100% REVIEWED HESI PN COMPREHENSIVE EXAM 3 FLASHCARD QUESTIONS & ANSWERS (RATED A+)

100% REVIEWED HESI PN COMPREHENSIVE EXAM 3 FLASHCARD QUESTIONS & ANSWERS (RATED A+) LATEST VERSION 2023 Terms in this set (100) Wha t intervention shoul d the practical nurse (PN) impl ement to meet the phy siol ogic integrity of a cl ient during a manic episo de of bipol ar disor der ? A. Pr ovide the cl ient with finger foo ds. B. Restrict the cl ient's oral fluid intake. C. Giv e the cl ient low-protein, low- cal orie sna cks. D. Interrupt the cl ient's perf ormance of rituals. A. Pr ovide the cl ient with finger foo ds. During the manic phase of bipol ar disor der, a cl ient is often unabl e to sit still long enough to ea t, so the cl ient shoul d be pr ovided finger foo ds that can be eaten while hyper activ e. Which action should the practical nurse (PN) implement for a young girl with pulmonary infection who is receiving chest physiotherapy? A. Encourage to hold her breath and then cough. B. Administer bronchodilators after the procedure. C. Allow the child to sit in a position of choice. D. Percuss the chest wall in a rhythmic fashion. D. Percuss the chest wall in a rhythmic fashion. Thick secretions that are difficult to cough up can be loosened by tapping, or percussing, and vibrating the chest. Percussion is carried out by cupping the hands and lightly striking the chest wall in a rhythmic fashion over the lung segment to be drained The practical nurse (PN) is preparing to administer erythromycin (Ilotycin) 0.5% ophthalmic ointment to a newborn. The father asks the PN the purpose of this medication. What rationale should the PN provide? A. To allow the baby's eyes to focus. B. To lubricate the baby's eyes. C. To prevent infection in the baby's eyes. D. Refer the father to the pediatrician. C. To prevent infection in the baby's eyes. Erythromycin is prescribed in the prophylaxis of ophthalmia neonatorum caused by Neisseria gonorrhea and Chlamydia trachomatis. The PN should explain the ointment is a prophylactic treatment to prevent infection in the baby's eyes. A client's cardiac telemetry reveals sinus bradycardia at 40 beats/minute. An IV dose of atropine is given per protocol. Which finding should the practical nurse (PN) identify as a therapeutic response? A. A decrease in blood pressure. B. A decrease in premature contractions. C. An increase in heart rate. D. An increase in sensorium. C. An increase in heart rate. Atropine increases heart rate (C) by its anticholinergic effects on the sinoatrial (SA) node. A client is admitted with a tumor of the hypothalamus. Which finding should the practical nurse (PN) report to the charge nurse? A. A pulse rate of 98 beats/min. B. Respirations of 20 breaths/min. C. An oral temperature of 101.8° F. D. A blood pressure of 130/80 mm Hg. C. An oral temperature of 101.8° F. The hypothalamus controls body temperature, so variation in the temperature should be reported to determine if the elevation is related to infection or cerebral pathology. The practical nurse (PN) is reinforcing instructions to a client who is scheduled for a bone marrow aspiration. The PN should prepare the client for the procedure at which site? A. The femur. B. The scapula. C. The antecubital fossa. D. The posterior iliac crest. D. The posterior iliac crest. Bone marrow samples are commonly aspirated from the posterior iliac crest or sternum, which are readily accessible obtaining a specimen of bone marrow via the biopsy needle. Which discharge instructions should the practical nurse (PN) reinforce with a client who has acute cholecystitis? A. Limit oral intake to three regular meals per day. B. Drink fluids between meals rather than with meals. C. Consume a low-fat diet in smaller, more frequent meals. D. Limit dietary fat intake to 35% of the daily calorie intake. C. Consume a low-fat diet in smaller, more frequent meals. Clients with acute cholecystitis are placed on small, frequent low-fat meals to decrease contraction of the gallbladder, thus decreasing pain, nausea, and vomiting. Fol lowing a cl ient's bl adder surger y, the pr actical nurse (PN) not es that the ur eteral ca theter is no longer draining urine. Wha t action shoul d the PN impl ement? A. Notify the heal thcar e provider immedia tely. B. Change the cl ient's position and continue to monit or. C. Cl amp the ur eteral ca theter for 30 minutes. D. Irriga te the ur eteral ca theter with 30 ml of sterile sal ine. A. Notify the heal thcar e pr ovider immedia tely. When ur eteral stents or ca theters are pl aced, patency must be maint ained to pr event hydronephr osis. Any significant decr ease in draina ge shoul d be r eport ed immedia tel y. A male client is being discharged after starting a new prescription of olanzapine (Zyprexa) for paranoid schizophrenia. Which discharge instructions should the practical nurse (PN) reinforce with the client? A. Sit in the sunlight for 20 minutes