Physiological Integrity

A nurse is evaluating a client admitted with severe urosepsis. The client has already received a 30 mL/kg bolus of 0.9% sodium chloride and broad-spectrum intravenous antibiotics. Upon reassessment, which of the following clinical changes most strongly indicates that the client is experiencing progressive physiological decompensation and transitioning from the early (hyperdynamic) phase to the late (hypodynamic) phase of septic shock?

A nurse is caring for a client who is two hours postoperative following a right-sided pneumonectomy. The client is drowsy but arousable. The latest arterial blood gas (ABG) results show a pH of 7.31, PaCO2 of 52 mm Hg, PaO2 of 72 mm Hg, and HCO3- of 25 mEq/L. Which of the following actions should the nurse take to reduce the client's risk of further physiological deterioration?

A nurse is preparing to administer amoxicillin oral suspension to a pediatric client diagnosed with acute otitis media. The prescription states: amoxicillin $45 \text{ mg/kg/day}$ orally, divided into equal doses to be administered every $12$ hours. The client's weight is $44 \text{ lb}$. The pharmacy provides amoxicillin suspension with a concentration of $400 \text{ mg}/5 \text{ mL}$. How many mL should the nurse administer per dose? (Record your answer using one decimal place.)

During a morning assessment on the progressive care unit, a nurse evaluates a client who experienced an anterior ST-elevation myocardial infarction (STEMI) three days ago. The client suddenly develops severe dyspnea, extreme restlessness, and cold, clammy skin. Vital signs demonstrate a heart rate of 134 beats/min, a respiratory rate of 36 breaths/min, and a blood pressure of 78/42 mm Hg. Cardiac auscultation reveals a newly developed loud holosystolic murmur at the apex, while pulmonary assessment shows coarse crackles throughout all lung fields. Point-of-care arterial blood gas testing reveals a pH of 7.21, a $\text{PaCO}_2$ of 65 mm Hg, a $\text{PaO}_2$ of 48 mm Hg, and an $\text{HCO}_3^-$ of 24 mEq/L. Which of the following actions should the nurse implement first?

An older adult client is admitted to the cardiac intensive care unit with cardiogenic shock and pulmonary edema. The client has a single-lumen peripheral venous catheter continuously infusing dobutamine. Assessment reveals a blood pressure of 82/48 mm Hg, severe orthopnea, and coarse crackles throughout both lung fields. The provider orders an immediate intravenous push of bumetanide. Drug reference materials indicate bumetanide is physically incompatible with dobutamine. Which action demonstrates the safest administration technique?

A nurse is planning care for a 72-year-old client diagnosed with peripheral arterial disease (PAD) who reports experiencing severe burning pain in the lower legs that frequently disrupts sleep. Which of the following nursing interventions is most appropriate to promote client comfort?

A client admitted with septic shock is receiving a continuous intravenous (IV) infusion of norepinephrine through a single peripheral IV line. The client's mean arterial pressure (MAP) is currently $68 \text{ mmHg}$. The healthcare provider prescribes a scheduled dose of IV push pantoprazole. Which of the following actions is the most appropriate for the nurse to take?

A nurse on a medical-surgical unit is preparing to administer a large-volume cleansing enema to an adult client experiencing severe constipation. In what order should the nurse perform the following actions? Arrange the steps in the correct chronological sequence.

A nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation. The ventilator's high-pressure alarm suddenly begins to sound continuously. Arrange the following nursing actions in the most appropriate chronological order from first to last.

A nurse is preparing to administer intermittent intravenous (IV) vancomycin to a client diagnosed with a severe methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following actions by the nurse are appropriate? Select all that apply.

During a shift assessment, the nurse reviews the electronic health record of a client being treated for a deep vein thrombosis. Unfractionated heparin is currently infusing continuously via a peripheral venous catheter. The provider has newly entered a prescription for ketorolac tromethamine 30 mg IV every 6 hours for reports of severe back pain. Which of the following is the priority nursing action?

Following an outpatient colonoscopy with the removal of three large polyps, a 54-year-old client is being monitored in the recovery area. At 0900, the client's baseline vital signs were a blood pressure of 126/78 mmHg and a heart rate of 72/min. At 1030, the client reports feeling lightheaded and having diffuse abdominal achiness. The current vital signs reveal a blood pressure of 110/84 mmHg, a heart rate of 104/min, and a respiratory rate of 20/min. Which action should the nurse take FIRST to prevent physiological decompensation?

A client receiving palliative care for metastatic bone cancer is experiencing restlessness and increasing pain. The family asks for interventions to help the client relax without administering additional sedating medications. Which nursing action is most appropriate to promote basic care and comfort?

A nurse is preparing to access a client's implanted venous access device (port) using a non-coring needle to administer intravenous chemotherapy. The nurse has gathered the necessary supplies, explained the procedure to the client, and performed hand hygiene. Arrange the following steps in the correct order to access the device safely.

A nurse in the emergency department is evaluating a client who sustained deep partial-thickness burns over 45% of their total body surface area (TBSA) 4 hours ago. The client has not yet received adequate intravenous fluid resuscitation. Which of the following clinical findings represent expected pathophysiological adaptations during this emergent phase of the injury? Select all that apply.

A client who recently underwent extensive gastrointestinal surgery is receiving continuous total parenteral nutrition (TPN) via a single-lumen central venous catheter. The client reports sudden, severe surgical site pain, and the provider prescribes a one-time dose of intravenous (IV) push morphine. Which of the following is the most appropriate action for the nurse to take?

A client presenting with a hypertensive emergency requires a continuous intravenous (IV) infusion of sodium nitroprusside. The client weighs $187\text{ lb}$. The healthcare provider prescribes the infusion to begin at a rate of $3\text{ mcg/kg/min}$. The pharmacy dispenses a premixed bag containing $50\text{ mg}$ of sodium nitroprusside in $250\text{ mL}$ of $5\%$ dextrose in water ($D5W$). At what rate in $\text{mL/hr}$ should the nurse set the IV infusion pump? (Record your answer to the nearest tenth.)

A client is recovering from severe bacterial pneumonia on a medical step-down unit. The client's family expresses concern about the client's extreme fatigue, fragmented sleep, and heightened sensitivity to unit noises. The nurse establishes a care plan focused on non-pharmacological comfort and rest promotion. Which interventions are appropriate to include? Select all that apply.

A nurse is preparing to administer a prescribed intravenous (IV) dose of phenytoin to a client. The client currently has a continuous IV infusion of 5% dextrose in water (D5W) running at 75 mL/hr through a peripheral IV catheter. Which action should the nurse take to administer the phenytoin safely?

A client arrives at the medical-surgical unit after a diagnostic cardiac catheterization performed via the right femoral artery. It has been 30 minutes since the procedure concluded. Which of the following actions is most appropriate for the nurse to implement?