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WorksheetsPhysiological Adaptation/Safety-NCLEX-PN
Total questions: 25
Worksheet time: 13mins
An LPN notes a postoperative client has restlessness, heart rate 118/min, urine output 20 mL/hr, and cool skin. Which finding is most concerning?
Heart rate
Urine output
Restlessness
Cool skin
Which findings indicate poor tissue perfusion?
Delayed capillary refill
Bounding pulses
Decreased urine output
Confusion
Warm, flushed skin
Which client is at greatest risk for deep vein thrombosis (DVT)?
Client ambulating twice daily
Client receiving anticoagulants
Client on bedrest after hip surgery
Client with controlled hypertension
Which findings suggest early hypovolemia?
Tachycardia
Hypotension
Restlessness
Increased urine output
Dry mucous membranes
An LPN suspects neurovascular compromise in a client with a cast. Which assessment finding requires immediate RN notification?
Mild swelling
Capillary refill of 2 seconds
Increasing pain unrelieved by medication
Warm toes
Which signs indicate neuromuscular compromise?
Paresthesia
Pallor
Strong distal pulses
Paralysis
Increased appetite
Which finding best differentiates urinary retention from dehydration?
Decreased urine output
Suprapubic distention
Dry mucous membranes
Tachycardia
Which clients are at highest risk for dehydration?
Older adult with decreased thirst sensation
Client taking loop diuretics
Client with high-protein diet
Client with cognitive impairment
Client receiving IV fluids
Which assessment finding best indicates early shock?
Hypotension
Restlessness
Cyanosis
Anuria
Which actions help reduce the risk for pressure injuries?
Reposition every 2 hours
Massage reddened areas
Keep skin clean and dry
Use pressure-reducing surfaces
Limit protein intake
A client with dysphagia begins coughing during meals. What is the priority nursing action?
Offer water
Continue feeding slowly
Stop feeding and notify the RN
Document the finding
Which findings increase aspiration risk?
Decreased level of consciousness
Upright positioning
Wet or gurgly voice
Pocketing food
Alert mental status
Which client is at greatest risk for a healthcare-associated infection (HAI)?
Client ambulating independently
Client with an indwelling Foley catheter
Client receiving oral antibiotics
Client with a healed incision
Which actions help prevent catheter-associated urinary tract infections (CAUTIs)?
Maintain a closed drainage system
Secure catheter to thigh
Keep drainage bag above bladder
Perform routine perineal care
Remove catheter as soon as possible
While collecting a clean-catch urine specimen, which action would contaminate the specimen?
Collecting midstream urine
Touching the inside of the container
Cleansing the perineal area
Refrigerating specimen if delayed
Which clients are at high risk for tissue injury?
Client with incontinence
Client with poor nutritional intake
Client ambulating frequently
Client in traction
Client repositioned regularly
Which finding suggests early DVT rather than expected postoperative discomfort?
Bilateral leg soreness
Localized unilateral calf pain
Incisional tenderness
General muscle stiffness
Which findings indicate circulatory compromise in an extremity?
Pallor
Tingling
Warm skin
Weak pulses
Increasing pain
Which finding best indicates effective perfusion?
Urine output of 10 mL/hr
Delayed capillary refill
Alert mental status
Cool extremities
Which interventions reduce aspiration risk in tube-fed clients?
Elevate head of bed 30–45°
Verify tube placement per policy
Place client flat after feeding
Pause feeding during repositioning
Check residuals per facility policy
A client reports numbness and tingling distal to a cast. What is the best action?
Document and reassess later
Elevate the extremity
Notify the RN immediately
Administer pain medication
Which findings indicate increased fall risk?
Orthostatic hypotension
Opioid use
Clear mental status
Recent surgery
Non-skid footwear
Which client should the LPN see first?
Client requesting pain medication
Client with oxygen saturation of 88%
Client awaiting discharge
Client eating breakfast
Which findings suggest fluid volume deficit?
Dry mucous membranes
Tachycardia
Bounding pulses
Decreased urine output
Weight gain
Which scenario best represents Reduction of Risk Potential?
Monitoring vital signs after surgery
Teaching insulin administration
Repositioning an immobile client
Administering prescribed medication
