Physiological Integrity

A nurse receives the shift report for a group of assigned clients on a medical-surgical trauma unit. Which client requires the nurse's immediate assessment and intervention?

A nurse is providing care for a client with a T4 spinal cord injury. The client suddenly reports a severe, pounding headache. Upon assessment, the nurse notes profuse diaphoresis on the client's face and neck, severe facial flushing, a blood pressure of 218/114 mm Hg, and a heart rate of 52 beats/min. The client has an indwelling urinary catheter in place. Arrange the following nursing interventions in the correct order of priority, from first to last.

A nurse is caring for a client admitted 12 hours ago with severe acute pancreatitis. The client's current assessment reveals pale, diaphoretic skin and a total urine output of 25 mL over the past two hours. Current vital signs are: blood pressure 84/50 mm Hg, heart rate 136 beats/min, and respiratory rate 28 breaths/min. Arterial blood gas (ABG) results show a pH of 7.28, PaCO2 of 31 mm Hg, and HCO3- of 15 mEq/L. What is the priority nursing action?

A nurse is evaluating a client who was intubated and placed on mechanical ventilation $2$ hours ago for acute respiratory failure. Current assessment findings include a heart rate of $132$ bpm, blood pressure of $86/52$ mm Hg, and cool, pale extremities. The latest arterial blood gas (ABG) results are pH $7.26$, $PaCO_2$ $62$ mm Hg, $HCO_3^-$ $25$ mEq/L, and $PaO_2$ $58$ mm Hg. Based on these assessment findings, which of the following clinical judgments and nursing actions are appropriate? Select all that apply.

A nurse assumes care for a client with severe Crohn's disease who is malnourished and receiving Total Parenteral Nutrition (TPN) via a peripherally inserted central catheter (PICC). The client's current vital signs are stable, and the continuous infusion is running on an electronic pump. Which of the following nursing actions must be included in the client's plan of care? Select all that apply.

The nurse is preparing to administer a large-volume cleansing enema to an adult client. Arrange the following procedural steps in the correct chronological order.

While receiving total parenteral nutrition (TPN) through a single-lumen peripherally inserted central catheter (PICC), a client suddenly develops a high fever. The healthcare provider prescribes an immediate dose of intravenous ceftriaxone. What is the most appropriate action for the nurse to take?

A client with an intra-abdominal infection is receiving a continuous intravenous infusion of metronidazole. The client reports severe nausea, and the healthcare provider prescribes a dose of intravenous ondansetron. The client has a single peripheral intravenous line. After consulting a pharmacological reference, the nurse identifies that metronidazole and ondansetron are incompatible at the Y-site. Which action should the nurse take to safely administer the prescribed antiemetic?

A client admitted with septic shock is currently receiving a continuous intravenous (IV) infusion of pantoprazole through a single peripheral IV catheter. The client's blood pressure drops to $74/42\text{ mmHg}$ with a heart rate of $122\text{ bpm}$, prompting the healthcare provider to prescribe a stat continuous IV infusion of norepinephrine. Upon checking a pharmacological reference, the nurse discovers that norepinephrine and pantoprazole are incompatible at the Y-site. Which action should the nurse take first?

A nurse evaluates a client with distributive shock who is receiving a continuous intravenous (IV) infusion of norepinephrine through a peripheral venous catheter in the right forearm. The nurse observes that the skin around the insertion site is severely blanched, cold to the touch, and edematous. Which of the following actions should the nurse perform? Select all that apply.

A nurse is assisting a healthcare provider with a bedside thoracentesis for a client diagnosed with a right-sided pleural effusion. Which nursing actions are appropriate to reduce the risk of procedural complications? Select all that apply.

A nurse is developing a plan of care for an adult client recovering from a right-sided cerebrovascular accident (stroke), which has resulted in left-sided hemiplegia and dysphagia. Which basic care and comfort interventions should the nurse include in the client's plan? Select all that apply.

A client who underwent the surgical creation of a descending colostomy two days ago reports abdominal discomfort and asks for assistance with pouch maintenance before going to sleep. Which nursing action is most appropriate to promote the client's comfort and physical hygiene?

A nurse is developing a plan of care for an older adult client who is receiving continuous enteral tube feedings and is on bedrest due to generalized weakness. Which of the following interventions should the nurse include in the client's plan of care to promote basic care, comfort, and safety? Select all that apply.

An order is written for liquid acetaminophen at $15 \text{ mg/kg}$ per dose for a toddler who weighs $16 \text{ kg}$. The medication bottle is labeled $160 \text{ mg}/5 \text{ mL}$. Calculate the total volume in $\text{mL}$ that should be administered for a single dose. (Record your answer to one decimal place.)

A critical care nurse is managing a client diagnosed with acute respiratory failure who is receiving mechanical ventilation. The laboratory reports the following arterial blood gas results: pH 7.28, PaCO2 62 mm Hg, PaO2 55 mm Hg, and HCO3 24 mEq/L. To reduce the risk of further physiological deterioration, which of the following interventions are appropriate? Select all that apply.

While a unit of packed red blood cells (PRBCs) is infusing, the client suddenly develops severe lower back pain, dyspnea, and visible shivering. The nurse suspects an acute hemolytic transfusion reaction. Arrange the following nursing interventions in the correct chronological order of priority. (Place the first action at the top and the last action at the bottom.)

A client diagnosed with a pulmonary embolism has a documented admission weight of 187 lbs. The healthcare provider orders a continuous intravenous (IV) heparin infusion at a dose of 18 units/kg/hr. The pharmacy dispenses an IV bag containing 25,000 units of heparin in 250 mL of 5% dextrose in water. Calculate the required infusion pump rate in mL/hr. (Round the answer to the nearest tenth.)

A nurse is monitoring a client who is receiving a continuous intravenous regular insulin infusion for the treatment of diabetic ketoacidosis (DKA). The client's current blood glucose level is $240$ mg/dL ($13.3$ mmol/L). Which laboratory finding poses the greatest risk for a physiological complication and requires immediate intervention?

An adult client is receiving care in the intensive care unit for massive gastrointestinal hemorrhage. Despite aggressive fluid resuscitation, the bleeding persists. Which assessment findings suggest that the client has entered the progressive (uncompensated) stage of hypovolemic shock? Select all that apply.