everyday. B. Avoid the use of antihistamines and alcohol. C. Maintain an average dietary intake of sodium. D. Defer making business decisions for a month. B. Avoid the use of antihistamines and alcohol. Zypexia, an atypical antipsychotic that improves negative symptoms, can produce sedating effects early in therapy, so concomitant use of alcohol or antihistamines should be avoided to minimize synergistic effects. In which position should the practical nurse (PN) place a client after the client has a liver biopsy? A. Prone. B. Supine. C. Left side-lying. D. Right-side lying. D. Right-side lying. The largest lobe of the liver, which is the most frequently biopsied site, lies in the right hypochrondriac region of the abdomen. After a liver biopsy, the client should be turned onto the right side for the first 2 hours to provide local pressure to the puncture site to minimize bleeding. The pr actical nurse is discussing gl ucose b alance with a cl ient who is newly dia gnosed with type 2 diabet es mel litus. Which phy siol ogical process supports the movement of gl ucose int o the cel ls? A. Gl ucose mo ves to low concentr ations in the cel l. B. Bloo d pr essur e pushes gl ucose int o cel ls. C. Insul in is needed to carr y gl ucose int o cel ls. D. Cel ls absorb gl ucose when needed. C. Insul in is needed to carr y gl ucose int o cel ls. The transport of gl ucose occur s because insul in carries gl ucose across the cel l membr ane . The pr actical nurse (PN) adminis ters a pr escribed opia te for a cl ient with acut e pancr ea titis who is having severe ab dominal p ain. Which additional intervention in the pl an of car e shoul d the PN impl ement? A. Monit or dail y serum amyl ase levels. B. Maintain cl ient's NPO status. C. Giv e pr escribed morphine PRN. D. Pl ace cl ient in a position of comf ort. B. Maintain cl ient's NPO status. A cl ient with acut e p ancr ea titis shoul d be NPO to minimiz e p ancr eatic auto-diges tion from p ancr ea tic enzymes. The practical nurse (PN) palpates the insertion site of an IV infusion that is pale and swollen, and determines the area is cool to touch. Which action should the PN implement first? A. Report to the nurse. B. Apply warm compresses to the site. C. Monitor client's temperature q4 hours. D. Discontinue the IV infusion. D. Discontinue the IV infusion. Infiltration is the most common complication of intravenous (IV) therapy and is evident by pale, swollen, and cool tissue at the site. The first action is to discontinue the infusion to minimize the volume of fluid extravasation. The practical nurse (PN) is administering an otic medication to an adult client. In which direction should the PN pull the pinna during instillation? A. Up and back. B. Down and back. C. Up and forward. D. Down and forward. A. Up and back. The pinna of the adult should be pulled up and back, to ensure the medication flows through the external ear canal and to the tympanic membrane. What method should the practical nurse (PN) implement to elicit information from a client during an admission interview? A. Explain the purpose of the admission interview. B. Summarize with the client the information collected. C. Ask information-seeking or closed-ended questions. D. Request relatives to leave during the interview. C. Ask information-seeking or closed-ended questions. Closed questions have a definite place when specific essential data, such as information seeking, is needed during the initial phases of data collection. An older client who is a resident in a skilled nursing facility likes to walk for exercise. The client is taking a vasodilator for hypertension. Which action should the practical nurse (PN) implement for this client? A. Monitor blood pressure daily. B. Provide a walker for long walks. C. Document intake and output. D. Assist client to stand up slowly. D. Assist client to stand up slowly. Blood pressure fluctuations with position changes are common in the elderly and increase the risk of falls when taking medications that can cause orthostatic hypotension. To minimize falls related to dizziness with mobilization, the PN should assist the client to stand up slowly (D) before beginning to ambulate. Which finding requires immediate action by the practical nurse (PN)? A. The client's affected heel is supported off of the bed. B. The weights are touching the floor at the end of the bed. C. The affected leg and foot are resting away from the footboard. D. The client's affected leg is aligned parallel to the edge of the bed. B. The weights are touching the floor at the end of the bed. To ensure the weight of the Buck's traction is creating a pull to reduce a fracture and relieve muscle spasms, the PN should intervene when the weights are on the floor and not hanging freely. To help prevent complications for a client who is abusing amphetamines, it is important for the practical nurse to implement what action? A. Measure intake and output. B. Perform