Physiological Integrity

A healthcare provider prescribes haloperidol $3 \text{ mg}$ intramuscularly (IM) for a client experiencing severe agitation. The pharmacy supplies a vial labeled haloperidol $5 \text{ mg/mL}$. How many $\text{mL}$ should the nurse administer? (Record the answer using one decimal place.)

A 65-year-old client is transferred to the telemetry unit immediately following a diagnostic cardiac catheterization accessed via the right femoral artery. The client is awake, reports feeling hungry, and has stable vital signs. The right pedal pulse is palpable. To reduce the risk of severe hemorrhage or hematoma at the puncture site, which positioning directive must the nurse enforce?

A nurse is planning a bed bath and a linen change for a client who is 12 hours post-operative following a craniotomy and is currently being managed for increased intracranial pressure (ICP). Which of the following actions should the nurse implement to ensure client safety and comfort?

A nurse is preparing to administer a large-volume cleansing enema to an adult client experiencing severe constipation. In what order should the nurse perform the following actions? Arrange the steps from first to last.

A nurse is assessing the risk profiles of several clients on a medical-surgical unit. Which of the following clients are at greatest risk for developing respiratory acidosis? (Select all that apply.)

A client is brought to the emergency department experiencing a severe panic attack. The client is acutely tachypneic with a respiratory rate of 34 breaths/minute and reports numbness and tingling in the fingers. Based on these clinical findings, which acid-base imbalance should the nurse suspect?

A nurse is establishing a plan for basic care and comfort for a client who returned to the surgical unit 4 hours ago following a transsphenoidal hypophysectomy. The client has nasal packing in place and is restricted to breathing through the mouth. Which interventions should the nurse include in the client's care plan? Select all that apply.

A nurse is preparing to administer an intermittent intravenous (IV) piggyback antibiotic to a client. The client currently has a continuous primary IV infusion of 0.9% sodium chloride running via an electronic infusion pump. In what order should the nurse perform the following actions? Arrange the steps from first to last.

A nurse enters the room of a client receiving internal radiation therapy (brachytherapy) for cervical cancer. The nurse discovers that the intracavitary radioactive applicator has accidentally dislodged and is resting on the client's bed linens. To safely reduce the risk of harmful radiation exposure, arrange the following nursing actions in the correct priority sequence.

A nurse is caring for a client with a history of heart failure who suddenly develops severe dyspnea, extreme anxiety, and a cough producing pink, frothy sputum. The nurse suspects acute pulmonary edema. In what order should the nurse perform the following actions? (Arrange the actions in the correct sequence from first to last)

A charge nurse is evaluating the care of a client who returned to the unit following a large-volume paracentesis for severe ascites. Which of the following assessment findings or nursing actions require IMMEDIATE follow-up to prevent physiological decompensation? (Select all that apply.)

A surgical nurse is developing a daily care regimen for a client who is 48 hours postoperative following a right above-the-knee amputation. To prevent musculoskeletal complications and ensure safe hygiene practices, which intervention is most appropriate to include in the plan?

A nurse is assessing a client who is recovering from a major abdominal surgery. Which vital sign change should the nurse identify as the earliest compensatory indicator of developing hypovolemic shock?

An 78-year-old client with a history of mild dementia is 24 hours post-operative following a right total hip arthroplasty (posterior approach). During morning rounds, the client becomes acutely agitated and continuously attempts to pull at their indwelling urinary catheter. Which basic care and comfort intervention should the nurse implement?

An adult client is receiving a continuous intravenous (IV) infusion of Lactated Ringer's solution at $100$ mL/hr through a peripheral catheter. The healthcare provider prescribes a stat dose of ceftriaxone $1$ gram IV piggyback to treat a diagnosed bacterial infection. Which of the following actions should the nurse take to safely administer the medication?

A clinical nurse preceptor is reviewing the care plan drafted by a newly licensed nurse for an 82-year-old client. The client is bedbound with right-sided hemiplegia following an ischemic stroke, receives continuous enteral nutrition via a nasogastric (NG) tube, and has recently developed urinary incontinence. Which of the following planned interventions should the preceptor identify as correct and appropriate for the client's basic care and comfort? Select all that apply.

A nurse is preparing to administer an intravenous piggyback (IVPB) of cefazolin $1 \text{ gram}$ in $50 \text{ mL}$ of $0.9\%$ sodium chloride to a client with a surgical site infection. The medication is prescribed to infuse over $30 \text{ minutes}$. At what rate in $\text{mL/hr}$ should the nurse set the electronic infusion pump? Record your answer as a whole number.

A client admitted with cardiogenic shock is prescribed a continuous intravenous (IV) infusion of dopamine at $5 \text{ mcg/kg/min}$. The client weighs $176 \text{ lbs}$. The pharmacy provides dopamine $400 \text{ mg}$ mixed in $250 \text{ mL}$ of $0.9\% \text{ NaCl}$.

At what rate in $\text{mL/hr}$ should the nurse program the IV infusion pump? Record your answer as a whole number.

A nurse is caring for a client who was admitted with severe pneumonia and dehydration. The client has a double-lumen central venous catheter, is receiving a continuous infusion of 0.9% sodium chloride, and has new prescriptions for scheduled IV levofloxacin and PRN IV morphine. Which of the following actions by the nurse demonstrate safe parenteral therapy practices? Select all that apply.

A clinical nurse is managing a client admitted with severe acute pyelonephritis. The client suddenly develops new-onset restlessness and confusion. Assessment reveals bounding peripheral pulses, warm and flushed skin, and the following vital signs: temperature $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), heart rate $128$ beats/minute, respiratory rate $30$ breaths/minute, and blood pressure $86/50\text{ mm Hg}$. An arterial blood gas (ABG) sample drawn on room air demonstrates a pH of $7.50$, PaCO $_2$ of $26\text{ mm Hg}$, PaO $_2$ of $82\text{ mm Hg}$, and HCO $_3^-$ of $21\text{ mEq/L}$. Based on this clinical picture, what is the most critical immediate action the nurse should execute?