Physiological Integrity

A nurse is evaluating a client who returned to the neurological unit 30 minutes ago following a lumbar puncture. Which of the following assessment findings or observations require immediate intervention by the nurse? (Select all that apply.)

A nurse is caring for an older adult client who has right-sided hemiplegia and severe dysphagia following a recent cerebrovascular accident. Which of the following actions should the nurse take when managing the client's nutritional intake?

A nurse is caring for a conscious client with diabetes mellitus who suddenly becomes diaphoretic, tachycardic, and reports feeling shaky. In what order should the nurse perform the following actions? Arrange the actions in the correct sequence from first to last.

A nurse is reviewing the medication administration records for four newly admitted clients. Which prescribed parenteral therapy should the nurse question immediately?

A nurse is monitoring a client who has sustained severe bleeding and is at risk for hypovolemic shock. Which of the following vital sign changes should the nurse identify as an early indicator of this condition?

During a shift, a nurse is preparing to administer a scheduled dose of intermittent intravenous (IV) ciprofloxacin to a client. The client has only one peripheral IV catheter, which is currently being used for a continuous IV infusion of pantoprazole. Which action is the priority for the nurse to take?

During a shift assessment, a client with a history of severe chronic obstructive pulmonary disease (COPD) is found to be lethargic and responds only to painful stimuli. The client was admitted earlier in the day for an acute respiratory exacerbation and is receiving continuous oxygen therapy at 4 L/min via nasal cannula. Stat arterial blood gas (ABG) results reveal a pH of 7.24, PaCO2 of 71 mm Hg, PaO2 of 65 mm Hg, and HCO3 of 32 mEq/L. Which action should the nurse prioritize?

A nurse is titrating a continuous intravenous infusion of sodium nitroprusside for a client experiencing a hypertensive emergency. The client weighs $198 \text{ lbs}$. The medication is supplied as $50 \text{ mg}$ of sodium nitroprusside mixed in $250 \text{ mL}$ of 5% dextrose in water ($D_5W$). The client's current infusion rate is set at $15 \text{ mL/hr}$. The healthcare provider prescribes an increase in the continuous infusion dose by $0.5 \text{ mcg/kg/min}$. What is the new infusion pump setting in $\text{mL/hr}$? (Record answer to the nearest tenth.)

A nurse is educating a client who sustained a right fractured tibia and is prescribed non-weight-bearing status on the affected leg. The client is learning how to ascend a flight of stairs using a three-point crutch gait. Arrange the following instructions in the correct chronological sequence.

A nurse is removing a client's central venous access device (CVAD). As the catheter is withdrawn, the client suddenly gasps, reports severe chest pain, and becomes acutely dyspneic. The oxygen saturation drops abruptly to 83%. Suspecting a venous air embolism, in what order should the nurse perform the following actions? (Arrange the items in the correct sequence from first to last.)

The charge nurse is rounding on a medical-surgical unit. Which observation of client care requires the charge nurse to intervene immediately to reduce the risk of a severe physiological complication?

A nurse is preparing to provide a complete bed bath for a client who is receiving continuous enteral nutrition via a nasogastric tube. The procedure requires lowering the head of the bed to a supine position. Which of the following actions is the most appropriate for the nurse to take to ensure client safety?

A client with diabetic ketoacidosis (DKA) is receiving a continuous intravenous infusion of regular insulin. Which nursing interventions are appropriate when managing this parenteral therapy? Select all that apply.

While monitoring a client 6 hours after an open cholecystectomy, the nurse notes several subtle physiological changes and suspects the development of early (compensatory) hypovolemic shock due to internal bleeding. Which of the following assessment findings support this physiological adaptation? (Select all that apply)

A client with acute kidney injury is admitted to the intensive care unit. The client's serum potassium level is $7.5$ mEq/L ($7.5$ mmol/L), and the bedside cardiac monitor shows a widened QRS complex with tall, peaked T waves. The healthcare provider prescribes several interventions. In what order should the nurse execute these actions? Arrange the sequence from first to last.

A nurse is assessing a client who sustained multiple injuries in a motor vehicle crash and is at risk for hypovolemic shock. Which assessment findings should the nurse identify as early indicators of the compensatory stage of shock? Select all that apply.

A critically ill client is receiving a continuous intravenous (IV) infusion of norepinephrine for the management of severe septic shock. The client's mean arterial pressure (MAP) is currently maintained at 68 mm Hg. Arterial blood gas results reveal severe metabolic acidosis, and the healthcare provider prescribes a stat intravenous bolus of sodium bicarbonate. The client currently has a single-lumen central venous catheter and no peripheral IV access. Which action by the nurse represents the safest and most appropriate clinical judgment?

A nurse is preparing to transfer a client with right-sided weakness from the bed to a wheelchair. In what order should the nurse perform the following actions? Arrange the steps in the correct sequence.

A 72-year-old client with a history of severe chronic obstructive pulmonary disease (COPD) is admitted to the progressive care unit with a respiratory infection. The client is lethargic and confused. Vital signs are: blood pressure 86/52 mmHg, heart rate 122 beats/min, respiratory rate 32 breaths/min, and oxygen saturation 83% on room air. The arterial blood gas (ABG) results are: pH 7.25, PaCO2 68 mmHg, HCO3 29 mEq/L, and PaO2 50 mmHg. To reduce the risk of further physiological decompensation, which actions should the nurse take? Select all that apply.

A registered nurse is developing a care plan for an older adult client who is recovering from a recent cerebrovascular accident (stroke) and has been diagnosed with new-onset dysphagia. Which of the following actions should the nurse include in the client's mealtime plan of care?