Physiological Integrity

A nurse is preparing to administer an intermittent bolus enteral feeding to a client via a gastrostomy tube. Place the following nursing actions in the correct chronological order.

A client receiving parenteral nutrition via a right subclavian central venous access device (CVAD) suddenly reports severe chest pain, shortness of breath, and a feeling of impending doom. The nurse observes that the intravenous tubing has become disconnected from the catheter hub. Which of the following immediate interventions should the nurse implement? (Select all that apply.)

A nurse is caring for a client who returned to the medical-surgical unit one hour ago following a diagnostic cardiac catheterization via the right femoral artery approach. The client reports mild lower back discomfort and requests a change in position. Which of the following positioning interventions is most appropriate for this client?

The healthcare team is preparing to perform a bed bath and linen change for a client receiving continuous enteral nutrition via a nasogastric tube. Which action should the registered nurse take to maintain safety during this care?

A nurse is caring for a client who requires a transfusion of packed red blood cells (PRBCs) for symptomatic anemia. The client has a single $18$-gauge peripheral intravenous (IV) catheter, which is currently infusing Lactated Ringer's solution at $75 \text{ mL/hr}$. Which of the following is the most appropriate action by the nurse?

During shift report on a progressive care unit, a nurse receives handoff for a client recovering from a massive anterior wall myocardial infarction. The previous shift's documented vital signs were: blood pressure 128/74 mm Hg, heart rate 80 beats/min, and respiratory rate 14/min. Upon initial rounds, the nurse observes the client fidgeting in bed. Vital signs are now: blood pressure 104/86 mm Hg, heart rate 118 beats/min, and respiratory rate 24/min. Which of the following conclusions should the nurse draw from this assessment?

An emergency nurse is evaluating a client with type 1 diabetes mellitus who presents with altered mental status, profound lethargy, and a distinct sweet-smelling breath odor. The client is exhibiting heavily labored respirations with an increased depth at a rate of $34$ breaths per minute. Cardiac monitoring displays sinus tachycardia at $132$ beats per minute, and the non-invasive blood pressure reads $84/44$ mm Hg. Laboratory results indicate a capillary blood glucose of $612$ mg/dL, $\text{pH}$ of $7.15$, $\text{PaCO}_2$ of $23$ mm Hg, and $\text{HCO}_3^-$ of $10$ mEq/L. Which action should the nurse execute immediately?

A clinical nurse leader is evaluating the care plan for an older adult client who is essentially bedbound due to severe generalized deconditioning and has recently developed episodic urinary incontinence. Which interventions are appropriate for the client's basic care and comfort? Select all that apply.

A nurse is caring for a client with a pulmonary embolism who is receiving a continuous intravenous (IV) infusion of unfractionated heparin through a single-lumen peripheral IV catheter. The healthcare provider prescribes a scheduled dose of IV gentamicin to be infused over $60 \text{ minutes}$. A pharmacological reference indicates that heparin and gentamicin are physically incompatible at the Y-site. Which action is most appropriate for the nurse to take?

A client admitted with septic shock is receiving a continuous intravenous infusion of norepinephrine through a single 20-gauge peripheral catheter. The healthcare provider prescribes an intermittent intravenous piggyback of ceftriaxone to be administered immediately. The nurse reviews a drug reference guide and notes that ceftriaxone is incompatible with norepinephrine. Which action should the nurse take?

A client is recovering on the medical-surgical unit shortly after undergoing an exploratory laparotomy and intestinal resection. To promptly detect and mitigate potential postoperative complications, which interventions should the nurse implement? Select all that apply.

A nurse is preparing to administer an intravenous (IV) dose of phenytoin $300\text{ mg}$ to a client with a seizure disorder. The client has a continuous IV infusion of $5\%$ dextrose in water (D5W) infusing at $75\text{ mL/hr}$ through a single peripheral IV catheter. Which of the following is the most appropriate action by the nurse?

A nurse is assessing a client who has experienced severe vomiting and diarrhea for the past 3 days. Which assessment findings indicate the client has developed early compensatory hypovolemic shock? Select all that apply.

A nurse is assessing a 45-year-old client who is 6 hours post-operative following a total thyroidectomy for Graves' disease. Which of the following clinical findings indicate a developing complication that requires IMMEDIATE intervention? Select all that apply.

A client who weighs $165\text{ lb}$ is experiencing prolonged seizure activity. The healthcare provider prescribes an intravenous (IV) loading dose of phenytoin at $15\text{ mg/kg}$. To prevent severe hypotension and cardiac dysrhythmias, institutional policy dictates that IV phenytoin must not be administered faster than $50\text{ mg/min}$.

What is the minimum time, in minutes, required to safely infuse this loading dose? Record your answer using one decimal place.

A nurse is monitoring a client who is 48 hours post-operative following an emergency bowel resection for a perforated diverticulum. The client has become increasingly restless over the past two hours. Which of the following assessment findings should the nurse identify as early (hyperdynamic) indicators of septic shock? Select all that apply.

An older adult client is being monitored in the surgical intensive care unit following an open abdominal aortic aneurysm repair. Over the past hour, the client's urine output has dropped to $15\text{ mL}$. Current vital signs reveal a blood pressure of $86/52\text{ mm Hg}$, a heart rate of $122\text{ beats/minute}$, and a respiratory rate of $26\text{ breaths/minute}$. Recent arterial blood gas results show a pH of $7.31$, a PaCO2 of $34\text{ mm Hg}$, and an HCO3 of $15\text{ mEq/L}$. Which intervention should the nurse implement first?

A client receiving a packed red blood cell (PRBC) transfusion suddenly reports severe lower back pain, chills, and shortness of breath. Suspecting an acute hemolytic transfusion reaction, arrange the following nursing actions in the correct priority order to mitigate further risk to the client.

An 82-year-old client with a long history of severe chronic obstructive pulmonary disease (COPD) is brought to the emergency department for worsening shortness of breath and a productive cough. Which assessment findings should indicate to the nurse that the client is experiencing acute hypercapnic respiratory failure rather than expected chronic baseline changes? (Select all that apply)

A nurse is caring for an adult client who has a serum potassium level of $2.8 \text{ mEq/L}$. The healthcare provider prescribes $40 \text{ mEq}$ of intravenous potassium chloride (KCl) diluted in $100 \text{ mL}$ of $0.9\%$ sodium chloride to be infused over $30 \text{ minutes}$ via a peripheral venous catheter. Which of the following is the priority nursing action?