Physiological Integrity

A nurse is caring for a client who has a multi-lumen central venous catheter and is receiving multiple continuous intravenous (IV) therapies, including total parenteral nutrition (TPN). Which of the following actions by the nurse demonstrate correct application of parenteral therapy safety principles? Select all that apply.

A nurse is evaluating the arterial blood gas (ABG) results of a client with severe hyperemesis gravidarum who has experienced intractable vomiting for the past 48 hours. The client appears lethargic, and the respiratory rate is currently 10 breaths per minute. To accurately assess the client's risk for physiological decompensation, which ABG pattern should the nurse anticipate?

A client with a pulmonary embolism is receiving a continuous intravenous (IV) heparin infusion at $1,200\text{ units/hr}$. The pharmacy provides heparin as $25,000\text{ units}$ mixed in $250\text{ mL}$ of $5\%$ dextrose in water ($D_5W$). The client's morning activated partial thromboplastin time (aPTT) is $120\text{ seconds}$ (normal control: $30\text{ seconds}$). The healthcare provider orders the nurse to hold the infusion for 1 hour and then decrease the dose by $200\text{ units/hr}$. Which of the following actions should the nurse take regarding this client's parenteral therapy?

An assigned nurse is preparing to initiate an intermittent intravenous (IV) piggyback antibiotic for a patient receiving a continuous primary infusion of $0.9\%$ sodium chloride. The primary line is controlled by an electronic infusion device. After performing hand hygiene and verifying medication rights, how should the nurse sequence the setup steps?

While providing care for an individual hospitalized with a severe renal infection, the nurse notes a sudden increase in restlessness. Assessment reveals that the client's skin is unexpectedly warm and visibly flushed. Vital signs show a temperature of $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), a heart rate of $124$ beats/minute, a respiratory rate of $26$ breaths/minute, and a blood pressure of $84/48$ mm Hg. The previous blood pressure recorded two hours ago was $116/72$ mm Hg. Which intervention must the nurse execute immediately?

A nurse is caring for a client who underwent a left-sided partial nephrectomy four hours ago. Over the past two hours, the client's heart rate has increased from 84 to 110 beats per minute, blood pressure has narrowed from 134/76 to 108/82 mm Hg, and urine output has decreased to 20 mL over the last hour. The client reports mild incisional pain. Which action should the nurse perform next?

An adult client with advanced hepatic cirrhosis has just been transferred back to the medical-surgical unit after a therapeutic paracentesis that removed 4.5 liters of ascitic fluid. To minimize the risk of severe physiological decompensation, which of the following nursing actions should be included in the client's immediate plan of care? Select all that apply.

A nurse is caring for a client who is receiving a continuous infusion of Total Parenteral Nutrition (TPN) through a dedicated single-lumen peripherally inserted central catheter (PICC). The healthcare provider prescribes a stat dose of intravenous ceftriaxone to treat a newly diagnosed infection. The client currently has no other intravenous access. Which of the following actions should the nurse take?

A client admitted with cardiogenic shock requires hemodynamic support. The primary healthcare provider orders a dopamine infusion at a rate of $5\text{ mcg/kg/min}$. The client weighs $85\text{ kg}$. The pharmacy dispenses a premixed intravenous bag containing dopamine $400\text{ mg}$ in $250\text{ mL}$ of $5\%$ dextrose in water (D5W).

At what rate should the electronic infusion pump be programmed? (Round the final answer to the nearest tenth.)

An orthopedic unit nurse is caring for a client who sustained a long bone fracture of the right leg yesterday. The client abruptly exhibits extreme restlessness and complains of shortness of breath. The nurse observes new-onset pinpoint red spots on the client's upper chest. The vital signs show a heart rate of 122 beats/min and a respiratory rate of 34 breaths/min. An arterial blood gas (ABG) analysis reveals $pH = 7.52$, $\text{PaCO}_2 = 26 \text{ mm Hg}$, and $\text{PaO}_2 = 52 \text{ mm Hg}$. Which intervention should the nurse implement first?

A client is resting in a medical-surgical bed two hours after undergoing a percutaneous liver biopsy. Upon responding to the call light, the nurse finds the client reporting a sudden increase in right upper quadrant pain. Which of the following assessment findings strongly suggest the client is developing early compensatory hemorrhagic shock? (Select all that apply.)

A nurse is establishing a plan of care for a client who has just returned to the medical-surgical unit following a percutaneous liver biopsy. To minimize the client's risk of severe post-procedure complications, which of the following actions should the nurse include in the plan?

While monitoring a client undergoing a packed red blood cell (PRBC) transfusion, the nurse observes the client suddenly shivering. The client reports intense bilateral flank pain and dyspnea. Current vital signs indicate a temperature of $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), a heart rate of $122\text{ beats/min}$, and a blood pressure of $86/52\text{ mmHg}$. After immediately halting the transfusion, what is the nurse's next priority action?

A nurse is preparing to administer intravenous (IV) phenytoin to a client who recently experienced status epilepticus. Which actions should the nurse include in the plan of care to ensure safe parenteral administration? (Select all that apply.)

Following change-of-shift report on a medical-surgical step-down unit, which of the following assigned clients must the nurse assess first?

A client admitted with atrial fibrillation with rapid ventricular response is receiving a continuous intravenous infusion of diltiazem. The healthcare provider prescribes an intermittent intravenous infusion of piperacillin-tazobactam for a respiratory tract infection. The client currently has a single peripheral intravenous catheter. Which action should the nurse take first?

A 68-year-old client with a history of severe chronic obstructive pulmonary disease (COPD) is admitted for an acute exacerbation. The nurse notes that the client has become increasingly lethargic over the past hour. The most recent arterial blood gas (ABG) results reveal a pH of 7.26, a $PaCO_2$ of 68 mm Hg, and an $HCO_3^-$ of 25 mEq/L. To minimize the risk of respiratory arrest, which of the following actions should the nurse take first?

A nurse is caring for a client with a T4 spinal cord injury who suddenly complains of a severe, throbbing headache. The nurse notes profuse diaphoresis above the level of the injury, flushing of the skin, and a blood pressure of 210/115 mmHg. Arrange the following nursing interventions in the correct order of priority from first to last.

A nurse is preparing to withdraw a prescribed parenteral medication from a glass ampule. Arrange the following actions in the correct chronological order to ensure safe preparation. All options must be used.

A client who underwent a total colectomy with a newly placed ileostomy three days ago has had 1,800 mL of liquid stool output over the past 8 hours. The client reports dizziness upon sitting up and severe muscle cramps. Assessment reveals a heart rate of 122 bpm, a supine blood pressure of 86/54 mm Hg, and a respiratory rate of 24 breaths/minute. An arterial blood gas (ABG) analysis shows a pH of 7.22, PaCO2 of 38 mm Hg, and HCO3 of 15 mEq/L. Which conclusion by the nurse represents the most accurate interpretation of this client's physiological status?