Physiological Integrity

A client has just returned to the medical-surgical unit after undergoing a percutaneous liver biopsy. To minimize the risk of post-procedure hemorrhage, which of the following positions should the nurse assist the client into?

A nurse is developing a post-procedure plan of care for a 54-year-old client who has just returned to the medical-surgical unit following a flexible bronchoscopy with a transbronchial biopsy under conscious sedation. Which of the following nursing actions should be included to reduce the risk of potential complications? Select all that apply.

A client with an established gastrostomy tube is scheduled to receive an intermittent bolus feeding. Arrange the following nursing actions in the correct sequential order from first to last.

A 70-year-old client with a history of severe chronic obstructive pulmonary disease (COPD) is hospitalized for treatment of a left lower extremity deep vein thrombosis. The client suddenly develops sharp, pleuritic chest pain, severe dyspnea, and profound apprehension.

Current Assessment and Laboratory Data:
- Vital Signs: BP 94/60 mmHg (baseline 135/82), HR 122 bpm, RR 32/min, Temperature 98.9°F (37.2°C).
- SpO2: 84% on 2 L/min oxygen via nasal cannula.
- Skin: Pale, diaphoretic, with circumoral cyanosis.
- Arterial Blood Gas (ABG):
- pH: 7.54
- PaCO2: 28 mmHg (baseline 55 mmHg)
- HCO3-: 26 mEq/L
- PaO2: 52 mmHg

The nurse suspects an acute pulmonary embolism. To reduce the client's risk for immediate cardiopulmonary collapse, which of the following is the most critical initial action?

A nurse is caring for a critically ill client who has a double-lumen peripherally inserted central catheter (PICC). Lumen 1 is infusing continuous norepinephrine, and Lumen 2 is infusing 0.9% sodium chloride at a keep-vein-open rate. The healthcare provider prescribes a continuous infusion of pantoprazole, an intermittent IV piggyback of vancomycin, and a STAT dose of IV push furosemide $40\text{ mg}$. The client's total urine output over the past 2 hours is $25\text{ mL}$. Which of the following nursing actions are appropriate? Select all that apply.

A client recovering from a cluster of generalized tonic-clonic seizures has a single 20-gauge peripheral intravenous (IV) catheter in the right forearm. A continuous maintenance infusion of 5% dextrose in 0.45% sodium chloride is currently infusing at 100 mL/hr. The healthcare provider prescribes a loading dose of IV phenytoin to be administered immediately to prevent further seizure activity. Which action is the most appropriate for the nurse to implement?

A client is being monitored on the medical-surgical unit for severe bilateral pneumonia. The most recent arterial blood gas (ABG) results show a pH of 7.31, PaCO2 of 56 mm Hg, and HCO3- of 24 mEq/L. Which of the following assessment findings correlate with this acid-base imbalance? Select all that apply.

The nursing team is providing morning hygiene care for a client who recently sustained a right-sided cerebrovascular accident (CVA). The client presents with left-sided hemiplegia and left homonymous hemianopsia, and is receiving continuous enteral nutrition via a nasogastric (NG) tube. The registered nurse (RN) is providing specific parameters to the unlicensed assistive personnel (UAP) regarding the care routine. Which directive from the RN represents the safest and most comprehensive approach to this client's basic care and comfort?

An adult client requires a morning dose of both short-acting (regular) and intermediate-acting (NPH) insulin. The nurse is drawing up both medications into a single syringe. Place the steps of this preparation process in the correct chronological sequence.

A nurse is caring for an adult client who is post-operative day one following a right total hip arthroplasty. The client is receiving a continuous intravenous (IV) infusion of $0.9\%$ sodium chloride. The provider has prescribed several new oral and intravenous medications. Which of the following nursing actions demonstrate safe pharmacological and parenteral therapy practices? Select all that apply.

An oncology registered nurse is preparing to obtain a blood specimen from a client's implanted venous access port. The nurse has gathered all necessary supplies. Arrange the following steps for accessing the port and drawing the blood specimen in the correct chronological sequence.

A nurse is developing a plan of care for a 62-year-old client who has just been admitted to the telemetry unit following a left-sided cardiac catheterization via the femoral approach. The client has a documented history of severe chronic obstructive pulmonary disease (COPD). Which of the following nursing actions are appropriate to reduce the risk of potential complications? (Select all that apply)

A nurse is caring for a client who has experienced profuse, watery diarrhea for the past 48 hours. The nurse monitors the client closely for early indications of hypovolemic shock. Which of the following vital sign changes represents the earliest physiological compensatory mechanism for fluid volume deficit?

An 82-year-old client with advanced Parkinson's disease is admitted for severe dehydration and profound weight loss. Assessment reveals pronounced bradykinesia, freezing of gait episodes, and prominent dysphagia with coughing during meals. When prioritizing the daily basic care, mobility, and comfort needs for this client, which of the following evidence-based interventions should be incorporated? Select all that apply.

An older adult client with generalized weakness and a history of mild dysphagia is about to receive their lunch tray. Which nursing action is most appropriate to promote safe swallowing and prevent aspiration?

A client with a history of heart failure is receiving a continuous intravenous infusion of 0.9% sodium chloride at 125 mL/hr. During a reassessment, the nurse notes new-onset bibasilar crackles, a respiratory rate of 28 breaths/min, and an oxygen saturation of 88% on room air. The latest arterial blood gas (ABG) results are pH 7.30, $PaCO_2$ 52 mm Hg, $PaO_2$ 55 mm Hg, and $HCO_3^-$ 25 mEq/L. Which action should the nurse take first to reduce the risk of further physiological deterioration?

A nurse is providing care for a postoperative client who is prescribed strict bed rest. To reduce the client's risk of developing deep vein thrombosis (DVT), which interventions should the nurse include in the plan of care? Select all that apply.

A nurse is evaluating a client who underwent a percutaneous liver biopsy two hours ago. The client is currently resting on their right side with a rolled towel under the puncture site. Which of the following assessment findings requires the most immediate notification to the healthcare provider to reduce the risk of a severe physiological complication?

A nurse is caring for a client receiving parenteral nutrition via a subclavian central venous catheter (CVC). Upon entering the room, the nurse discovers the IV tubing has disconnected from the catheter hub. The client is suddenly grasping their chest, gasping for air, and reporting a feeling of impending doom. Arrange the following nursing actions in the correct order of priority to manage this life-threatening complication.

Following a right femoral cardiac catheterization, a client is admitted to the progressive care unit. To minimize the risk of a severe physiological complication, which assessment must the nurse prioritize?