Physiological Integrity

A nurse is preparing to administer a scheduled dose of intravenous phenytoin to a client who has a seizure disorder and is currently NPO (nothing by mouth). The client has a single peripheral intravenous (IV) catheter with a continuous infusion of 5% dextrose in water (D5W) infusing at 75 mL/hr. Which action should the nurse take to safely administer the phenytoin?

A telemetry nurse is monitoring a $58$-year-old client who had a percutaneous coronary intervention (PCI) via the right femoral approach $3$ hours ago. The client suddenly complains of a new, constant aching pain in the lower back. The latest vital signs indicate a blood pressure of $96/54$ mm Hg (baseline $128/76$ mm Hg), a heart rate of $115$ beats/min, and a respiratory rate of $24$ breaths/min. An arterial blood gas (ABG) sample drawn on room air shows a pH of $7.47$, $PaCO_2$ of $30$ mm Hg, $PaO_2$ of $94$ mm Hg, and $HCO_3^-$ of $22$ mEq/L. Which action should the nurse take first to mitigate the risk of further physiological deterioration?

A client with a newly diagnosed deep vein thrombosis is admitted to the medical-surgical unit. The client weighs $85\text{ kg}$. The healthcare provider initiates a weight-based heparin protocol, prescribing a continuous intravenous maintenance infusion at $18\text{ units/kg/hr}$. The medication arrives from the pharmacy as a premixed IV bag containing $25,000\text{ units}$ of heparin in $250\text{ mL}$ of $0.45\%$ sodium chloride. At what rate, in $\text{mL/hr}$, should the continuous infusion pump be set? (Round to the nearest whole number).

While assisting a client who had abdominal surgery three days ago, the client coughs forcefully and suddenly reports feeling a tearing sensation. Upon inspection, the nurse observes a portion of the small intestine protruding through the open surgical wound. What is the correct priority sequence of nursing actions? Place the interventions in the correct order from first to last.

Shift report is completed for a client who underwent an exploratory laparotomy 24 hours ago for a severe bowel obstruction. Current assessment reveals a heart rate of 124 beats per minute, a respiratory rate of 28 breaths per minute, and a blood pressure of 96/68 mm Hg (a decrease from 118/74 mm Hg four hours ago). The client's extremities are cool to the touch, and urine output has been 45 mL over the past three hours. Arterial blood gas (ABG) analysis on room air indicates a pH of 7.28, $PaCO_2$ of 30 mm Hg, $HCO_3^-$ of 15 mEq/L, and $PaO_2$ of 64 mm Hg. Based on these findings, which of the following nursing actions are appropriate? (Select all that apply.)

An adult client is receiving care in the high-dependency unit on the third day of treatment for necrotizing pancreatitis. During the current assessment, the client appears highly agitated and is exhibiting significant intercostal retractions. Auscultation reveals diffuse fine crackles across all lung fields. Hemodynamic parameters show a blood pressure of 92/54 mm Hg and a heart rate of 128 bpm. The client's respiratory rate is 38 breaths per minute with an oxygen saturation of 83% while utilizing a non-rebreather mask at maximum flow. Laboratory analysis of arterial blood demonstrates a pH of 7.22, a partial pressure of carbon dioxide (PaCO2) of 62 mm Hg, and a partial pressure of oxygen (PaO2) of 46 mm Hg. Based on these clinical findings, what is the most critical intervention the nurse should anticipate?

A nurse is caring for a client who is receiving continuous total parenteral nutrition (TPN) via a central venous catheter. Which of the following nursing interventions are essential for the safe administration and monitoring of this therapy? Select all that apply.

An adult client presents to the emergency department after three days of intractable diarrhea. Initial assessment reveals a blood pressure of 106/82 mm Hg, an apical pulse of 118 beats per minute, and a respiratory rate of 28 breaths per minute. Laboratory analysis indicates a pH of 7.29, PaCO2 of 32 mm Hg, and HCO3 of 15 mEq/L. Based on these clinical findings, what is the most accurate conclusion regarding the client's condition?