neurologic assessments. C. Check oxygen levels frequently. D. Keep the lights on continuously. B. Perform neurologic assessments. Amphetamines are CNS stimulants that increasing cardiovascular centers. Close monitoring of a client who is abusing amphetamines should focus on changes in cardiac or neurologic status since myocardial infarction and cerebral hemorrhage have occurred from amphetamine abuse. In addition to lowering dietary sodium intake, which dietary changes should the practical nurse (PN) encourage the client to make when learning to manage high blood pressure? A. Vary the types of dairy products, such and milk and cheese. B. Select vegetable proteins, such as canned beans. C. Include calcium and magnesium food sources daily. D. Increase protein source of shellfish to most days of the week. C. Include calcium and magnesium food sources daily. Diet and exercise can reduce high risk behaviors and promote healthy living life styles. Adequate levels of calcium and magnesium play a role in the maintenance of blood pressure. A client is admitted with possible head trauma after a motor vehicle collision. Which action should the practical nurse (PN) implement? A. Auscultate heart sounds. B. Monitor client's weight. C. Check for verbal and motor response. D. Auscultate lung and abdominal sounds. C. Check for verbal and motor response. A client experiencing a traumatic closed head injury should be monitored for signs of increased intracranial pressure (ICP). A neurologic examination, such as the Glasgow Coma Scale, is performed the detect early signs of ICP, as manifested by changes in verbal and motor response. A client who is taking gentamicin (Garamycin) tells the practical nurse (PN) that he has been hearing ringing in his ears since he began his prescription. What additional assessment finding should the PN report to the healthcare provider? A. Thirst. B. Diarrhea. C. Sedation. D. Dizziness. D. Dizziness. Gentamicin, an aminoglycoside antibiotic, is known to have ototoxic side effects, which are manifested by tinnitus and vertigo. Complaints of ringing in the ears accompanied by dizziness are early signs of hearing loss and should be reported to the healthcare provider. The practical nurse (PN) is caring for a client in the oliguric phase of acute renal failure (ARF). What nursing action should the PN implement? A. Meticulous skin care. B. Liberal fluid intake. C. Protective isolation precautions. D. High dietary protein intake. A. Meticulous skin care. Poor nutritional status and edema accompanying renal failure can cause skin breakdown. Meticulous skin care, frequent turning, and special mattresses are priority concepts in basic care and comfort. A mal e cl ient returns to the surgical nursing unit from the pos tanes thesia car e unit and is still drowsy. The pr actical nurse (PN) uses verb al stimulation to keep the cl ient responsiv e. In wha t position shoul d the PN pl ace the cl ient until he is mor e rea ctiv e? A. Supine . B. Side-l ying. C. Head of bed at 30 degr ees with head and neck midl ine. D. Head of bed at 4 5 degr ees with head and neck midl ine. B. Side-l ying. The cl ient shoul d be turned to a side-l ying position or positioned with his head turned to the side to prevent aspir ation. To obt ain a cl ient's apical heart rate, which ana tomical loca tion shoul d the pr actical nurse (PN) use when auscul tating at the point of ma ximal impul se (PMI)? A. Fifth int ercos tal sp ace, l eft midcl avicul ar line. B. Second int ercos tal sp ace, right midcl avicul ar line. C. Fifth int ercos tal sp ace, l eft anterior axil lary line. D. Fourth int ercos tal sp ace, l eft lateral sternal bor der. A. Fifth int ercos tal sp ace, l eft midcl avicul ar line. The PMI of the heart is loca ted at the fifth intercos tal sp ace, along the l eft midcl avicul ar line. A client with type 1 diabetes mellitus who uses an insulin pump comes to the clinic for follow-up evaluation. The client consistently has a fasting blood glucose between 70 and 80 mg/dl, a postprandial blood glucose level below 200 mg/dl, and a hemoglobin A1 c level of 5.5%. What evaluation should the practical nurse (PN) convey to the client? A. Signs of insulin resistance. B. Good control of blood glucose. C. Risk for developing hypoglycemia. D. Increased risk for hyperglycemia. B. Good control of blood glucose. Based on standardized guidelines, the client is maintaining blood glucose levels within the defined ranges for tight control (fasting blood glucose 60 to 120 mg/dl, postprandial blood glucose less than 200 mg/dl, hemoglobin A1c no greater than 7 % ) The practical nurse (PN) is caring for a client with a chest tube and finds there is an absence of bubbling in the suction control chamber of the chest tube. What action should the PN implement first? A. Turn up the wall suction. B. Report the finding to the charge nurse. C. Check the tubing for air leaks. D. Add water to the suction