Physiological Integrity

A nurse is caring for a client receiving a packed red blood cell (PRBC) transfusion. Fifteen minutes after the transfusion begins, the client reports sudden chills, severe lower back pain, and dyspnea. The client's heart rate is 115 beats/min and blood pressure is 88/52 mm Hg. What is the correct sequence of priority for the nurse's actions? Arrange the following steps in the correct order.

A nurse is preparing to change the soiled bed linens for a client who is receiving continuous enteral nutrition via a nasogastric tube. The client is currently resting comfortably in a semi-Fowler's position. Which action must the nurse take first before lowering the head of the bed to turn the client?

A nurse is assessing a client who has a central venous catheter (CVC) in place. The client suddenly reports acute chest pain and shortness of breath, and the nurse observes a loose connection at the catheter hub. Suspecting a catheter-related air embolism, arrange the following nursing actions in the priority order they should be performed. (Arrange from first action to last action.)

A nurse is reviewing a new medication order for a pediatric client who weighs $20\text{ kg}$. The healthcare provider has prescribed oral amoxicillin $400\text{ mg}$ every $8\text{ hours}$ for an infection. The pharmacy reference states that the safe pediatric dosage range is $20\text{ to }40\text{ mg/kg/day}$ administered in equally divided doses every $8\text{ hours}$. Based on this information, which of the following is the most appropriate action by the nurse?

Arterial blood gas (ABG) results for a client with a history of chronic obstructive pulmonary disease (COPD) reveal a pH of 7.28, PaCO2 of 68 mm Hg, HCO3- of 25 mEq/L, and PaO2 of 58 mm Hg. The client is restless and using accessory muscles to breathe. Which initial action by the nurse is the most appropriate?

An older adult client with a ten-year history of chronic obstructive pulmonary disease (COPD) is brought to the emergency department. The client's family reports a progressive decline in the client's level of consciousness over the past six hours, describing the client as 'extremely difficult to wake up.' The client's current respiratory rate is $8$ breaths per minute and shallow. Arterial blood gas (ABG) analysis on room air reveals the following: $pH = 7.21$, $PaCO_2 = 84 \text{ mm Hg}$, $PaO_2 = 52 \text{ mm Hg}$, and $HCO_3^- = 36 \text{ mEq/L}$. Based on these clinical findings, what is the highest priority nursing action?

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via a right subclavian central venous catheter (CVC). Upon entering the room, the nurse discovers that the intravenous tubing has inadvertently disconnected from the CVC hub, leaving the catheter open to the air. The client is suddenly gasping for breath, grasping their chest, and exhibits a blood pressure of $76/40\text{ mmHg}$ with a heart rate of $138\text{ bpm}$. To immediately mitigate the risk of a fatal physiological complication, which action should the nurse perform first?

A client arrives on the medical unit immediately after undergoing a diagnostic lumbar puncture. To decrease the risk of a cerebrospinal fluid leak and subsequent post-procedure headache, which position is most appropriate for the nurse to implement?

A nurse is preparing to provide oral hygiene to a comatose client. Arrange the following actions in the correct sequence from first to last.

A nurse is providing care for a client who underwent a right femoral-popliteal bypass graft 12 hours ago. The client also has a documented history of severe chronic venous insufficiency and chronic stasis dermatitis in the left lower extremity. The client is currently resting in a low-Fowler's position, reports aching discomfort in both legs, and requests an intervention for comfort. Which of the following nursing actions is most appropriate?

An adult client is currently receiving a continuous intravenous (IV) infusion of pantoprazole for a gastrointestinal bleed. The healthcare provider's new orders include a secondary IV infusion of ciprofloxacin and an IV push dose of ondansetron for nausea. Which of the following actions must the nurse perform to ensure safe parenteral medication administration? (Select all that apply.)

A nurse is caring for a client who is admitted with a deep vein thrombosis (DVT). The healthcare provider prescribes a continuous intravenous (IV) infusion of heparin at a rate of $18$ units/kg/hr. The client weighs $176$ lb. The pharmacy provides an IV bag containing $25,000$ units of heparin mixed in $250$ mL of $5\%$ dextrose in water (D5W). At what rate, in mL/hr, should the nurse set the IV infusion pump? (Round the answer to the nearest tenth.)

A client who sustained an extensive anterior wall myocardial infarction is receiving care in the coronary intensive care unit. Which of the following clinical indicators should alert the nurse that the client is transitioning into cardiogenic shock? Select all that apply.

A client arrives at the medical-surgical unit immediately after undergoing a lumbar puncture. To promote comfort and minimize post-procedure complications, which of the following positions should the nurse maintain the client in?

A nurse is caring for an older adult client who is admitted with right-sided lobar pneumonia. The client is receiving oxygen at 2 L/min via nasal cannula but continues to experience significant dyspnea, pleuritic chest pain, and increasing restlessness. The client's oxygen saturation is 88%. Which of the following actions should the nurse take to best promote the client's oxygenation and comfort?

A client diagnosed with severe gastroenteritis has a confirmed serum potassium level of $2.8\text{ mEq/L}$. The healthcare provider prescribes $20\text{ mEq}$ of intravenous potassium chloride (KCl) diluted in $250\text{ mL}$ of $0.9\%$ sodium chloride. Which action is essential for the nurse to implement for safe administration?

A nurse is preparing to administer an intermittent enteral feeding to a client via a nasogastric (NG) tube. Arrange the following steps in the correct order of performance from first to last.

A nurse is assisting a client to change a soiled hospital gown. The client has a continuous peripheral intravenous (IV) infusion in the right forearm. In what order should the nurse perform the following actions? (Arrange the steps from first to last.)

A nurse is assessing a client who was brought to the emergency department experiencing a severe panic attack. The client is visibly agitated and has been hyperventilating for the past twenty minutes. Based on this respiratory pattern, which of the following acid-base imbalances should the nurse expect?

During the immediate postoperative period following a posterior total hip arthroplasty, the nurse plans care to maintain joint stability. Which specific action must the nurse implement to protect the new prosthesis from dislocation?