Physiological Integrity

A client with severe cardiogenic shock is receiving a continuous intravenous (IV) infusion of milrinone via a single $22\text{-gauge}$ peripheral catheter. The client rapidly develops severe dyspnea, diffuse pulmonary crackles, and an oxygen saturation of $82\%$. The healthcare provider prescribes a stat dose of IV bumetanide. Upon consulting the pharmacological reference, the nurse notes that bumetanide and milrinone are physically incompatible. Which of the following is the most appropriate nursing action?

A nurse is assuming care for a client with severe Crohn's disease who is receiving continuous total parenteral nutrition (TPN) via a double-lumen central venous catheter. The client is currently resting comfortably. Which of the following nursing interventions are appropriate for managing this client's parenteral therapy? Select all that apply.

A client on the cardiac step-down unit requires a continuous intravenous infusion of procainamide to manage ventricular ectopy. The healthcare provider's prescription is for $2 \text{ mg/min}$. The available premixed solution contains $2 \text{ g}$ of procainamide in $500 \text{ mL}$ of $5\%$ dextrose in water. Calculate the required infusion rate in $\text{mL/hr}$.

A 54-year-old client with chronic hepatitis C has just arrived at the medical-surgical unit after undergoing a percutaneous liver biopsy. The client is alert and reports mild discomfort at the biopsy site. Initial vital signs are stable, with a blood pressure of 118/78 mm Hg, heart rate of 82 beats per minute, and oxygen saturation of 98% on room air. Which of the following actions is the priority to minimize the client's risk of immediate post-procedure complications?

A client with left-sided hemiparesis following a stroke is receiving assistance with morning activities. Which actions demonstrate correct principles of basic care, comfort, and mobility for this client? Select all that apply.

A nurse is assessing a client who is receiving intravenous morphine via a patient-controlled analgesia (PCA) pump following orthopedic surgery. Upon entering the room, the nurse observes that the client is somnolent, has a respiratory rate of 8 breaths/min, and an oxygen saturation of 87% on room air. Which of the following immediate actions should the nurse take? Select all that apply.

A client is transferred back to the medical unit following a percutaneous liver biopsy. The nurse is assisting the client into bed. To minimize the risk of post-procedure hemorrhage, which position should the nurse place the client in?

A nurse is caring for a client receiving a packed red blood cell (PRBC) transfusion. Fifteen minutes into the transfusion, the client reports sudden chills, severe lower back pain, and shortness of breath. In what chronological order should the nurse perform the following actions to reduce the risk of further physiological deterioration? Arrange the actions from first to last.

A nurse is preparing to administer ondansetron $4 \text{ mg}$ via intravenous (IV) push to a client experiencing nausea. The medication vial is labeled $2 \text{ mg/mL}$. How many milliliters (mL) should the nurse administer?

A nurse is preparing to administer an initial intravenous (IV) loading dose of phenytoin to a client diagnosed with a seizure disorder. The client has an existing continuous IV infusion of 5% dextrose in water (D5W) running at 75 mL/hr. Which action should the nurse take to ensure safe administration of the medication?

A nurse is evaluating a client who has been receiving continuous nasogastric (NG) suctioning for 3 days due to a paralytic ileus. The client reports new-onset severe muscle cramping and palpitations. The cardiac monitor displays frequent premature ventricular contractions (PVCs). The client's respiratory rate is 10 breaths/min and shallow. Arterial blood gas (ABG) results are: pH 7.54, PaCO2 49 mm Hg, PaO2 88 mm Hg, and HCO3 35 mEq/L. To reduce the risk of impending physiological decompensation, which action is the nurse's priority?

A nurse is preparing to administer sodium nitroprusside to a client experiencing a hypertensive emergency. The client weighs $78 \text{ kg}$. The prescribed continuous intravenous infusion rate is $4 \text{ mcg/kg/min}$. The pharmacy provides a prepared IV bag containing $50 \text{ mg}$ of sodium nitroprusside in $250 \text{ mL}$ of $5\%$ dextrose in water (D5W).

Calculate the required infusion pump rate in $\text{mL/hr}$. (Record your answer to the nearest whole number.)

A 78-year-old client with advanced Alzheimer's disease, severe kyphosis, and a recent right hemispheric stroke resulting in right homonymous hemianopsia and dysphagia is admitted to a palliative care unit. The client is completely bedbound, non-verbal, and grimaces frequently when turned. When planning the client's basic care and comfort interventions, which of the following actions should the nurse include in the plan of care? (Select all that apply.)

A surgical unit nurse is evaluating the clinical status of four clients who recently underwent major abdominal procedures. Based on the documented assessments, which client finding should the nurse recognize as the earliest physiological indicator of a developing hemorrhagic shock state?

Following an admission for severe pneumonia, a client's clinical status begins to deteriorate. Which of the following initial assessment findings should alert the nurse to the early development of septic shock?

A nurse is evaluating the most recent arterial blood gas (ABG) results for a client who was admitted with a severe asthma exacerbation. The results are: pH 7.28, PaCO2 56 mm Hg, and HCO3 24 mEq/L. Which of the following acid-base imbalances should the nurse identify?

A nurse is inserting a nasogastric (NG) tube for enteral nutrition in an alert adult client. Arrange the following procedural steps in the exact chronological sequence to ensure safe insertion and minimize the risk of tracheal intubation.

A client is admitted to the telemetry unit immediately after undergoing a cardiac catheterization using the right femoral artery approach. Which actions are essential for the nurse to take to minimize the risk of complications? Select all that apply.

A nurse is preparing to change the bed linens for a 78-year-old client who is receiving continuous enteral nutrition via a nasogastric (NG) tube. The client must be temporarily placed in a flat, supine position to allow the nurse to safely roll them side-to-side. Which of the following actions should the nurse take?

A nurse is caring for a client with a deep vein thrombosis who is receiving a continuous intravenous (IV) infusion of heparin via a single-lumen peripherally inserted central catheter (PICC). The client suddenly reports severe nausea and vomits dark, coffee-ground emesis. The client's most recent activated partial thromboplastin time (aPTT) is $125 \text{ seconds}$. The healthcare provider prescribes a stat dose of IV pantoprazole $40 \text{ mg}$. Which sequence of actions is the most appropriate for the nurse to perform?