neurological assessment?

Provide painful stimuli using a sternal rub technique. Rationale A client who is unresponsive to verbal, tactile, or one form of painful stimuli should be assessed using maximum stimulation for maximum response, such as a sternal rub (A) which is another type of painful stimulation. (B and C) are forms of tactile or sensory stimuli. The client must be conscious to respond to verbal stimuli, such as levels of orientation (D).

The practical nurse (PN) is caring for a male client who is in the rehabilitation unit following an acute brain attack (cerebral vascular accident (CVA) or stroke). The PN notes that the client eats food from only the right side of the plate. Which action should the PN take?

Teach to turn head to scan visual areas. Rationale After a stroke, a client who only visualizes half of the visual fields is most likely exhibiting homonymous hemianopsia. In the rehabilitation phase, the client should be instructed to consciously scan the environment by turning his head (D), especially to the affected side. CN II (optic nerve) function, which is assessed with a Snellen eye chart, is not related to hemianopsia. (B) is not indicated at this time. Glasses correct errors of refraction, not hemianopsia that results from a stroke.