Physiological Integrity

During the initial $12$ hours following a transsphenoidal hypophysectomy for a pituitary adenoma, the nurse evaluates a $45$-year-old client's clinical status. Which assessment findings indicate impending physiological decompensation and require immediate risk reduction interventions? (Select all that apply)

A 45-year-old client is receiving continuous mechanical ventilation in the intensive care unit following a severe traumatic brain injury. The client's current intracranial pressure (ICP) reads 24 mmHg. The nurse reviews the most recent assessment data:

- Neurological: Sedated; pupils are equal but sluggish to react.
- Hemodynamics: Blood pressure 170/86 mmHg, heart rate 54 bpm, temperature 37.4°C (99.3°F).
- Arterial Blood Gas (ABG): pH 7.31, PaCO2 56 mmHg, HCO3 25 mEq/L, PaO2 94 mmHg.
- Positioning: Head of the bed elevated at 30 degrees, neck in neutral midline alignment.

To reduce the risk of cerebral herniation, which action should the nurse implement first?

A nurse is assessing a client who is receiving a continuous peripheral intravenous (IV) infusion of norepinephrine. The nurse notes that the IV insertion site is blanched, cool to the touch, and swollen. The client reports a severe burning sensation at the site. Arrange the following nursing actions in the exact sequence they should be performed, from first to last.

A nurse is preparing to mix and administer regular insulin and NPH insulin in a single syringe for a client with diabetes mellitus. Arrange the following steps in the correct chronological order to ensure safe and effective medication preparation.

A nurse is caring for an older adult client who is 3 hours post-percutaneous coronary intervention (PCI) via a right femoral artery approach. The client, who has a history of osteoarthritis, reports severe lower back stiffness and requests to sit upright or get out of bed. Which intervention should the nurse implement to promote comfort while ensuring client safety?

A client with a seizure disorder is currently receiving a continuous infusion of 5% dextrose in water (D5W) through a single peripheral IV catheter. The healthcare provider prescribes an immediate dose of intravenous phenytoin. Knowing that phenytoin forms a precipitate when mixed with dextrose solutions, arrange the following nursing actions in the correct chronological sequence to safely deliver the medication.

A client with acute kidney injury is exhibiting profound muscle weakness. The bedside cardiac monitor suddenly displays a widened QRS complex and tall, peaked T waves. The laboratory reports a stat serum potassium level of $7.8\text{ mEq/L}$. The healthcare provider has prescribed several urgent interventions. Arrange the following pharmacological actions in the priority sequence the nurse must implement them.

During the morning shift, a nurse provides care for a client who underwent a right above-the-knee amputation 48 hours ago. The client is medically stable and preparing to begin physical therapy. To promote optimal physical mobility and prevent common musculoskeletal complications, which intervention should the nurse implement?

A client with a history of cirrhosis is being monitored $2$ hours after a large-volume paracentesis in which $6$ liters of ascitic fluid were removed. The client's current vital signs are: blood pressure $94/78$ mm Hg, heart rate $116$ bpm, and respiratory rate $24$/min. An arterial blood gas (ABG) analysis reveals a pH of $7.29$, a $PaCO_2$ of $31$ mm Hg, and an $HCO_3^-$ of $15$ mEq/L. The unlicensed assistive personnel (UAP) is preparing to assist the client into a high-Fowler's position to eat a meal. Which action should the nurse take first to reduce the risk of a severe complication?

A palliative care team is managing an older adult client who is completely bedbound due to profound cachexia and intractable bone pain. The client exhibits significant muscle wasting and thin, fragile skin. Which interventions are appropriate to include in the client's non-pharmacologic comfort and skin integrity regimen? Select all that apply.

A 55-year-old client returns to the medical-surgical unit following an esophagogastroduodenoscopy (EGD) with banding of esophageal varices. The client received intravenous midazolam and fentanyl during the procedure and is currently lethargic but arousable. The client's vital signs are: BP 110/70 mmHg, HR 85 bpm, RR 14/min, and SpO2 96% on room air. Which of the following actions is the most appropriate priority for the nurse to reduce the client's risk of physiological complications?

A client is brought to the emergency department experiencing a severe asthma exacerbation. The client is initially restless and tachypneic with an arterial blood gas (ABG) showing a pH of $7.50$, $PaCO_2$ of $28 \text{ mm Hg}$, and $HCO_3^-$ of $24 \text{ mEq/L}$. One hour later, the nurse notes that the client has become lethargic and the respiratory rate has decreased to $10$ breaths per minute. A repeat ABG shows a pH of $7.28$, $PaCO_2$ of $58 \text{ mm Hg}$, and $HCO_3^-$ of $24 \text{ mEq/L}$. Which of the following is the priority nursing action?

The charge nurse is observing a newly licensed nurse provide care for a client who is receiving continuous enteral nutrition through a percutaneous endoscopic gastrostomy (PEG) tube. Which of the following actions by the newly licensed nurse indicate appropriate basic care and comfort measures? Select all that apply.

A nurse is preparing to administer an intravenous piggyback (IVPB) dose of a prescribed antibiotic through a client's continuous primary intravenous infusion of 0.9% sodium chloride. In what order should the nurse perform the following actions? Arrange the steps from first to last.

A nurse is assessing a client who is recovering in the intensive care unit following a coronary artery bypass graft (CABG) surgery. Which of the following clinical findings should indicate to the nurse that the client is developing cardiac tamponade? Select all that apply.

A healthcare provider orders intermittent intravenous ceftriaxone for an adult client diagnosed with community-acquired pneumonia. The client's only vascular access is a peripheral catheter currently infusing lactated Ringer's solution at 100 mL/hr. What is the safest action by the nurse regarding the administration of this antibiotic?

A nurse is planning care for a group of clients receiving pharmacological and parenteral therapies. Which of the following actions demonstrate safe and effective nursing practice? (Select all that apply.)

A nurse is preparing to obtain a blood specimen for laboratory testing from a client's central venous catheter (CVC). A continuous intravenous infusion is currently running through the lumen. Arrange the following steps in the correct chronological order for safely drawing the blood specimen using the discard method.

A nurse is caring for a client who has been receiving continuous gastric suctioning via a nasogastric (NG) tube for the past 72 hours due to a mechanical bowel obstruction. During the morning assessment, the client reports muscle cramps and a tingling sensation in the fingertips. Based on the client's clinical presentation and current therapy, which of the following arterial blood gas (ABG) results should the nurse anticipate?

A client with a complete transection spinal cord injury at the T4 level suddenly reports a severe, pounding headache and blurred vision. Upon evaluation, profuse diaphoresis is noted above the level of the injury alongside a blood pressure reading of 215/115 mm Hg. Arrange the following nursing actions in the priority order they should be performed, from first to last.