Physiological Integrity

A healthcare provider prescribes 1,000 mL of lactated Ringer's solution to infuse intravenously over 8 hours. The manual intravenous (IV) administration set delivers 15 drops per milliliter (gtt/mL). Which of the following represents the correct drip rate for this infusion? (Round the final answer to the nearest whole number).

A nurse is caring for a client who underwent a left above-the-knee amputation 48 hours ago. The client reports mild discomfort in the residual limb and requests to be repositioned. Which of the following nursing actions is most appropriate to promote comfort and prevent musculoskeletal complications?

An 82-year-old client with advanced Alzheimer's disease and a history of dysphagia is admitted for the treatment of aspiration pneumonia. During the night shift, the client experiences a sudden onset of severe agitation, repeatedly attempts to dislodge a peripheral intravenous (IV) catheter, and demonstrates an inability to remain in bed. To promote the client's basic care and comfort while ensuring safety, which action should the nurse take?

A client at 35 weeks gestation is receiving a continuous intravenous (IV) infusion of magnesium sulfate for the management of severe preeclampsia. During an hourly assessment, the nurse notes the client is difficult to arouse, has a respiratory rate of $10\text{ breaths/minute}$, and deep tendon reflexes are absent. Which of the following is the priority nursing action?

A client with hepatic cirrhosis is recovering on the medical-surgical unit 30 minutes after a bedside paracentesis, during which 3.5 liters of ascitic fluid was removed. The client suddenly reports feeling dizzy and lightheaded. The nurse assesses a heart rate of 118 bpm, a blood pressure of 86/54 mmHg, and a respiratory rate of 18/min. Which action should the nurse take immediately to reduce the client's risk of severe circulatory compromise?

A nurse is preparing to administer a prescribed intermittent enteral tube feeding to a client. Arrange the following nursing actions in the correct chronological order.

While reviewing the chart of a client hospitalized with severe bilateral pneumonia, the central monitor alarms. The nurse enters the room and observes the client is highly agitated, diaphoretic, and increasingly confused. The client is currently receiving oxygen therapy via a non-rebreather mask at 15 L/min. Current vitals indicate a heart rate of 134 bpm, blood pressure of 84/46 mmHg, respiratory rate of 38 breaths/min, and an oxygen saturation of 84%. A stat arterial blood gas (ABG) is drawn and reports: pH 7.21, PaCO2 68 mm Hg, PaO2 50 mm Hg, and HCO3- 23 mEq/L. Which action is the priority for this client?

A postoperative client has an order for intravenous pantoprazole. The medication is prepared in a $100\text{ mL}$ bag of $0.9\%$ sodium chloride and needs to be infused over $15\text{ minutes}$. At what rate, in $\text{mL/hr}$, will the nurse set the infusion pump?

A nurse is caring for a client who returned to the medical-surgical unit 1 hour ago following a cardiac catheterization performed via the right femoral artery. Which intervention should the nurse prioritize to reduce the client's risk for a post-procedure complication?

A nurse is caring for an older adult client who has been diagnosed with dysphagia and is preparing to eat a meal. Which basic care actions should the nurse implement to promote comfort and ensure safety? Select all that apply.

The nursing team is developing a care plan for a client recovering from a traumatic brain injury. To minimize the risk of dangerous elevations in intracranial pressure (ICP), which specific actions are appropriate to implement? Select all that apply.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) through a central venous catheter (CVC). During an intravenous tubing change, the client suddenly grasps their chest and reports severe shortness of breath. The client's oxygen saturation drops rapidly to 85%. Suspecting a central line-associated air embolism, which of the following immediate actions should the nurse take? (Select all that apply.)

A nurse is caring for an older adult client who returned to the medical unit one hour ago following a percutaneous liver biopsy. The client reports a strong urge to void and requests assistance to walk to the bathroom. Which nursing intervention is the most appropriate?

A nurse is caring for a client with cardiogenic shock and metabolic acidosis who currently has a single peripheral intravenous (IV) line. The client is receiving a continuous IV infusion of $8.4\%$ sodium bicarbonate at $50\text{ mL/hr}$. The healthcare provider prescribes a new continuous IV infusion of dopamine at $5\text{ mcg/kg/min}$. The client weighs $176\text{ lbs}$. The pharmacy dispenses dopamine $400\text{ mg}$ diluted in $250\text{ mL}$ of $5\%$ dextrose in water (D5W). Based on this prescription, which of the following actions is the most appropriate for the nurse to take?

A nurse is preparing to change a two-piece ostomy appliance for a client with a newly established descending colostomy. In which order should the nurse perform the following actions? Arrange the steps from first to last.

A nurse is reviewing the medical record of a client who is scheduled for a computed tomography (CT) scan with intravenous (IV) iodinated contrast. Which finding is the most critical to report to the healthcare provider prior to the procedure?

An older adult client with advanced Parkinson's disease and acute pancreatitis is receiving continuous enteral nutrition through a nasojejunal tube. The client suddenly becomes highly restless, pulls at the bedsheets, and attempts to climb over the side rails. Which nursing action demonstrates the most appropriate approach to this client's basic care and comfort?

A nurse is preparing to safely transfer a client who has generalized weakness from the bed to a wheelchair. In what order should the nurse perform the following actions? Arrange the steps in the correct sequence from first to last.

A nurse is preparing to administer a prescribed dose of intravenous (IV) phenytoin to a client who is experiencing active seizure activity. The client has a single peripheral IV line with a continuous infusion of $5\%$ dextrose in water (D5W). Which of the following is the most appropriate action for the nurse to take?

A client with a documented history of severe chronic obstructive pulmonary disease (COPD) is brought to the emergency department by a caregiver. The caregiver reports that the client has become increasingly lethargic and confused over the past four hours. The healthcare provider orders an arterial blood gas (ABG) analysis on room air. Which of the following ABG results indicates an acute loss of compensatory mechanisms requiring immediate airway management?