A nurse is preparing to perform open airway suctioning for an adult client with a tracheostomy tube. To reduce the risk of procedure-related complications such as hypoxia and mucosal trauma, arrange the following actions in the correct chronological sequence.

A nurse is caring for a client diagnosed with cardiogenic shock who is receiving a continuous intravenous (IV) infusion of dobutamine through a single-lumen peripheral IV catheter. The healthcare provider prescribes a one-time dose of IV push furosemide to be administered immediately for acute pulmonary edema. Upon checking the institutional compatibility guide, the nurse confirms that dobutamine and furosemide are physically incompatible at the Y-site. Which of the following is the most appropriate action by the nurse?

A $45$-year-old client is recovering in the surgical unit following a subtotal thyroidectomy performed earlier in the day. During afternoon rounding, the nurse observes the client swallowing repeatedly and reporting a sensation of severe tightness in the anterior neck region. The client's heart rate has trended from $78$ to $115$ beats per minute over the past hour. Which action is essential for the nurse to perform immediately to mitigate potential physiological risk?

During morning rounds, a client who underwent a surgical tracheostomy two days prior begins coughing violently, completely expelling the tracheostomy tube. The client immediately exhibits severe stridor, and the pulse oximeter alarms at 81%. Arrange the critical nursing interventions in the correct chronological sequence to manage this acute airway emergency.

A client receiving an initial intravenous dose of ceftriaxone suddenly reports tightness in the throat and severe shortness of breath. The nurse observes facial angioedema and notes a precipitous drop in blood pressure to 82/48 mm Hg. Place the following emergency nursing actions in the correct order of priority, from first to last.

A nurse is assessing a $62$-year-old client who returned to the medical-surgical unit $4$ hours ago following a partial gastrectomy. The client is receiving continuous IV fluids and has a nasogastric tube set to low intermittent suction. Which of the following assessment findings represent early indicators of physiological decompensation requiring immediate intervention? Select all that apply.

A nurse is evaluating an older adult client hospitalized for a severe soft tissue infection. Over the past $4$ hours, the client's mentation has declined from alert to profoundly lethargic.

The current assessment reveals the following parameters:

Arterial blood gas (ABG) values are as follows:

Which of the following is the priority nursing action for this client?

A nurse is caring for an adult client who is 4 hours post-percutaneous coronary intervention (PCI) via the right femoral artery. The client reports a new onset of dull, aching pain in the lower back. Current vital signs reveal a heart rate of 118 bpm, a blood pressure of 102/78 mmHg, and a respiratory rate of 22 breaths/min. The client's baseline vital signs upon arrival to the unit were a heart rate of 76 bpm and a blood pressure of 128/74 mmHg. Which of the following is the priority nursing action?

A nurse in the emergency department is caring for a client with end-stage kidney disease who missed their last two scheduled hemodialysis sessions. The client presents with profound muscle weakness, lethargy, and a heart rate of 52 beats per minute. The cardiac monitor displays widened QRS complexes and peaked T waves. Arterial blood gas (ABG) analysis on room air reveals a pH of 7.29, PaCO2 33 mm Hg, HCO3 15 mEq/L, and PaO2 96 mm Hg. Which of the following immediate interventions should the nurse anticipate? Select all that apply.

A 72-year-old client is recovering in the surgical unit 12 hours after undergoing a right total hip arthroplasty using a posterior surgical approach. The client reports mild discomfort and requests assistance with repositioning. To reduce the risk of a post-operative prosthesis dislocation, which action should the nurse implement?

A nurse is caring for a client admitted with a hypertensive crisis. The healthcare provider prescribes a continuous intravenous (IV) infusion of sodium nitroprusside at $2.5 \text{ mcg/kg/min}$. The client weighs $187 \text{ lbs}$. The pharmacy dispenses an IV 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 infusion pump? (Record answer to the nearest whole number).

A nurse is continuously monitoring a client who was admitted with severe hematemesis due to a suspected bleeding peptic ulcer. Which of the following assessment findings should indicate to the nurse that the client is developing early compensatory hypovolemic shock? Select all that apply.