Physiological Integrity

A nurse is caring for a client who recently received an intravenous dose of morphine for severe postoperative pain. During the reassessment, the nurse notes that the client is difficult to arouse, has pinpoint pupils, and has a respiratory rate of 8 breaths per minute. Which of the following actions should the nurse take first?

A nurse is preparing to administer an intermittent enteral tube feeding to a client via a percutaneous endoscopic gastrostomy (PEG) tube. Place the following nursing actions in the correct sequence to ensure safe administration.

An older adult client is admitted to the medical-surgical floor with severe bilateral lower extremity edema associated with chronic venous insufficiency. What is the most appropriate action by the nurse to manage the client's swelling and promote comfort?

A client with acute decompensated heart failure is receiving continuous intravenous (IV) infusions of milrinone at $0.5 \text{ mcg/kg/min}$ and heparin at $1,200 \text{ units/hr}$ through a double-lumen central venous catheter (CVC). The client's morning serum potassium level is $2.6 \text{ mEq/L}$. The healthcare provider prescribes a single dose of potassium chloride (KCl) $40 \text{ mEq}$ in $100 \text{ mL}$ of $0.9\%$ sodium chloride to infuse intravenously over $4 \text{ hours}$. The nurse consults a parenteral drug reference and notes that KCl is physically incompatible with both milrinone and heparin at the Y-site. Which action is the most appropriate for the nurse to take?

An 82-year-old resident in a long-term care facility receives continuous enteral nutrition via a percutaneous endoscopic gastrostomy (PEG) tube. The nursing staff observes that the resident has recently developed sudden-onset confusion, frequent bowel incontinence, and worsening sacral erythema. Which action by the registered nurse demonstrates safe practice regarding the client's basic care and comfort?

An orthopedic nurse is reviewing postoperative orders for a client who underwent a right total hip arthroplasty using a posterolateral approach. To minimize the risk of prosthesis dislocation, which interventions should the nurse include in the daily care plan? Select all that apply.

A nurse assumes care for a client who is 4 hours postoperative following a right-sided pneumonectomy for bronchogenic carcinoma. The client has no chest tube in place. Current vital signs are: heart rate 112/min, respiratory rate 24/min, blood pressure 118/76 mm Hg, and SpO2 93% on 3 L/min of oxygen via nasal cannula. The nurse observes the client lying in the left lateral decubitus position with the head of the bed elevated 30 degrees. Assessment reveals absent breath sounds on the right side and a trachea that is deviated slightly to the right. Which intervention should the nurse implement FIRST to reduce the client's risk for sudden physiological decompensation?

A 72-year-old individual is receiving treatment on the medical-surgical floor for right-sided bacterial pneumonia. The client exhibits shallow breathing, generalized weakness, and expresses feeling exhausted from continuous coughing. What is the most appropriate action for the registered nurse to take?

A nurse is caring for a client receiving intravenous (IV) fluids. The client suddenly develops shortness of breath, a cough, and crackles in the lung bases. Arrange the following nursing actions in the priority order they should be performed.

A nurse is instructing a client who is non-weight-bearing on the left leg due to a fractured tibia on how to safely ascend a flight of stairs using crutches. Arrange the following steps of a three-point gait in the correct sequential order.

A nurse is assessing a client who is postoperative and at risk for hemorrhage. Which of the following clinical findings indicate the client is developing early hypovolemic shock? Select all that apply.

A nurse is preparing to administer a large-volume cleansing enema to an adult client to relieve constipation. Arrange the following procedural steps in the correct chronological order from first to last.

A nurse is caring for a client receiving total parenteral nutrition (TPN) via a central venous catheter (CVC). During a tubing change, the CVC accidentally disconnects from the injection cap. The client suddenly gasps, reports sharp chest pain, and exhibits dyspnea with cyanosis. Arrange the following risk-reduction actions in the chronological order the nurse must perform them to manage this complication.

A nurse is preparing to administer a prescribed intravenous (IV) piggyback dose of a reconstituted antibiotic. The client has a continuous primary IV infusion of $0.9\%$ sodium chloride running via an electronic infusion pump. Arrange the following steps in the correct chronological order to safely prepare and initiate the secondary IV piggyback infusion. All steps must be used.

A nurse is preparing to administer an intravenous (IV) push medication through a client's peripheral IV saline lock. In what order should the nurse perform the following actions? Arrange the steps in the correct sequence.

A nurse is receiving a client who just underwent a bedside thoracentesis for a large right-sided pleural effusion. Which of the following nursing actions are essential to monitor and reduce the risk of post-procedure complications? Select all that apply.

A nurse is monitoring a client with severe hepatic cirrhosis who is undergoing a large-volume therapeutic paracentesis. After 3.5 liters of ascitic fluid have been drained, the client reports sudden dizziness and nausea. The client's heart rate increases from 82 to 124 beats per minute, and the blood pressure drops from 130/84 mm Hg to 92/58 mm Hg. Which action should the nurse take first to reduce the risk of further physiological deterioration?

The nurse is preparing to obtain a capillary blood glucose measurement for a client with diabetes mellitus. To ensure accurate results and reduce the risk of infection, in what order should the nurse perform the following actions? Arrange the steps in the correct sequence.

A nurse is preparing to administer an intermittent secondary intravenous (IV) piggyback medication using a new sterile administration set. The client is currently receiving a continuous primary IV fluid infusion via an electronic pump. Arrange the following actions in the correct sequence.

A nurse is receiving a client who has just returned to the clinical unit after undergoing a diagnostic lumbar puncture. The client reports the onset of a mild headache. Which of the following positioning interventions should the nurse implement?