Physiological Integrity

A nurse is preparing to provide a bed bath and perineal care for a client who is receiving continuous enteral nutrition via a nasogastric tube. The procedure requires lowering the head of the bed to a flat, supine position. Which of the following is the priority action for the nurse to take?

A registered nurse is preparing to administer a prescribed intravenous (IV) loading dose of phenytoin to an adult client experiencing recurrent generalized seizures. Which of the following nursing actions are necessary during the preparation and administration of this parenteral medication? (Select all that apply.)

A nurse is closely monitoring a client who is 4 hours postoperative following an open abdominal surgery. Which of the following assessment findings should the nurse recognize as early indicators of impending hemorrhagic shock? Select all that apply.

A registered nurse is preparing to access a client's implanted venous access port (Port-a-Cath) to administer a scheduled intravenous infusion. Arrange the following steps in the correct chronological order to safely perform this procedure.

An adult client with symptomatic anemia is scheduled to receive a transfusion of packed red blood cells. The healthcare provider has prescribed the blood product to be infused over two hours. Which of the following intravenous fluids must the nurse select to prime the blood administration tubing?

A client has just arrived on the medical unit after undergoing a bedside lumbar puncture. To minimize the risk of developing a cerebrospinal fluid leak and subsequent headache, which of the following positioning interventions should the nurse implement?

The nurse is reviewing the care plan for a client who is 48 hours postoperative following a right below-the-knee amputation. Which interventions are appropriate to include in the client's basic care and comfort management? Select all that apply.

A registered nurse in the cardiovascular intensive care unit is caring for a client with severe decompensated heart failure.

Client data:
- Weight: $176\text{ lb}$
- Current cardiac index (CI): $1.8\text{ L/min/m}^2$
- Current dobutamine infusion rate: $12\text{ mL/hr}$
- Intravenous fluid bag: Dobutamine $500\text{ mg}$ in $250\text{ mL}$ of $5\%\text{ Dextrose in Water (D5W)}$

The unit's hemodynamic titration protocol states: "If CI is $< 2.0\text{ L/min/m}^2$, increase dobutamine infusion by $2.5\text{ mcg/kg/min}$ every 30 minutes until CI is $\geq 2.0\text{ L/min/m}^2$. Maximum dose: $20\text{ mcg/kg/min}$."

The nurse evaluates the client's current status and determines a titration is required. Based on the protocol, what should the nurse set the new infusion rate to in $\text{mL/hr}$? Record your answer to the nearest whole number.

Following a diagnostic lumbar puncture to analyze cerebrospinal fluid, a client arrives on the medical-surgical unit. To effectively mitigate the risk of a post-dural puncture complication, which intervention is most appropriate for the nurse to implement?

A nurse is formulating a comprehensive care plan for an 82-year-old client with advanced Alzheimer's disease, severe osteoarthritis, and dysphagia who is currently receiving treatment for aspiration pneumonia. The client is confined to bed, requires continuous intravenous (IV) fluid therapy, and intermittently attempts to remove the IV catheter. Which of the following interventions should the nurse include in the plan of care to address the client's basic care and comfort needs? Select all that apply.

Following a percutaneous liver biopsy, a client is transferred back to the medical-surgical unit for recovery. To minimize the risk of hemorrhage from the puncture site, what is the most appropriate position for the nurse to place the client in?

A 52-year-old client is admitted to the recovery area immediately after a percutaneous liver biopsy. The client is currently drowsy but responds appropriately to verbal stimuli. Which nursing interventions must be implemented to minimize the risk of complications? Select all that apply.

A 72-year-old client is 48 hours post-operative following a right above-the-knee amputation (AKA). The client is experiencing intermittent confusion, reports a "burning" sensation in the right foot, and frequently attempts to touch the surgical dressing. Which nursing action is most appropriate to promote the client's basic care, comfort, and safety?

During a mobility assessment, a client with left-sided hemiparesis needs to be moved from their bed to a sitting position in a wheelchair. What is the correct sequence of actions the nurse should take to execute this transfer safely?

While caring for a client requiring intravenous antibiotics, the nurse needs to initiate a secondary intermittent infusion (piggyback) through an active primary IV line. Assuming the secondary tubing has already been primed, arrange the following setup actions in the correct sequence.

A nurse is teaching a client who has a prescribed non-weight-bearing status on the right leg how to ascend stairs using crutches. In what order should the nurse instruct the client to perform the following steps? Arrange the actions in the correct sequence.

A client is admitted with profound hypokalemia, exhibiting a serum potassium level of 2.4 mEq/L (2.4 mmol/L). The healthcare provider prescribes an intravenous (IV) potassium replacement. The prescription reads: 'Potassium chloride 20 mEq in 100 mL of 0.9% sodium chloride IV to infuse over 30 minutes.' The client's only vascular access is a 20-gauge peripheral IV catheter in the right forearm. Which of the following is the priority nursing action?

A nurse is monitoring a 58-year-old client who returned to the medical-surgical unit one hour ago following a percutaneous left renal biopsy. Which of the following assessment findings indicates an impending physiological complication and requires the most immediate risk mitigation action by the nurse?

An 84-year-old client with advanced dementia, left-sided hemiplegia from a previous stroke, and a stage 3 sacral pressure injury is receiving continuous enteral feeding via a nasogastric (NG) tube. The client has become acutely restless, is repeatedly pulling at their soiled incontinence brief, and requires immediate perineal care. Which action by the nurse represents the safest integration of basic care and comfort principles?

A nurse is caring for a client who is 4 days postoperative following a median laparotomy. The client coughs forcefully and reports a 'giving way' sensation in the abdomen. The nurse inspects the incision and observes bowel loops protruding through the open wound. In what order should the nurse perform the following actions to minimize the risk of tissue necrosis and physiological decompensation?