Physiological Integrity

A client receiving a first dose of an intravenous antibiotic suddenly reports difficulty swallowing and feeling faint. The nurse observes facial swelling, audible wheezing, and a rapidly dropping blood pressure. Place the following nursing interventions in the correct sequence to manage this acute physiological emergency.

A nurse is evaluating the clinical data of a client with a small bowel obstruction who has received continuous nasogastric (NG) tube decompression for 72 hours. The client is lethargic with shallow respirations of 10 breaths/min. The cardiac monitor reveals a prolonged QT interval and frequent multifocal premature ventricular contractions (PVCs).

Morning laboratory results:
- pH: $7.56$
- $PaCO_2$: $54$ mm Hg
- $HCO_3^-$: $44$ mEq/L
- Potassium: $2.4$ mEq/L ($2.4$ mmol/L)
- Magnesium: $1.1$ mEq/L ($0.55$ mmol/L)

Which intervention must the nurse prioritize to reduce the client's risk of a life-threatening physiological complication?

A nurse is removing a non-tunneled central venous catheter (CVC) from a client's right subclavian vein. Immediately following the catheter's removal, the client suddenly gasps, exhibits severe dyspnea, clutches their chest, and their oxygen saturation rapidly drops to 84%. Suspecting an acute venous air embolism, arrange the following collaborative and nursing interventions in the priority order they must be implemented to mitigate physiological risk.

An adult client underwent a percutaneous left renal biopsy 4 hours ago. Baseline vital signs in the recovery unit included a blood pressure of 138/82 mm Hg and a heart rate of 76 beats/min. During the current assessment, the client reports a new, deep ache in the left flank and lower back. Vital signs demonstrate a blood pressure of 108/88 mm Hg, a heart rate of 115 beats/min, and a respiratory rate of 22 breaths/min. Based on these physiological changes, which intervention is the priority to minimize further client risk?

While evaluating a client who recently arrived at the surgical unit after a total abdominal hysterectomy, the nurse reviews the most recent vital signs and clinical presentation. Which assessment finding represents the earliest manifestation of internal bleeding?

An adult client in the intensive care unit is being treated for severe sepsis and metabolic acidosis. The client has a triple-lumen central venous catheter (CVC) in the right internal jugular vein. The current continuous intravenous (IV) infusions are as follows:

• Proximal port: $0.45\%$ sodium chloride with $150\text{ mEq}$ of sodium bicarbonate infusing at $150\text{ mL/hr}$.
• Medial port: Epinephrine infusing at $0.05\text{ mcg/kg/min}$ for blood pressure support.
• Distal port: Total parenteral nutrition (TPN) infusing at $75\text{ mL/hr}$.

The client's morning laboratory results indicate an ionized calcium level of $0.85\text{ mmol/L}$ (normal: $1.05\text{-}1.30\text{ mmol/L}$). The healthcare provider prescribes $1\text{ g}$ of intravenous calcium gluconate to be administered over 15 minutes. Which action by the nurse is the most appropriate?

The nurse is preparing to administer an intermittent bolus enteral feeding via a gastrostomy tube to a client with dysphagia. After verifying the provider's prescription, performing hand hygiene, and donning clean gloves, arrange the following nursing actions in the correct chronological sequence.

An older adult client with a history of moderate dementia is receiving continuous enteral nutrition via a nasogastric (NG) tube. During the night shift, the client becomes acutely restless, exhibits new-onset confusion, and repeatedly attempts to pull at the NG tube. The client also requires frequent linen changes due to urinary incontinence. What nursing action demonstrates the safest approach to managing this client's basic care and comfort?

A nurse is administering a prescribed intravenous (IV) push medication into a client's continuous IV infusion line. Immediately after injecting the medication into the Y-site, the nurse observes a cloudy, white precipitate forming in the IV tubing. What is the nurse's immediate priority action?

A nurse is preparing to collect a sterile urine specimen for a culture and sensitivity test from a client who has a closed indwelling urinary catheter system. In which order should the nurse perform the following actions to reduce the risk of infection and ensure an accurate diagnostic sample? Arrange the steps from first to last.

A nurse is caring for a client who is exhibiting severe respiratory depression with a respiratory rate of 8 breaths per minute following an opioid overdose. Which of the following arterial blood gas (ABG) results should the nurse most likely expect to find?

A nurse is preparing to administer a dissolved oral medication through a client's established nasogastric (NG) tube. To reduce the risk of complications, in what order should the nurse perform the following actions? Arrange the steps from first to last.

An older adult client is receiving basic care on a medical-surgical unit following a cerebrovascular accident (CVA). The client exhibits right-sided hemiplegia and moderate dysphagia. Which of the following nursing interventions should be included in the client's daily care regimen? (Select all that apply.)

A client with a seizure disorder has a continuous intravenous (IV) infusion of 5% dextrose in water (D5W) running through a peripheral catheter. The nurse needs to administer a scheduled dose of IV phenytoin. What is the most appropriate technique for the nurse to administer this medication through the existing access?

A critically ill client is mechanically ventilated via an oral endotracheal tube. The morning arterial blood gas (ABG) analysis reveals a pH of 7.28, PaCO2 of 62 mm Hg, HCO3- of 26 mEq/L, and PaO2 of 70 mm Hg. The client suddenly exhibits profound diaphoresis, restless movements, and begins biting the endotracheal tube. Which intervention should the nurse implement first to mitigate the risk of further physiological deterioration?

A nurse is evaluating a client with an acute exacerbation of chronic obstructive pulmonary disease (COPD) who is undergoing a spontaneous breathing trial (SBT) via a T-piece. To reduce the risk of cardiopulmonary collapse and extubation failure, which assessment findings require the nurse to immediately terminate the trial and resume mechanical ventilation? Select all that apply.

A nurse is caring for an adult client who is receiving a massive blood transfusion protocol (6 units of packed red blood cells over the past 3 hours) due to severe gastrointestinal hemorrhage. The nurse assesses the client for potential physiological complications of the rapid, massive transfusion. Which of the following assessment findings require immediate intervention by the nurse? Select all that apply.

A nurse is managing the care of an older adult client who is receiving continuous enteral nutrition via a nasogastric (NG) tube. The client has become restless and requires a linen change as well as a sacral skin assessment. Which of the following nursing actions is most appropriate?

A nurse is caring for a client with a history of chronic heart failure who is receiving a transfusion of packed red blood cells (PRBCs) at a rate of $120 \text{ mL/hr}$. Approximately forty-five minutes into the infusion, the client suddenly reports shortness of breath. The nurse's assessment reveals a bounding heart rate of $112 \text{ bpm}$, blood pressure of $178/96 \text{ mmHg}$, jugular venous distention, and new-onset bibasilar crackles. The client's temperature remains unchanged at $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$). Which of the following sequences of actions is the priority for the nurse?

A nurse is caring for a client with a mechanical small bowel obstruction who has been receiving continuous nasogastric (NG) decompression for three days. The client suddenly reports a new onset of severe, unrelenting abdominal pain. The healthcare provider orders an arterial blood gas (ABG) analysis, which reveals the following results: pH 7.28, PaCO2 36 mm Hg, and HCO3- 15 mEq/L. Based on these findings, which conclusion should the nurse draw?