Physiological Integrity

A charge nurse is conducting safety rounds on a medical-surgical unit and observes the positioning of several clients. Which client positions increase the risk for physiological complications and require immediate intervention by the nurse? (Select all that apply.)

A nurse is evaluating a client four hours after a percutaneous liver biopsy. The client now reports a new onset of dull right shoulder pain. The nurse reviews the client's vital sign trends:

Which of the following actions should the nurse take first?

A nurse is caring for a client who is receiving a continuous intravenous (IV) infusion of heparin for a deep vein thrombosis. The healthcare provider prescribes a scheduled dose of IV vancomycin to treat a concurrent wound infection. The client currently has a single-lumen peripheral IV catheter. When checking a drug reference guide, the nurse notes that heparin and vancomycin are chemically incompatible. Which action is the most appropriate for the nurse to take?

A nurse is monitoring a client who is receiving a unit of packed red blood cells. Fifteen minutes into the infusion, the client reports sudden, severe lower back pain and a feeling of impending doom. The client's heart rate is 124 beats per minute, blood pressure is 86/52 mm Hg, and the nurse observes dark, reddish-brown urine in the Foley catheter tubing. Arrange the following nursing actions in the correct priority sequence from first to last.

A client who is experiencing frequent seizure activity has a single peripheral intravenous (IV) catheter infusing 5% dextrose in water (D5W) continuously. The healthcare provider prescribes a stat dose of IV phenytoin. Which of the following actions should the nurse perform to safely administer this medication? (Select all that apply)

A 68-year-old client with a history of coronary artery disease and mild chronic obstructive pulmonary disease (COPD) is recovering on the telemetry unit 2 hours after a percutaneous coronary intervention (PCI) via the right femoral artery. The client's baseline vital signs upon admission were blood pressure 138/82 mm Hg and heart rate 72 beats/min. Which assessment finding requires the nurse to intervene immediately?

A trauma client is admitted to the critical care unit with a radiographically confirmed fracture of the C5 vertebra following a motor vehicle collision. During the ongoing physical assessment, the nurse monitors for systemic complications associated with a high cervical cord injury. Which specific clinical presentation most accurately indicates that the client is developing neurogenic shock?

An adult client is receiving treatment for acute necrotizing pancreatitis on the medical-surgical unit. Over the past two hours, the client has become increasingly agitated. Current assessment reveals a heart rate of $122\text{ bpm}$, a blood pressure of $98/80\text{ mm Hg}$, and a respiratory rate of $28\text{ breaths/min}$. Arterial blood gas (ABG) results on room air demonstrate a pH of $7.49$, $\text{PaCO}_2$ of $29\text{ mm Hg}$, $\text{PaO}_2$ of $56\text{ mm Hg}$, and $\text{HCO}_3^-$ of $23\text{ mEq/L}$. Based on these findings, which action should the nurse implement first?

During a routine assessment, a postoperative client reports sudden and severe surgical site pain, rating it a 9 on a 0-to-10 scale. The client currently has an active transfusion of packed red blood cells (PRBCs) infusing through their only established peripheral intravenous (IV) catheter. The provider has prescribed an as-needed dose of intravenous morphine. Which action represents the safest method for the nurse to deliver this analgesic?

A nurse is assessing a client who is two days postoperative following an exploratory laparotomy. The client coughs unexpectedly and reports a sudden "popping" sensation in the abdomen. The nurse inspects the surgical site and observes that a loop of bowel is protruding through the incision. Arrange the following nursing actions in the priority order they should be performed.

Following shift report on a medical-surgical unit, which client condition demands the nurse's immediate evaluation?

A nurse is preparing to administer an intravenous (IV) push medication through a client's established peripheral IV saline lock. Place the following nursing actions in the correct chronological sequence.

A nurse is caring for a client who experienced massive hematemesis secondary to a bleeding peptic ulcer. The bleeding has been medically managed, but the nurse is performing frequent assessments to monitor for hypovolemic shock. Which assessment finding indicates the client is currently in the initial compensatory stage of shock?

A nurse is assessing a client who has just been transferred to the medical-surgical unit following a flexible bronchoscopy with a tissue biopsy. Which of the following assessment findings indicate a potential complication that requires immediate intervention? Select all that apply.

A healthcare provider prescribes a continuous intravenous (IV) infusion of lidocaine at $2\text{ mg/min}$ for a client exhibiting ventricular tachycardia. The pharmacy delivers an infusion bag containing $2\text{ g}$ of lidocaine mixed in $500\text{ mL}$ of $5\%$ dextrose in water ($\text{D}_5\text{W}$). What is the infusion rate in $\text{mL/hr}$ that should be programmed into the IV pump? (Record your answer as a whole number.)

An adult client is recovering on the surgical unit 4 hours after a laparoscopic appendectomy. The client becomes increasingly restless and repeatedly asks for water due to severe thirst. The nurse reviews the client's vital sign trends over the past hour:

Which of the following is the priority nursing action to reduce the risk of further physiological deterioration?

A nurse is caring for a client with acute decompensated heart failure who is experiencing severe dyspnea and pulmonary edema. The healthcare provider prescribes furosemide $80\text{ mg}$ intravenous (IV) push STAT. The medication is supplied in a vial containing $10\text{ mg/mL}$. The client currently has a single peripheral IV line infusing a continuous amiodarone drip. Which of the following actions is most appropriate for the nurse to take?

A client is receiving intravenous antibiotics for acute pyelonephritis. During hourly rounding, the client appears restless and mildly confused. The physical examination reveals warm, flushed skin. Current vital signs demonstrate a blood pressure of $104/62 \text{ mm Hg}$, a heart rate of $114 \text{ bpm}$, a respiratory rate of $28 \text{ breaths/min}$, and a temperature of $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$). Based on this early stage of physiological decompensation, which of the following arterial blood gas (ABG) profiles is most likely present?

A client receiving intravenous fluids via a central venous catheter suddenly develops severe shortness of breath, chest pain, and lightheadedness. The nurse notes that the catheter's injection cap has fallen off and the lumen is open to room air. Suspecting an air embolism, in what order should the nurse perform the following actions to reduce the risk of further physiological compromise? Arrange the interventions from first to last.

A client is admitted to the emergency department with a diagnosis of severe diabetic ketoacidosis (DKA). The client is lethargic, has a respiratory rate of $32$ breaths/minute with deep, rapid breathing, and a blood glucose level of $680$ mg/dL ($37.7$ mmol/L). Arrange the following nursing actions in the correct priority order of implementation.