Physiological Integrity

A nurse is caring for a client who is receiving a packed red blood cell (PRBC) transfusion. Fifteen minutes after the infusion begins, the client suddenly reports severe lower back pain, chills, and shortness of breath. What is the priority sequence of nursing actions to minimize the risk of further physiological deterioration? Arrange the steps in the correct chronological order.

A nurse is managing the care of a 78-year-old client who is in balanced suspension skeletal traction following a comminuted right femur fracture. The client, who has a history of osteoarthritis, reports a new onset of dull, aching pain in the right heel and increasing stiffness in the lower back. Which of the following nursing actions is the most appropriate?

An 81-year-old client with bulbar amyotrophic lateral sclerosis (ALS) is admitted for treatment of aspiration pneumonia. The client has a newly inserted percutaneous endoscopic gastrostomy (PEG) tube for continuous enteral feeding, a Stage II sacral pressure injury, and exhibits intermittent periods of profound disorientation. Which nursing interventions are appropriate for this client's basic care and comfort? Select all that apply.

A nurse is planning care for an older adult client who is on strict bed rest due to severe generalized weakness. Which of the following interventions should the nurse include in the client's plan of care? Select all that apply.

A nurse is removing a non-tunneled central venous access device (CVAD) from a client's right subclavian vein. Immediately after the catheter is withdrawn, the client exhibits sudden, severe dyspnea, diaphoresis, and a loud, continuous "churning" murmur over the precordium. To mitigate the risk of fatal hemodynamic collapse, arrange the following nursing actions in the priority order they should be performed. (Place the first action at the top and the last action at the bottom.)

A nurse is developing a plan of care for a client who is 2 hours postoperative following a total thyroidectomy. Which of the following nursing actions are appropriate to reduce the risk of postoperative complications? Select all that apply.

A nurse is caring for a client who underwent a percutaneous coronary intervention (PCI) via the right femoral artery 3 hours ago. The client's current vital signs are: blood pressure 104/62 mmHg (baseline 128/78 mmHg) and heart rate 102 bpm (baseline 76 bpm). The client reports new-onset moderate right flank pain. Which of the following is the most appropriate initial nursing action?

A nurse is removing a central venous catheter from a client's subclavian vein. Immediately after the catheter is withdrawn, the client suddenly gasps for air, reports sharp chest pain, and becomes severely dyspneic and pale. Suspecting an air embolism, arrange the following nursing actions in the priority order they should be performed to reduce the risk of a fatal cardiopulmonary complication.

During the immediate postoperative period following a coronary artery bypass grafting (CABG) procedure, the client's mediastinal chest tube drainage abruptly stops. The client becomes increasingly restless and diaphoresis is noted. Which of the following subsequent clinical findings support a developing complication of cardiac tamponade? Select all that apply.

A client on a medical-surgical unit is receiving an infusion of packed red blood cells (PRBCs) for symptomatic anemia. Ten minutes after the transfusion begins, the client reports sudden severe lower back pain, dyspnea, and chills. The nurse notes visible flushing and shivering. Place the following nursing interventions in the correct order of priority. (Arrange from first action to last action.)

A client is recovering 24 hours post-operatively following an emergency repair of a ruptured abdominal aortic aneurysm. Due to significant intraoperative blood loss, the client required massive fluid and blood product resuscitation. The nurse assesses the client and notes a tensely distended abdomen, a sudden decrease in urine output to 12 mL/hr, and increasing peak inspiratory pressures on the mechanical ventilator. Current hemodynamic monitoring reveals a blood pressure of 84/46 mm Hg, a heart rate of 128 beats/min, and a central venous pressure (CVP) of 18 mm Hg. Which of the following is the nurse's MOST appropriate initial action?

A client hospitalized with a massive pulmonary embolism is receiving a continuous intravenous infusion of unfractionated heparin through a single-lumen peripheral catheter. The client develops a systemic bloodstream infection, and the healthcare provider prescribes an intermittent intravenous infusion of vancomycin to run over 90 minutes. Upon consulting the facility's parenteral drug reference, the nurse notes that heparin and vancomycin are physically incompatible. Which action represents the safest nursing practice in this situation?

An adult client who underwent a diagnostic lumbar puncture four hours ago is now complaining of a severe, throbbing headache that worsens upon sitting. When planning interventions to promote comfort and safety, which action should the nurse implement?

During a routine assessment on the surgical unit, a nurse evaluates a client who underwent an open splenectomy earlier in the day. The client's spouse reports that the client has suddenly become restless and anxious. A review of the electronic health record reveals the following vital sign trends:

The client's urine output for the past hour is 15 mL. Based on these findings, which action is the priority to prevent further physiological deterioration?

A nurse is caring for an alert and oriented client with diabetes mellitus who reports feeling shaky and sweaty. The client's capillary blood glucose level is 55 mg/dL. Arrange the following nursing interventions in the correct order of priority.

During a clinic visit, a client reports continuous, severe vomiting over the last two days due to a gastrointestinal illness. The nurse anticipates that this prolonged loss of gastric secretions places the client at highest risk for which acid-base imbalance?

A $35$-year-old client is $6$ hours post-operative following an open reduction and internal fixation (ORIF) of a severe pelvic fracture. The client is receiving a continuous epidural infusion of bupivacaine and fentanyl. The nurse collects the following assessment data:

Which of the following actions should the nurse perform immediately to reduce the risk of further physiological deterioration?

A registered nurse is caring for an older adult client with cognitive impairment who is receiving continuous enteral feeding via a percutaneous endoscopic gastrostomy (PEG) tube. The client is increasingly restless, frequently scratching at the peri-stomal skin, and attempting to pull the feeding tubing. Which of the following actions is the most appropriate for the nurse to implement?

An adult client experiencing recurrent seizure activity is admitted to the neurological unit. The client has a single patent $20$-gauge peripheral intravenous catheter infusing $5\%$ dextrose in $0.45\%$ sodium chloride at $80 \text{ mL/hr}$. The provider prescribes a stat loading dose of phenytoin $1000 \text{ mg}$ intravenously. The pharmacy delivers the medication diluted in $100 \text{ mL}$ of normal saline. What is the safest method for the nurse to administer this medication?

A nurse is educating a client who has a right fractured tibia and is prescribed non-weight-bearing status. The client is learning to ascend a flight of stairs using axillary crutches. In what order should the nurse instruct the client to perform the following movements?