control chamber. C. Check the tubing for air leaks. Bubbling is expected in the suction control chamber of chest tubes when suction is applied. Absence of bubbling may indicate a leak in the tubing, so the PN should first check all tubing connections for a potential source of air leaks. Twelve hours after implantation of a cervical cesium implant, the practical nurse (PN) finds the client crying. What action should the PN provide? A. Leave the client alone to cry in private. B. Don a lead shield and sit at her bedside. C. Call the client on the phone and ask her why she is crying. D. Stand at the head of the bed and offer support for 15 minutes. D. Stand at the head of the bed and offer support for 15 minutes. The cesium implant delivers radiation at the tumor site and places healthcare workers at risk for radiation exposure. Emotional support should be provided with bedside presence while limiting radiation exposure by standing at the head of the bed, several feet away from the implants, and by limiting the duration of the client visit. A new mother who delivered vaginally is being discharged today with her first-born infant. Which information is most important for the practical nurse (PN) to review with the client before she goes home with the new infant? Select all that apply. A. Breast feeding techniques and bottle supplementation. B. Self care of the episiotomy. C. Signs or symptoms of infection. D. Weaning from breastfeeding to bottle feeding. E. Infant immunizations during the first year. A. Breast feeding techniques and bottle supplementation. B. Self care of the episiotomy. C. Signs or symptoms of infection. Self care and infant care are priority discharge topics that should be reviewed with the client before the client goes home with the baby. Which action is most important for the practical nurse (PN) to implement when applying a wet dressing to the skin of a client with impetigo? A. Use antimicrobial soaps and cool solutions to cleanse lesions. B. Wear clean gloves when in contact with wound drainage. C. Apply topical antibiotic ointment to wound at dressing changes. D. Pour saline on 4-inch square gauze for direct application B. Wear clean gloves when in contact with wound drainage. Impetigo, caused by group A b-hemolytic Streptococci or Staphylococci, is infectious and contagious. Drainage from the lesions requires the implementation of standard precautions to prevent spread of the infection. The practical nurse (PN) is interviewing a client who has intermittent chest pain while working in the garden. Which history should the PN obtain that predisposes this client to cardiovascular disease? Select all that apply. A. Obesity. B. Diabetes. C. Hypertension. D. Hyperlipidemia. E. Family history. F. Type B personality. A. Obesity. B. Diabetes. C. Hypertension. D. Hyperlipidemia. E. Family history. Risk factors that are related to inheritance that may lead to cardiovascular disease include obesity, diabetes, hypertension, high cholesterol, and family history. The pr actical nurse (PN) is perf orming a digit al extraction of an imp action for an older cl ient. Which finding indica tes to the PN that the pr ocedur e shoul d be s topped ? A. Sl owing heart rate bel ow 60 bea ts/minute. B. Reflex incontinence of urine and s tool. C. Incr eased bl oo d pr essur e by 20 mmHg D. Incr eased r espir ator y rate by 6 br ea ths. A. Sl owing heart rate bel ow 60 bea ts/minute. The s timulation of the r ectum by digit al examina tion may stimulate the vagus ner ve, which then sl ows the heart rate, so the cl ient shoul d be monit ored for reflex br ady car dia. A client who is 3 days postoperatively for a coronary artery bypass graft surgery (CABG) has a serum potassium level of 4.5 mEq/L. What action should the practical nurse (PN) implement based on this finding? A. Notify the healthcare provider. B. Document the finding only. C. Administer potassium replacement. D. Decrease the IV solution flow rate. B. Document the finding only. Post CABG can contribute to hypokalemia from hemodilution, nasogastric suction, or diuretic therapy, so monitoring serum electrolytes is important to determine the client's risk for cardiac dysrhythmias. The client's serum potassium is within normal limits (norm 3.5 to 5.0 mEq/L) and requires documentation only. What action should the practical nurse (PN) implement to improve the quality of sleep for a confused client? A. Give warm black tea at bedtime. B. Keep client awake during the day. C. Give routine sedative medications at HS. D. Avoid HS care 90 minutes before bedtime B. Keep client awake during the day. Stimulating the client to be active and awake during the day allows the client to experience some fatigue by nighttime so sleep is easier to achieve. A client who is recently diagnosed with bipolar disorder receives a new prescription for lithium (Eskalith). Which information should the practical nurse (PN) reenforce to ensure