Physiological Integrity

A nurse is evaluating a client who is receiving a continuous intravenous infusion of magnesium sulfate for the management of severe preeclampsia. Which of the following clinical findings indicates severe toxicity and requires the nurse to immediately stop the infusion and prepare the prescribed antidote?

A nurse is monitoring a critically ill client who is receiving a continuous intravenous infusion of norepinephrine through a peripheral vein in the right forearm. The nurse assesses the insertion site and notes it is blanched, cold, and swollen, and the client reports severe burning pain. Arrange the following nursing interventions in the correct order of priority to mitigate tissue necrosis.

A nurse is evaluating a client who presents to the emergency department with severe hematemesis. Which clinical manifestations indicate the client is experiencing the compensatory (early) stage of hypovolemic shock? Select all that apply.

Two hours following a percutaneous liver biopsy, a client suddenly becomes restless and anxious. The nurse assesses the client and obtains the following vital signs: blood pressure $104/84$ mm Hg, heart rate $118$ beats per minute, and respiratory rate $22$ breaths per minute. The client is currently resting on their right side. What is the priority nursing action to reduce the risk of physiological decompensation?

A nurse is preparing to administer a large-volume cleansing enema to a client who is experiencing severe constipation. In what order should the nurse perform the following procedural steps? (Arrange from first to last.)

A client admitted with cardiogenic shock requires hemodynamic support. The healthcare provider orders an intravenous infusion of dopamine at a rate of $5 \text{ mcg/kg/min}$. The client's admission weight is $176 \text{ lbs}$. The pharmacy dispenses a premixed bag containing $400 \text{ mg}$ of dopamine in $250 \text{ mL}$ of $0.9\%$ sodium chloride. At how many $\text{mL/hr}$ should the nurse program the infusion pump? (Record answer as a whole number.)

An adult client is brought to the emergency department following a suspected overdose of a narcotic analgesic. The client is difficult to arouse, with a respiratory rate of 8 breaths per minute and shallow respirations. Based on these clinical findings, which acid-base imbalance should the nurse anticipate?

A client is receiving care on the surgical unit 48 hours after undergoing a right below-the-knee amputation. Which positioning strategy should the nurse implement to prevent the most common musculoskeletal complication associated with this recovery phase?

A nurse is developing a plan of care for an older adult client who is 12 hours postoperative following a right total hip arthroplasty (posterior approach). Which of the following nursing actions will effectively reduce the client's risk for post-surgical complications? Select all that apply.

A family member brings a client with a history of congestive heart failure to the urgent care clinic. The family reports the client accidentally took a double dose of their prescribed loop diuretic over the last three days. The client now reports profound weakness, dizziness when standing, and severe muscle cramps in the lower extremities. The clinical assessment reveals a respiratory rate of 10 breaths per minute with shallow effort. The arterial blood gas (ABG) analysis yields the following results:

* pH: 7.52
* PaCO2: 49 mm Hg
* HCO3-: 33 mEq/L
* PaO2: 88 mm Hg

Which of the following represents the most accurate clinical interpretation of this client's condition?

A 68-year-old client is admitted with a small bowel obstruction and has been receiving continuous nasogastric (NG) tube wall suctioning for the past 48 hours. The nurse notes the client has become increasingly irritable, with a respiratory rate of 11 breaths/min and shallow chest expansion. Arterial blood gas (ABG) results are: pH 7.54, PaCO2 49 mm Hg, HCO3- 35 mEq/L, and PaO2 85 mm Hg. Based on these findings, which action is the priority for the nurse to implement to reduce the risk of an impending complication?

A registered nurse is managing the care of a client with severe Crohn's disease who is receiving continuous Total Parenteral Nutrition (TPN) and a separate 20% intravenous fat emulsion (IVFE) via a multi-lumen central venous catheter. Which of the following interventions must the nurse implement to ensure the safe administration and monitoring of these therapies? Select all that apply.

A charge nurse is conducting clinical rounds on a medical-surgical unit and reviewing the status of four clients. Which client assessment finding indicates a life-threatening complication that requires the most urgent intervention?

A nurse enters the room of a client receiving intravenous fluids via a central venous catheter (CVC). The nurse discovers that the intravenous tubing has disconnected from the CVC hub. The client is suddenly experiencing severe dyspnea, tachycardia, and a feeling of impending doom. Arrange the following nursing actions in the correct order of priority to manage this complication.

A preceptor is evaluating a newly licensed nurse who is caring for a 64-year-old client. The client is mechanically ventilated for severe acute respiratory distress syndrome (ARDS) and is in the early stages of septic shock. Which actions by the newly licensed nurse require the preceptor to intervene immediately to reduce the client's risk of life-threatening complications? (Select all that apply)

A nurse is preparing to transfer a client who has generalized weakness and right-sided hemiparesis from the bed to a wheelchair. The client is able to bear partial weight. Which action should the nurse take to ensure a safe transfer?

A nurse enters the room of a client receiving continuous intravenous fluids via a central venous catheter (CVC). The nurse discovers that the IV tubing has disconnected from the catheter hub, leaving it open to the air. The client suddenly becomes tachypneic, diaphoretic, and reports severe shortness of breath. Arrange the following nursing actions in the correct priority order to mitigate the risk of further complications.

A client diagnosed with a deep vein thrombosis is prescribed a continuous intravenous infusion of heparin. The client's current weight is $198\text{ lb}$. The provider's prescription requires an initial infusion rate of $18\text{ units/kg/hr}$. The available medication is a $250\text{ mL}$ intravenous bag containing $25,000\text{ units}$ of heparin sodium. At what rate in $\text{mL/hr}$ should the nurse program the infusion pump? Record your answer using one decimal place.

A nurse is caring for a client with a T4 spinal cord injury. The client suddenly reports a severe, pounding headache, and the nurse notes profuse diaphoresis above the level of the injury. The client's blood pressure is 210/110 mm Hg. Arrange the following nursing interventions in the correct order of priority from first to last.

A client with symptomatic anemia is receiving a transfusion of packed red blood cells (PRBCs) through a peripheral intravenous catheter. Fifteen minutes after the transfusion begins, the client reports acute lower back pain, severe chills, and dyspnea. The nurse observes that the urine in the urinary drainage bag has suddenly turned dark reddish-brown. The nurse immediately stops the blood transfusion. Which of the following is the most critical next action for the nurse to take?