Physiological Integrity

A 54-year-old client with a history of chronic hepatitis C and cirrhosis has just arrived at the medical-surgical unit following an ultrasound-guided percutaneous liver biopsy. The client is currently drowsy but arousable, with a baseline blood pressure of 118/76 mmHg and a heart rate of 74 bpm. Which of the following nursing actions are appropriate to reduce the risk of potential complications? Select all that apply.

A nurse is evaluating an adult client admitted with acute pancreatitis who is receiving aggressive intravenous fluid resuscitation. Which of the following clinical findings indicate a developing complication that requires immediate intervention? (Select all that apply)

The healthcare team is reviewing the mobility and comfort orders for a client who underwent a right above-knee amputation two days ago. Which intervention should the nurse implement to prevent long-term musculoskeletal complications?

A client returns to the surgical unit following a right total hip arthroplasty using a posterior approach. When assisting this client in bed, which nursing action promotes safe positioning?

An older adult client with advanced Parkinson's disease and documented oropharyngeal dysphagia requires assistance with feeding to mitigate aspiration risk. In what chronological order should the nurse execute the following mealtime interventions?

A client requires a combined dose of regular and NPH insulin for morning glycemic control. What is the correct sequence of actions for drawing up these medications into a single syringe? Arrange the steps in chronological order.

A client with a deep vein thrombosis has a prescription for a continuous heparin infusion at $1,200\text{ units/hr}$. The pharmacy dispenses an intravenous bag containing $25,000\text{ units}$ of heparin mixed in $250\text{ mL}$ of $5\%$ dextrose in water (D5W). At what rate should the nurse set the infusion pump? Record your answer as a whole number.

While caring for a hospitalized client, the nurse prepares to hang a scheduled intravenous (IV) antibiotic. The client already has a continuous IV drip of a different medication infusing through a single-lumen peripheral venous catheter. What is the most critical action the nurse must take before connecting the antibiotic to the Y-site?

A night-shift nurse is caring for an older adult client with chronic obstructive pulmonary disease (COPD) who reports worsening shortness of breath and an inability to fall asleep. Which independent nursing interventions should be implemented to promote physical comfort and rest? (Select all that apply.)

An older adult client is receiving a continuous intravenous heparin infusion for a newly diagnosed left lower extremity deep vein thrombosis (DVT). The nurse is developing a plan of care focusing on the client's basic comfort, mobility, and safety. Which intervention is the most appropriate to include in the plan of care?

A client with terminal esophageal cancer and severe ascites is receiving continuous enteral nutrition via a newly placed percutaneous endoscopic jejunostomy (PEJ) tube. The client experiences severe orthopnea requiring upper body elevation, but reports that elevating the head of the bed by bending the mattress at the hips causes agonizing abdominal pressure and intractable nausea. Which action by the nurse best manages the enteral feeding safely while simultaneously addressing the client's competing comfort and respiratory needs?

A $62\text{-year-old}$ client is admitted to the telemetry unit with an exacerbation of heart failure. The client has +3 pitting edema in the bilateral lower extremities. The client's vital signs are blood pressure $148/92\text{ mmHg}$, heart rate $88\text{ bpm}$, and respiratory rate $22\text{ breaths/min}$. The most recent basic metabolic panel reveals a serum potassium level of $4.2\text{ mEq/L}$. The healthcare provider prescribes $40\text{ mg}$ of intravenous (IV) furosemide. Which of the following is the most important nursing action when administering this medication?

A nurse is developing a care plan focusing on basic care and comfort for a client admitted with acute decompensated heart failure. The client is experiencing severe orthopnea, fatigue, and marked dependent pitting edema in the lower extremities. Which nursing interventions should be included in the plan of care? Select all that apply.

A nurse is formulating a plan of care focusing on basic care and comfort for an older adult client who sustained deep partial-thickness burns to the anterior neck, chest, and bilateral axillae 48 hours ago. Which of the following interventions should the nurse include? Select all that apply.

An individual who recently experienced a cerebrovascular accident has residual hemiparesis on the right side of their body. The nurse is preparing to assist the client in transferring from the edge of the bed to a wheelchair. Which placement of the wheelchair is most appropriate for a safe transfer?

A critically ill pediatric client weighing $15 \text{ kg}$ is prescribed an epinephrine infusion at $0.1 \text{ mcg/kg/min}$ to manage severe hypotension. The available medication concentration is $1 \text{ mg}$ of epinephrine mixed in $50 \text{ mL}$ of $5\%$ dextrose in water. A newly licensed nurse programs the infusion pump to deliver $4.5 \text{ mL/hr}$ and prepares to connect the primary tubing to the client's $22\text{-gauge}$ peripheral forearm catheter. Which evaluation by the supervising nurse is most accurate regarding this intended action?

A registered nurse is preparing to administer a prescribed dose of intravenous (IV) push furosemide to a client. The client is currently receiving a continuous IV infusion of milrinone. A drug reference guide indicates that furosemide and milrinone are incompatible, and the client has only one peripheral IV access site. What is the correct sequence of actions for the nurse to safely administer the furosemide?

The registered nurse is preparing to administer medications to an older adult client who has a continuous intravenous (IV) fluid infusion. The client has new prescriptions for an IV piggyback antibiotic and an IV push opioid analgesic. To ensure safe parenteral therapy, which of the following actions are appropriate for the nurse to perform? Select all that apply.

A client with a systemic methicillin-resistant *Staphylococcus aureus* (MRSA) infection and a deep vein thrombosis is receiving a continuous intravenous (IV) infusion of heparin through a single-lumen peripheral IV catheter. The nurse prepares to administer a scheduled dose of IV vancomycin $1\text{ g}$, which must infuse over $90\text{ minutes}$. A drug reference indicates that vancomycin and heparin are incompatible at the Y-site. Which action should the nurse take?

A client is admitted to the neurosurgical unit immediately following a supratentorial craniotomy for tumor resection. The client is lethargic but appropriately responsive to verbal stimuli. To promote comfort and optimize physiological stability, which positioning intervention should the nurse implement?