Physiological Integrity

A client with a history of recurrent seizures is admitted to the medical unit. The client has a single patent peripheral intravenous catheter with a continuous infusion of 5% dextrose in water (D5W) at 75 mL/hr. The healthcare provider prescribes an intermittent infusion of intravenous phenytoin. Which action is most appropriate for the nurse to take?

A nurse is assessing a client who had an exploratory laparotomy 3 days ago. While the nurse is in the room, the client sneezes forcefully and reports a sudden "popping" sensation. The nurse inspects the surgical site and observes a loop of bowel protruding through the incision. In what order should the nurse perform the following actions to reduce the risk of further complications? Arrange the actions in the correct sequence.

A nurse is caring for a client admitted with severe diabetic ketoacidosis (DKA). The client is currently receiving a continuous intravenous regular insulin infusion along with normal saline. Which assessment finding requires the most immediate intervention by the nurse?

A nurse is preparing to remove a non-tunneled central venous catheter (CVC) from a client's internal jugular vein. Place the following nursing actions in the correct chronological order to ensure client safety and prevent complications during the procedure.

A nurse is assessing a client admitted with an acute exacerbation of peptic ulcer disease. The client's baseline blood pressure was $134/78$ mm Hg, and the resting heart rate was $82$ beats per minute. Which new assessment finding is the most critical early indicator that the client is developing a life-threatening physiological complication?

While assessing a client experiencing an acute asthma exacerbation, the nurse notes severe work of breathing with a respiratory rate of $36\text{ breaths/minute}$. Initial arterial blood gas (ABG) results show a pH of $7.52$, $PaCO_2$ of $28\text{ mmHg}$, and $PaO_2$ of $72\text{ mmHg}$. After one hour of continuous bronchodilator therapy, the client appears quieter, the respiratory rate decreases to $14\text{ breaths/minute}$, and wheezing is no longer audible. A repeat ABG reveals a pH of $7.36$, $PaCO_2$ of $44\text{ mmHg}$, and $PaO_2$ of $62\text{ mmHg}$. Which of the following is the priority nursing action?

While pushing an intravenous (IV) medication, the nurse observes that the client suddenly develops intense facial flushing and reports a severe, pounding headache along with chest tightness. A rapid assessment reveals a blood pressure of 82/48 mmHg, a heart rate of 118 beats/min with an irregular rhythm, and a respiratory rate of 24 breaths/min. Which of the following is the priority nursing action?

A nurse is planning care for a client who has just returned to the clinical unit following a bedside right-sided thoracentesis for a pleural effusion. Which interventions should the nurse implement to monitor for and reduce the risk of potential complications? Select all that apply.

A client with a severe exacerbation of asthma is admitted to the emergency department. The healthcare provider prescribes an intravenous loading dose of aminophylline $5\text{ mg/kg}$ to be infused over $30\text{ minutes}$. The client weighs $154\text{ lbs}$. The pharmacy dispenses aminophylline $500\text{ mg}$ mixed in $500\text{ mL}$ of $5\%$ dextrose in water (D5W). At what rate in $\text{mL/hr}$ should the nurse program the infusion pump?

A nurse receives a handoff report for a client who is $48\text{ hours}$ post-coronary artery bypass graft surgery. The previous shift reports that the mediastinal chest tube drainage abruptly stopped $2\text{ hours}$ ago. Upon entering the room, the client appears highly restless and reports a severe sensation of tightness in the chest. Current vital signs reveal a heart rate of $124\text{ beats/min}$, a respiratory rate of $24\text{ breaths/min}$, and a blood pressure of $96/82\text{ mm Hg}$. Auscultation of the chest reveals muffled heart tones.

Based on these clinical findings, which of the following is the priority nursing action?

A client is receiving a continuous intravenous (IV) infusion of heparin for the treatment of a pulmonary embolism. The client has a single peripheral IV catheter. The healthcare provider prescribes a scheduled dose of IV piggyback levofloxacin. Upon checking a drug reference guide, the nurse determines that levofloxacin is physically incompatible with heparin. What is the most appropriate action by the nurse?

A 28-year-old client is receiving mechanical ventilation in the intensive care unit following a severe traumatic brain injury. An external ventricular drain is in place, and the monitor displays a sustained intracranial pressure (ICP) of 24 mm Hg. The nurse evaluates the client's morning arterial blood gas (ABG) results, which reveal a pH of 7.29, PaCO2 of 54 mm Hg, PaO2 of 92 mm Hg, and HCO3- of 25 mEq/L (25 mmol/L). Which of the following interventions is the highest priority for the nurse to implement to reduce the risk of further neurological damage?

An adult individual recovering from a severe gastrointestinal resection is receiving total parenteral nutrition (TPN) via a peripherally inserted central catheter (PICC). The nurse observes that the current bag of TPN has less than $20\text{ mL}$ remaining. The hospital pharmacy informs the unit that the next prepared nutritional solution will be delayed by approximately two hours. Based on the client's current therapy, which of the following is the most appropriate nursing action to take next?

A nurse is managing the care of a postoperative client who is receiving intravenous (IV) morphine via a patient-controlled analgesia (PCA) pump. Which of the following nursing actions are appropriate for this client? Select all that apply.

A hospitalized individual with community-acquired pneumonia is currently receiving supplemental oxygen via nasal cannula at $2\text{ L/min}$. During hourly rounds, the nursing staff observes that the individual has become highly restless, confused, and is utilizing accessory muscles to breathe.

Which action represents the priority intervention for this individual?

A nurse is planning care for a client who returned to the surgical unit 2 hours ago following a lumbar laminectomy. Which of the following nursing interventions should the nurse implement to reduce the risk of postoperative complications? Select all that apply.

A nurse is caring for an adult client who is receiving a unit of packed red blood cells (PRBCs) for symptomatic anemia. Twenty minutes after the transfusion is initiated, the client reports sudden lower back pain and feeling unusually cold. The nurse notes the client is restless with a blood pressure of 88/52 mmHg. Arrange the following nursing actions in the correct order of priority. (Place the highest priority action first.)

A client is admitted to the medical-surgical unit with infective endocarditis. The client's vital signs include a temperature of 102.4°F (39.1°C), heart rate of 112 bpm, and blood pressure of 108/64 mmHg. The healthcare provider prescribes intermittent intravenous (IV) infusions of penicillin G and gentamicin. The client currently has a single 20-gauge peripheral IV line established. Which action by the nurse represents the safest administration technique for these medications?

A nurse is preparing to administer a prescribed intravenous (IV) push medication through a client's non-valved central venous catheter (CVC). Arrange the following steps in the correct order of execution. All steps must be used.

An emergency department nurse evaluates a client presenting with a three-day history of profound watery diarrhea and poor oral fluid intake. The client exhibits marked lethargy and dry mucous membranes. Initial assessment reveals a heart rate of $116\text{ beats/min}$, a respiratory rate of $28\text{ breaths/min}$, and a blood pressure of $94/60\text{ mm Hg}$. Arterial blood gas analysis demonstrates a pH of $7.29$, a $PaCO_2$ of $32\text{ mm Hg}$, and an $HCO_3^-$ of $15\text{ mEq/L}$. Which action represents the highest priority for this client?