Physiological Integrity

An older adult client with right-sided hemiparesis and a history of severe gastroesophageal reflux disease (GERD) is bedbound and receiving continuous enteral tube feedings. During the shift assessment, the nurse notes a non-blanchable, localized area of deep red skin over the client's sacrum and right greater trochanter. To simultaneously address the client's nutritional needs, airway safety, and impaired skin integrity, which comprehensive positioning and care strategy should the nurse implement?

A nurse is planning basic care and comfort measures for an older adult client who is restricted to bed rest. Which of the following actions should the nurse include in the plan of care? Select all that apply.

A client who is experiencing continuous seizure activity requires an urgent intravenous (IV) dose of phenytoin. The client has a single peripheral IV access site that is currently infusing 5% dextrose in water (D5W). Which action should the nurse take to safely administer the prescribed medication?

An adult client is receiving continuous total parenteral nutrition (TPN) through a dedicated single-lumen peripherally inserted central catheter (PICC). The client now requires a scheduled dose of intravenous pantoprazole. Which action represents the safest practice for administering this medication?

A nurse is preparing to transfer a non-weight-bearing client from the bed to a wheelchair using a mechanical floor lift equipped with a U-shaped (universal) sling. The client is currently lying supine in the center of the bed. In what chronological order should the nurse perform the following actions to safely complete the transfer?

A nurse is providing discharge education to a client who sustained a right tibial fracture and has a strict non-weight-bearing order for the right lower extremity. The client must learn how to ascend a flight of stairs using axillary crutches. Arrange the following actions in the exact order the client should perform them.

A registered nurse is caring for a client who is receiving an intravenous infusion of packed red blood cells (PRBCs). Fifteen minutes into the transfusion, the client reports sudden lower back pain, chills, and shortness of breath. Arrange the following nursing actions in the correct priority order.

The nurse is preparing to administer a prescribed large-volume cleansing enema to an adult client to relieve severe constipation. To promote comfort and facilitate the downward flow of the solution into the sigmoid colon, in which position should the nurse place the client?

A nurse is providing night-shift care for an older adult client who is experiencing severe orthopnea and reports difficulty breathing while lying down. Which of the following actions should the nurse take to best promote the client's comfort?

A client is admitted to the intensive care unit with acute digoxin toxicity. Initial laboratory results reveal a serum digoxin level of $5.2\text{ ng/mL}$ and a serum potassium level of $6.4\text{ mEq/L}$. The healthcare provider prescribes a continuous intravenous infusion of digoxin immune Fab. Which of the following assessment findings during the hours following administration requires the nurse's immediate intervention?

A registered nurse is preparing to administer a prescribed dose of intravenous (IV) phenytoin to an adult client who recently experienced a generalized tonic-clonic seizure. The client has a single peripheral IV line with a continuous infusion of $5\%$ dextrose in water (D5W) infusing at $75\text{ mL/hr}$. Which of the following is the safest and most appropriate action by the nurse?

A client is recovering on the surgical unit 48 hours after a right below-the-knee amputation. During the morning assessment, the client reports a pain level of 6 on a 0-to-10 scale in the absent right foot. The residual limb exhibits mild, non-pitting edema. Which of the following positioning interventions is most appropriate for the nurse to implement?

A nurse is preparing to administer an intravenous (IV) antibiotic piggyback to a client receiving a compatible continuous primary infusion of 0.9% sodium chloride. Place the following steps for setting up the secondary infusion in the correct chronological order.

A client weighing $78\text{ kg}$ is admitted to the progressive care unit with a hypertensive crisis. The healthcare provider prescribes a continuous intravenous infusion of sodium nitroprusside at a rate of $3\text{ mcg/kg/min}$. The medication is supplied as sodium nitroprusside $50\text{ mg}$ mixed in $250\text{ mL}$ of $5\%$ dextrose in water (D5W). At what rate should the nurse set the infusion pump in $\text{mL/hr}$? Round your answer to the nearest tenth.

A nurse is preparing to provide oral hygiene to an unconscious client. Arrange the following steps of the procedure in the chronological order the nurse should perform them to ensure client safety.

A nurse is caring for a client who is receiving continuous enteral nutrition via a nasogastric tube. The client suddenly begins coughing vigorously, becomes tachypneic, and their oxygen saturation drops to 88% on room air. Arrange the following nursing actions in the correct order of priority to mitigate the risk of further respiratory compromise.

During morning rounds, the nurse assesses an older adult client who underwent a right total hip arthroplasty (posterior approach) the previous day. The client demonstrates acute confusion and requires total assistance with hygiene and mobility. Which interventions are appropriate for the nurse to implement? Select all that apply.

A registered nurse is preparing to initiate a continuous intravenous (IV) regular human insulin infusion for a client admitted with diabetic ketoacidosis (DKA). Arrange the following nursing actions in the correct sequence.

A nurse in the intensive care unit is managing a critically ill client diagnosed with septic shock. The client is currently supported by a continuous intravenous (IV) infusion of norepinephrine via a single peripheral catheter. Recent arterial blood gas results reveal a pH of 7.15 and an $HCO_3^-$ of 14 mEq/L (14 mmol/L). The healthcare provider prescribes an immediate IV bolus of sodium bicarbonate. Which of the following is the most appropriate action by the nurse?

A critically ill client weighing $154\text{ lbs}$ is prescribed a continuous intravenous (IV) infusion of milrinone at $0.55\text{ mcg/kg/min}$ for the management of severe heart failure. The pharmacy supplies a premixed IV bag containing $20\text{ mg}$ of milrinone in $100\text{ mL}$ of $5\%$ dextrose in water ($D_5W$). The client's current heart rate is $118\text{ beats/min}$ and blood pressure is $96/58\text{ mmHg}$. What should the nurse set the infusion pump rate to in $\text{mL/hr}$? Record your answer to the nearest tenth.