Physiological Integrity

A 54-year-old client is being monitored in the recovery unit two hours after an esophagogastroduodenoscopy (EGD) with esophageal dilation. The client suddenly reports severe, sharp pain in the chest and neck area that worsens with swallowing. The nurse notes a heart rate of 122 bpm, a respiratory rate of 26 breaths/min, and a blood pressure of 90/58 mm Hg. Which of the following is the priority nursing action?

A nurse is creating a plan of care for a newly admitted client experiencing an acute exacerbation of chronic obstructive pulmonary disease (COPD) accompanied by severe dyspnea, orthopnea, and profound fatigue. Which interventions should the nurse include to address the client's basic care and comfort? Select all that apply.

A nurse is caring for a client with a complete spinal cord injury at the T3 level. The client suddenly reports a severe, pounding headache. The nurse notes profuse diaphoresis on the client's face and neck, cutis anserina (goosebumps), a blood pressure of 220/115 mm Hg, and a heart rate of 52 bpm. Arrange the following nursing interventions in the priority order they should be performed.

A pediatric client weighing $48.4\text{ lb}$ is prescribed a continuous intravenous (IV) infusion of fentanyl at $2\text{ \mu g/kg/hr}$ for pain management. The pharmacy dispenses an IV bag containing $500\text{ \mu g}$ of fentanyl in $100\text{ mL}$ of $0.9\%$ sodium chloride. At what rate, in $\text{mL/hr}$, should the nurse set the IV infusion pump? Record your answer using one decimal place.

A nurse is evaluating a client who has been receiving continuous nasogastric tube suctioning for the past 72 hours due to a mechanical small bowel obstruction. During the morning assessment, the client exhibits shallow respirations, bilateral muscle twitching, and a heart rate of 110 beats per minute. Which of the following arterial blood gas (ABG) results best correlates with this client's current clinical presentation?

An older adult client is admitted to the medical unit with severe dehydration. The client is currently experiencing generalized muscle weakness, sudden-onset confusion, and frequent urinary incontinence. An intravenous (IV) fluid infusion is in progress. Which nursing intervention is the most appropriate to maintain this client's basic care and comfort?

A nurse is caring for a client with type 1 diabetes mellitus in the emergency department. The client has a blood glucose level of 450 mg/dL, deep and rapid respirations, and a fruity breath odor. Which of the following acid-base imbalances is this client most likely experiencing?

A client diagnosed with septic shock is admitted to the intensive care unit and remains profoundly hypotensive despite adequate fluid resuscitation. The healthcare provider orders a continuous intravenous infusion of norepinephrine. The client's weight is $198\text{ lb}$. The order indicates starting the infusion at $0.1\text{ mcg/kg/min}$. The medication arrives from the pharmacy as a premixed solution containing $8\text{ mg}$ of norepinephrine in $250\text{ mL}$ of 5% dextrose in water ($\text{D}_5\text{W}$). At what rate should the nurse program the infusion pump? Record your answer in $\text{mL/hr}$ rounded to the nearest tenth.

An adult client has just arrived at the medical-surgical unit after undergoing a lumbar puncture. To prevent a common post-procedure complication, how should the nurse position this client in bed?

A nurse is planning basic care for an 84-year-old client with advanced Alzheimer's disease who is receiving continuous enteral feedings via a percutaneous endoscopic gastrostomy (PEG) tube. The client has a stage 2 pressure injury on the left greater trochanter and has become acutely agitated during the shift, repeatedly attempting to pull at the feeding tube. Which of the following interventions represents the MOST appropriate evidence-based practice for this client?

A nurse is preparing to administer an intermittent bolus enteral feeding through a client's established gastrostomy tube. Place the following steps in the correct chronological order from first to last.

A nurse is preparing a client with advanced cirrhosis for a therapeutic bedside paracentesis to relieve severe ascites. To minimize the risk of procedural complications and ensure physiological stability, arrange the following nursing actions in the correct chronological sequence.

A nurse is caring for a client who is experiencing an acute asthma exacerbation. The client is tachypneic, has visible intercostal retractions, and an oxygen saturation of 86% on room air. Arrange the following nursing actions in the priority order they should be performed, from first to last.

A critical care nurse is managing a client with severe decompensated heart failure. The client has an admission weight of $184.8 \text{ lbs}$.

The provider's prescription reads:
- Initiate dobutamine continuous IV infusion at $2.5 \text{ mcg/kg/min}$.
- Titrate upward by $2.5 \text{ mcg/kg/min}$ every $15 \text{ minutes}$ until mean arterial pressure (MAP) $> 65 \text{ mm Hg}$, up to a maximum dose of $20 \text{ mcg/kg/min}$.

The pharmacy dispenses a customized dobutamine solution containing $1,000 \text{ mg}$ of dobutamine in $250 \text{ mL}$ of $5\%$ dextrose in water (D5W). A dedicated central venous catheter port is used for the infusion, alongside a separate line of $0.9\%$ sodium chloride running at $20 \text{ mL/hr}$.

After initiating the infusion, the nurse performs exactly three upward titrations over the next $45 \text{ minutes}$ before the client's MAP stabilizes at $72 \text{ mm Hg}$.

What is the dobutamine infusion pump rate in $\text{mL/hr}$ at this effective dose? (Record your answer to the nearest tenth.)

A nurse is preparing to administer an intravenous (IV) loading dose of phenytoin to a 42-year-old client who recently experienced a tonic-clonic seizure. The client's vital signs are stable, but they remain postictal and drowsy. The client has a single peripheral IV catheter currently infusing 5% dextrose in water (D5W) at 75 mL/hr. Which of the following is the most appropriate nursing action?

A nurse is planning morning hygiene and mobility care for an 80-year-old client who recently had a halo vest external fixator applied for a stable cervical spine fracture. Which of the following actions is the most appropriate for the nurse to include in the plan of care?

A nurse is evaluating a 72-year-old client who sustained an acute anterior myocardial infarction 24 hours ago. The client has become increasingly restless and reports mild confusion. Current assessment findings include cool and pale skin, a heart rate of 118 beats/minute, and a blood pressure of 102/84 mm Hg. The client's urine output for the past hour was 15 mL. Which action should the nurse take first?

A client on a medical-surgical unit requires a cleansing enema for relief of severe constipation. To facilitate the flow of the enema solution into the colon and promote retention, in which position should the nurse place the client?

A nurse is preparing to transfer a client with left-sided hemiplegia and a history of orthostatic hypotension from the bed to a wheelchair. Arrange the following nursing actions in the correct chronological sequence.

The nurse is conducting initial rounds on a medical-surgical unit. Which client positioning observation requires immediate intervention by the nurse to reduce the risk of complications?