the client's understanding? A. Obtain serum lithium blood levels once a month. B. Eliminate foods high in salt from the daily diet. C. Discontinue lithium if fine hand tremors occur. D. Withhold lithium if fever develops during a "cold." A. Obtain serum lithium blood levels once a month. Monthly serum lithium should be monitored to ensure the prescribed dosage maintains the client's blood levels within a narrow therapeutic range. A client who delivered a normal baby 4 hours ago has been unable to void. What nursing intervention should the practical nurse (PN) implement first? A. Increase oral fluid intake to 2500 ml. B. Use urinary catheter to drain bladder. C. Rinse the perineum with warm water. D. Palpate suprapubic area for distention. C. Rinse the perineum with warm water. Non-invasive measures, such as pouring warm water over the client's perineum to create the urge to urinate should be implement first. The practical nurse (PN) is examining a newborn and identifies that the gluteal skin folds of the buttocks are uneven and one of the thighs is shorter than the other. Which assessment should the PN implement next? A. Visualize the anal and urinary meatus openings. B. Manipulate both ankles for range of motion. C. Count the number of fingers and toes. D. Flex and abduct hips simultaneously D. Flex and abduct hips simultaneously A focused assessment for congenital hip dysplasia, which is manifested with uneven gluteal skin folds, apparent shortening of one femur, and limited abduction with flexion of hips during the Ortolani maneuver, should be performed. The practical nurse (PN) assigns the unlicensed assistive personnel (UAP) to take the vital signs for a client with bacterial meningitis. Which finding should the PN direct the UAP to report immediately? A. Subnormal temperatures. B. Muscle flaccidity. C. Low blood pressure. D. Changes in consciousness. D. Changes in consciousness. In bacterial meningitis, meningeal irritation can cause complications such as seizures and increased intracranial pressure (ICP). The UAP should be directed to report a change in the client's consciousness, which is an early sign of elevated ICP that can compromise cerebral perfusion. Which cl ient out come shoul d the pr actical nurse (PN) identify for a cl ient with heart failure (HF)? A. The cl ient's weight fluctua tes by less than 2 kg per da y. B. The cl ient reques ts medica tion for anxiety onl y at night. C. The heart rate incr eases by 50 bea ts per minute with mil d exercise . D. The cl ient is abl e to dress and feed sel f without experiencing dy spnea. D. The cl ient is abl e to dress and feed sel f without experiencing dy spnea. A cl ient with HF that is effectiv ely mana ged shoul d be independent with activities of dail y living without dy spnea. Which acid-base imbalance is a client with a history of severe chronic obstructive pulmonary disease (COPD) likely to develop? A. Metabolic acidosis. B. Metabolic alkalosis. C. Respiratory acidosis. D. Respiratory alkalosis. C. Respiratory acidosis. The retention of carbon dioxide in a client with COPD causes chronic respiratory acidosis. A client with a massive cerebral bleed who is diagnosed as brain dead is receiving mechanical ventilation. The healthcare provider has just talked to the family about removing the client from life support. Which family concern should the practical nurse (PN) relay to the charge nurse immediately? A. Family request for an autopsy. B. Client's designation for organ donation. C. Referral to the coroner's office. D. Notification of the insurance company. B. Client's designation for organ donation. The family's concerns about the client's designation of organ donation should be reported to the charge nurse immediately so organ oxygenation can be maintained until organ procurement. A client has collapsed while getting out of bed, has no pulse, and is not breathing. After calling for help and an automated external defibrillator (AED), which action should the practical nurse (PN) take? A. Give two quick short breaths. B. Palpate for a carotid pulse. C. Defibrillate using the AED. D. Begin cardiac compressions. D. Begin cardiac compressions. Basic Life Support (BLS) for a client who is unconscious and not breathing should begin with cardiac compressions. The practical nurse (PN) is completing the morning focused assessment for a client who is admitted with cellulitis of the right leg. Which finding about the client's lower extremities is most important for the PN to report immediately to the charge nurse? A. Warm with bounding pulses. B. Edematous with slow capillary refill. C. Pale, cool to the touch, and diminished pulses. D. Postural color changes when feet are dependent. C. Pale, cool to the touch, and diminished pulses. An extremity that is pale, cool to the touch, and has decreased pulses is indicative of decreased perfusion that should be reported. Which task should the practical nurse (PN) assign to an unlicensed assistive personnel (UAP)? A. Check medical record for new prescriptions. B. Change dressings for a client with an infected wound. C. Toilet a client on a bladdertraining regimen. D. Evaluate blood pressure for a client who has fallen. C. Toilet a client on a bladder-training regimen. Hygiene related to elimination is within the scope of a UAP. Which action should the practical nurse (PN) implement to facilitate an effective airway clearance for a client who has a stridor and is coughing while experiencing an allergic reaction? A. Turn the client to a sidelying position. B. Offer the client a glass of water to drink. C. Place the client in a high Fowler's position. D. Percuss the client's back during coughing. C. Place the client in a high Fowler's position. To ensure effective airway clearance, the client should be placed in a high Fowler's position to promote diaphragmatic excursion that helps to strengthen coughing. The practical nurse (PN) is obtaining a history from a client with acute glomerulonephritis (AGN). Which information should the PN ask to focus on this disease etiology? A. Long-term analgesic use. B. A history of hypertension. C. Recent streptococcal infections. D. Repeated urinary tract infections. C. Recent streptococcal infections. The comprehensive history from a client with acute glomerulonephritis should include information about recent streptococcal infections, such as strep throat, impetigo, scarlet fever. A client who had a cardiac catheterization 2 hours ago has a pressure dressing in the left groin. The practical nurse (PN) is taking vital signs q2 hours. Which additional assessment should the PN make? A. Pedal pulse. B. Apical pulse. C. Femoral pulse. D. Brachial pulse. A. Pedal pulse. Pedal pulses should be monitored q2 hours postcardiac catheterization to ensure arterial perfusion distal to the femoral arterial access is intact. Which action should the practical nurse implement to reduce the risk of edema for a client who had a leg cast applied for a fractured tibia? A. Examine the cast for dents. B. Petal the edges of the cast. C. Elevate the newly casted leg on two pillows. D. Tell the client not to insert objects under the cast. C. Elevate the newly casted leg on two pillows. Elevating the leg to heart level using two pillows helps reduce edema formation. A client with a spinal cord injury is flushed and sweating profusely, complaining of headache and nausea, and has an elevated blood pressure with a slow pulse rate. What intervention should the practical nurse (PN) implement first? A. Notify the healthcare provider immediately. B. Check urine flow from indwelling catheter. C. Administer antihypertensive medication. D. Elevate head of the bed to a sitting position. D. Elevate head of the bed to a sitting position. The client is manifesting symptoms of autonomic dysreflexia. The first action is to elevate the head of the bed to a sitting position immediately. The pr actical nurse (PN) is placing a cl ient who had a knee r epl acement into a continuous p assiv e motion (CPM) ma chine . Which action shoul d the PN impl ement? A. K eep the side r ails lowered for access to unpl ug the machine . B. Raise the head of bed to a high F owler's position. C. Ensur e the k nee is pl aced corr ectl y to flex with the machine . D. El evate the ma chine on a pillow at the foot of the bed. C. Ensur e the k nee is pl aced corr ectl y to flex with the ma chine . The e xtremity shoul d be cent ered on the ma chine surface with the cl ient's knee flexing with the machine . A female college student is brought to the hospital by friends because she was having visual and auditory hallucinations and became extremely agitated after smoking a dose of "speed amphetamines. The client has a blood pressure of 162/98 mm Hg, an irregular heart rate of 142 beats/minute, and 32 respirations/minute. Which interventions should the practival nurse implement? a) monitor the client's telemetry and vital signs b) promote continuous ambulation and physical activity orient client with consistent verbal contact c) orient client with consistent verbal contact d) obtain a health history that includes prior drug use Answer: A Rationale: "Speed," an amphetamine, is a CNS stimulant, which, in the event of excessive dosing, can cause cardiac arrhythmias, myocardial infarction, or cerebral hemorrhage. The priority is to monitor the client's electrocardiogram and vital signs for impending complications (A). Since illicit use of amphetamines is highly stimulating, (B) may increase the client's likelihood of experiencing a psychotic or paranoid episode. (C and D) are not priority interventions. An older client receives a prescription for warfarin (Coumadin) 7.5 mg at bedtime. The medication is available in the Pyxis MedStationTM medication dispensing unit and is labeled, 5 mg tablets. How many tablets should the practical nurse administer? 1.5 tablets