Physiological Integrity

A 72-year-old client who underwent a diagnostic lumbar puncture two hours ago rings the call bell. The client reports a severe, throbbing headache that significantly worsens when attempting to sit up, and the client appears mildly disoriented to time. What is the most appropriate initial nursing action to promote comfort and safety?

A client diagnosed with short bowel syndrome is receiving continuous total parenteral nutrition (TPN) via a single-lumen peripherally inserted central catheter (PICC). The healthcare provider prescribes an intermittent intravenous dose of famotidine to be administered every 12 hours. Which action should the nurse take to safely administer this medication?

A 68-year-old client with advanced cirrhosis and refractory ascites is receiving care on a medical-surgical unit. The client's baseline blood pressure is 132/82 mmHg. Three hours after a large-volume paracentesis during which 6 liters of ascitic fluid were removed, the client reports feeling slightly fatigued and nauseated. The client's current vital signs reveal a blood pressure of 102/64 mmHg, a heart rate of 110 beats/minute, a respiratory rate of 20 breaths/minute, and an oxygen saturation of 97% on room air. The abdominal dressing is dry and intact. What is the priority nursing action to mitigate the client's risk of further physiological decompensation?

A nurse is preparing to administer a prescribed unit of packed red blood cells (PRBCs) to a client with severe anemia. In what order should the nurse perform the following actions? Arrange the steps in the correct chronological sequence.

A nurse is closely monitoring a client who is receiving a transfusion of packed red blood cells (PRBCs) through an 18-gauge peripheral intravenous (IV) catheter. Fifteen minutes into the transfusion, the client reports acute shortness of breath, chest tightness, and severe lower back pain. Current vital signs reveal a blood pressure of $82/48\text{ mmHg}$, a heart rate of $128\text{ bpm}$, and a temperature of $101.8^\circ\text{F}$ ($38.8^\circ\text{C}$). The nurse immediately stops the transfusion. Which of the following is the priority parenteral therapy action for the nurse to take next?

A nurse receives a client who has just been admitted to the medical-surgical unit following a percutaneous liver biopsy. The client's vital signs are stable. Which of the following positions is the most appropriate for the nurse to assist the client into during the initial post-procedure period?

A 62-year-old client is admitted to the progressive care unit with severe right-sided lobar pneumonia. The client exhibits significant dyspnea, tachypnea, and a productive cough. Laboratory analysis of an arterial blood sample while the client is on 2 L/min of supplemental oxygen reveals a pH of 7.30, PaCO2 of 54 mm Hg, PaO2 of 58 mm Hg, and HCO3 of 25 mEq/L. To immediately optimize ventilation-perfusion matching and reduce the risk of worsening respiratory failure, which action should the nurse perform?

A nurse is caring for a client who is receiving intravenous antibiotics for a severe bacterial infection. The nurse is monitoring the client for the development of systemic complications. Which of the following physiological findings provides the earliest indication that the client is entering the hyperdynamic (warm) phase of septic shock?

A nurse is preparing to transfer a client with right-sided weakness from the bed to a wheelchair. Arrange the following steps in the correct sequence to ensure a safe transfer.

An adult client on a medical-surgical unit is undergoing a packed red blood cell (PRBC) transfusion for symptomatic anemia. Shortly after the initiation of the blood product, the client suddenly develops severe flank pain, chills, and shortness of breath. Place the following nursing interventions in the correct sequential order of priority.

While monitoring a client receiving a newly prescribed intravenous cephalosporin, the nurse observes sudden-onset audible stridor, diffuse urticaria, and a precipitous drop in blood pressure to 78/46 mm Hg. Arrange the following nursing interventions in the correct order of priority.

During a bedside assessment, a nurse evaluates a client undergoing continuous intravenous heparin therapy for a pulmonary embolism. The client's most recent activated partial thromboplastin time (aPTT) is $105$ seconds. The latest arterial blood gas (ABG) results on $2$ L/min oxygen via nasal cannula are: pH $7.38$, $PaCO_2$ $42$ mm Hg, and $PaO_2$ $88$ mm Hg. The client suddenly reports a new, severe throbbing headache and blurred vision. Which action should the nurse take first?

A nurse in the intensive care unit is caring for a client who is receiving a continuous intravenous infusion of norepinephrine through a peripheral venous catheter. During the hourly assessment, the nurse notes blanching, coolness, and swelling at the insertion site, and the client reports severe burning pain. In what order should the nurse perform the following actions to minimize tissue injury? Arrange the actions from first to last.

An older adult client is completely immobile and receiving continuous enteral nutrition via a gastrostomy tube. The nursing team is preparing to provide perineal care and perform a complete bed linen change, which will require lowering the bed. Which nursing action is the most appropriate to ensure the client's safety during this basic care procedure?

A 72-year-old client is two hours post-percutaneous coronary intervention (PCI) via the right femoral artery. The client suddenly reports severe shortness of breath. Assessment reveals a respiratory rate of 34/min, production of pink, frothy sputum, and coarse crackles throughout both lung fields. Which immediate action minimizes the risk of procedural complications while addressing the acute change in condition?

A nurse is caring for a client with a pulmonary embolism who weighs $85.4\text{ kg}$. The client is receiving a continuous intravenous heparin infusion. The current infusion rate is $14\text{ units/kg/hr}$. The heparin is supplied as $25,000\text{ units}$ in $250\text{ mL}$ of 5% dextrose in water.

The client's morning activated partial thromboplastin time (aPTT) is $39\text{ seconds}$. According to the hospital's weight-based heparin protocol, for an aPTT between $36$ and $44\text{ seconds}$, the nurse must administer an intravenous bolus of $40\text{ units/kg}$ and increase the continuous infusion rate by $2\text{ units/kg/hr}$.

Calculate the client's new continuous infusion pump rate in $\text{mL/hr}$. (Record your answer using one decimal place.)

A nurse is preparing to administer a prescribed intravenous dose of phenytoin to a client with a seizure disorder. The pharmacy delivers the medication labeled as 'phenytoin 300 mg in 50 mL of 5% dextrose in water (D5W)'. The client has a continuous intravenous (IV) infusion of 0.9% sodium chloride running at 50 mL/hr. Which action should the nurse take?

A nurse is assessing a client 2 hours after a therapeutic thoracentesis in which 1,400 mL of pleural fluid was removed. Which finding indicates a life-threatening complication that requires immediate intervention by the nurse?

A 62-year-old client with advanced hepatic cirrhosis is 1 hour post-paracentesis, during which $4.5$ liters of ascitic fluid were removed. The client reports feeling extremely dizzy and exhibits delayed cognitive responses. The nurse assesses the following clinical data:

Which action should the nurse take to mitigate the risk of severe physiological decompensation?

A nurse is preparing to draw up a mixed dose of Regular insulin and NPH insulin into a single syringe. Arrange the following steps of the procedure in the correct chronological sequence.