Physiological Integrity

A nurse is monitoring a client who is receiving a continuous intravenous infusion of packed red blood cells (PRBCs). Fifteen minutes after the transfusion begins, the client reports sudden lower back pain, chills, and dyspnea. Place the following nursing actions in the correct order of performance. (All steps must be used).

A nurse is monitoring a client diagnosed with Guillain-Barré syndrome who reports increasing weakness in the upper body. The client's forced vital capacity (FVC) has decreased from 40 mL/kg to 14 mL/kg over the past shift. The most recent arterial blood gas (ABG) results on room air reveal a pH of 7.29, PaCO2 of 58 mm Hg (7.7 kPa), PaO2 of 64 mm Hg (8.5 kPa), and HCO3- of 25 mEq/L (25 mmol/L). Based on these findings, what is the priority nursing action?

A client who recently experienced a cerebrovascular accident requires an intermittent bolus enteral feeding through an established nasogastric (NG) tube. Place the following nursing actions in the correct sequence for safely delivering this nutrition. (Arrange the steps in chronological order.)

A healthcare provider prescribes an intermittent intravenous vancomycin infusion of $15\text{ mg/kg}$ for a client with a severe bacterial infection. The client weighs $154\text{ lb}$. To prevent red man syndrome, institutional guidelines require vancomycin to be administered at a maximum rate of $10\text{ mg/min}$. Calculate the minimum safe infusion time in minutes for this dose. Record your answer as a whole number.

A nurse is evaluating an adult client who returned to the cardiac step-down unit $45\text{ minutes}$ ago following a percutaneous coronary intervention (PCI) via the right femoral artery. The client's baseline vital signs prior to the procedure were: blood pressure $138/82\text{ mm Hg}$, heart rate $72\text{ beats per minute}$, and respiratory rate $16\text{ breaths per minute}$. Which of the following assessment findings require immediate intervention by the nurse to reduce the risk of physiological decompensation? (Select all that apply.)

A nurse is developing a plan of care for a client who is 12 hours postoperative following an exploratory laparotomy and bowel resection. Which of the following nursing actions should be implemented to reduce the risk of potential physiological complications? (Select all that apply.)

A nurse is caring for an older adult client with advanced Parkinson's disease who is on aspiration precautions due to documented oropharyngeal dysphagia. The client frequently experiences fatigue and bilateral hand tremors during mealtimes. Which of the following is the most appropriate nursing intervention to promote safe nutritional intake?

A nurse is evaluating a client 12 hours after a partial hepatectomy. The client is restless, anxious, and reports intense thirst. Assessment reveals pale, cool skin. Vital signs are: heart rate 122 bpm, blood pressure 104/86 mm Hg, and respiratory rate 26 breaths/min. The client's urinary output has been 40 mL over the past two hours. An arterial blood gas (ABG) analysis shows a pH of 7.32, $\text{PaCO}_2$ of 33 mm Hg, and $\text{HCO}_3^-$ of 18 mEq/L. Based on these physiological findings, which of the following complications is the client most likely experiencing?

A nurse is assessing a client who is 4 hours post-operative following an open abdominal surgery with significant intraoperative blood loss. Which of the following clinical findings indicate the client is experiencing the early (compensatory) stage of hypovolemic shock? (Select all that apply)

A nurse is performing a routine administration set change for a client receiving continuous parenteral nutrition via a right subclavian central venous catheter. While the nurse is transitioning the tubing, the client takes a sudden, deep inspiration before the connection is secured. The client immediately grasps their chest, reporting severe pain, shortness of breath, and a sense of impending doom. The cardiac monitor shows a heart rate of $132$ beats per minute and the blood pressure drops to $86/48$ mmHg. Which of the following is the priority nursing action?

A nurse is caring for a client who sustained a pelvic fracture following a motor vehicle collision. The nurse monitors the client closely for internal bleeding and suspects the onset of the early compensatory stage of hypovolemic shock. Which clinical manifestations support this assessment? Select all that apply.

A nurse is conducting a postoperative assessment on a client who underwent a partial nephrectomy 4 hours ago. The client's baseline preoperative blood pressure was 130/76 mm Hg, and the heart rate was 78/min. Current vital signs reveal a blood pressure of 106/84 mm Hg, a heart rate of 114/min, and a respiratory rate of 20/min. The client's urinary output has been 15 mL over the past hour. Which of the following actions should the nurse prioritize to reduce the risk of physiological decompensation?

An intensive care nurse is monitoring a client with end-stage renal disease who is undergoing their first hemodialysis treatment via a newly placed right internal jugular central venous catheter. Approximately $90\text{ minutes}$ into the session, the client becomes increasingly restless and reports a severe, throbbing headache accompanied by nausea. The client's vital signs display a blood pressure of $184/106\text{ mm Hg}$, elevated from a pre-dialysis baseline of $152/86\text{ mm Hg}$. Which immediate action should the nurse take to mitigate this developing complication?

While completing a shift assessment on a telemetry unit, a nurse evaluates a client who experienced an acute myocardial infarction 48 hours ago. The client exhibits sudden, severe dyspnea, expectorates pink, frothy sputum, and has coarse crackles auscultated throughout both lung fields. Which of the following is the priority nursing action?

A nurse is planning care for a client who has a serum potassium level of $2.6\text{ mEq/L}$ and a prescription for intravenous potassium chloride (KCl) replacement. Which of the following nursing actions are required for the safe administration of this medication? (Select all that apply.)

A client diagnosed with an acute pulmonary embolism is receiving a continuous intravenous infusion of unfractionated heparin via a single peripheral catheter. The healthcare provider prescribes a scheduled dose of intravenous vancomycin to treat a concurrent soft tissue infection. A review of the medication reference guide indicates that heparin and vancomycin are physically incompatible. What is the most appropriate nursing action?

A nurse is discontinuing a right subclavian non-tunneled central venous catheter for a client whose intravenous antibiotic therapy is complete. To minimize the risk of complications, in what order should the nurse perform the following actions?

A nurse in the surgical intensive care unit is planning care for a $54$-year-old client who is $4$ hours postoperative following an emergency bowel resection and formation of a temporary colostomy due to an intestinal perforation. The client is receiving continuous intravenous (IV) fluids and has an arterial line in place for hemodynamic monitoring. Which nursing actions are essential to reduce the risk of physiological complications? Select all that apply.

A nurse is caring for a client who is 3 days postoperative following a total right hip arthroplasty. The client suddenly reports sharp, pleuritic chest pain and a feeling of impending doom. The nurse obtains the following assessment data:

Which of the following is the priority nursing action?

A nurse is caring for a client who has just returned to the medical-surgical unit following a percutaneous liver biopsy. What is the priority nursing action to reduce this client's risk for post-procedure hemorrhage?