Physiological Integrity

A nurse is caring for a client who returned to the telemetry unit 1 hour ago following a diagnostic cardiac catheterization via the right femoral artery. Which of the following interventions should the nurse include in the client's immediate plan of care? Select all that apply.

A nurse is reviewing medication orders for a client admitted with hypokalemia. The healthcare provider has prescribed 40 mEq of intravenous (IV) potassium chloride (KCl) mixed in 100 mL of 0.9% sodium chloride to be infused over 1 hour via a peripheral IV catheter. Which of the following is the priority nursing action?

A 58-year-old client is admitted with a severe acute asthma exacerbation. The client is diaphoretic, restless, and using accessory muscles to breathe. The nurse reviews two sets of arterial blood gas (ABG) results drawn two hours apart on room air:

Initial ABG: pH 7.51, PaCO2 28 mm Hg, PaO2 74 mm Hg
Current ABG: pH 7.37, PaCO2 44 mm Hg, PaO2 59 mm Hg

Based on these clinical findings and the ABG trend, which action should the nurse anticipate immediately to reduce the risk of a severe physiological complication?

A nurse is caring for a client admitted with severe acute pancreatitis who is receiving continuous intravenous normal saline at 100 mL/hr. The nurse reviews the client's vital signs and hourly urine output over the past four hours:

At 12:00, the client's arterial blood gas (ABG) results on room air are: pH 7.38, $\text{PaCO}_2$ 33 mmHg, $\text{HCO}_3^-$ 19 mEq/L, and $\text{PaO}_2$ 86 mmHg. Based on these findings, which of the following is the priority nursing action?

A nurse is caring for a client who is 3 days postoperative following an open exploratory laparotomy. The client coughs forcefully and reports a sudden "giving way" sensation in the abdomen. The nurse inspects the surgical site and observes that the incision has separated and a portion of the bowel is protruding. In what order should the nurse perform the following actions? Arrange the actions from first to last.

A client in the intensive care unit is receiving a continuous intravenous (IV) infusion of sodium bicarbonate to treat severe metabolic acidosis. During the infusion, the nurse observes that the client has developed muscle cramping and a positive Trousseau's sign. The healthcare provider prescribes a dose of calcium gluconate via intravenous piggyback (IVPB). The client currently has a single-lumen peripherally inserted central catheter (PICC) in the right arm. Which of the following actions is the most appropriate for the nurse to take?

A nurse is evaluating a client who is two days postoperative following an exploratory laparotomy. The client suddenly reports a 'popping' sensation in the abdomen after a forceful cough. Upon inspection, the nurse observes that the surgical incision has separated and loops of bowel are protruding. In what order should the nurse perform the following interventions? (Arrange the actions from first to last)

A nurse is managing the care of a client who is receiving a continuous intravenous (IV) infusion of unfractionated heparin for the treatment of a pulmonary embolism. Which of the following actions should the nurse take to ensure the safe administration and monitoring of this parenteral therapy? Select all that apply.

A client is admitted to the emergency department following blunt abdominal trauma from a motor vehicle collision. The nurse is closely monitoring the client for suspected internal hemorrhage. Which of the following assessment findings is the earliest physiological indicator that the client is developing hypovolemic shock?

A nurse is planning care for a client who was admitted to the intensive care unit $1$ hour ago following a left-sided pneumonectomy. Which of the following interventions should the nurse implement to minimize the risk of potential complications? Select all that apply.

A nurse is caring for a client with a single-lumen peripheral intravenous (IV) catheter infusing $5\%$ dextrose in water (D5W) at $100\text{ mL/hr}$. The healthcare provider prescribes a STAT dose of IV push haloperidol for severe agitation. The nurse consults a drug compatibility database and notes that haloperidol is physically incompatible with D5W. Which of the following actions should the nurse take to safely administer the medication?

While managing the care of a client with a severe traumatic brain injury and continuously elevated intracranial pressure (ICP), a nurse prepares to reposition the client. Which positioning strategy is indicated to mitigate the risk of further intracranial pressure elevation?

During continuous monitoring of an individual experiencing a severe asthma exacerbation, the nurse notes prominent accessory muscle use, diaphoresis, and a respiratory rate of $32$ breaths per minute. A recent assessment of lung sounds indicates a marked reduction in bilateral wheezing compared to baseline. The concurrent arterial blood gas (ABG) panel on room air yields a pH of $7.39$, a $\text{PaCO}_2$ of $41\text{ mm Hg}$, and a $\text{PaO}_2$ of $58\text{ mm Hg}$. What is the priority nursing intervention in this scenario?

A nurse is preparing to administer a prescribed intravenous (IV) push medication through a client's central venous catheter (CVC). The specific lumen to be used is currently capped and locked with a heparin solution. Place the following steps for administering the medication in the correct chronological order.

A client admitted with an acute upper gastrointestinal bleed is receiving an infusion of packed red blood cells (PRBCs) through a single-lumen peripheral intravenous catheter. The healthcare provider issues a stat prescription for intravenous pantoprazole to help control the bleeding. What is the most appropriate nursing action for administering the pantoprazole?

A nurse is caring for a client who is two days postoperative following a right total knee arthroplasty. The client suddenly reports sharp, pleuritic chest pain, severe shortness of breath, and a feeling of impending doom. The client appears diaphoretic and highly agitated. Arrange the following nursing actions in the priority order they should be performed. (Place the first action at the top and the last action at the bottom.)

A nurse receives the shift report on four clients admitted to a medical-surgical unit. Which client should the nurse assess first?

A nurse is caring for a pediatric client who weighs $22\text{ kg}$. The healthcare provider has prescribed intravenous ceftriaxone $50\text{ mg/kg/day}$ divided into two equal doses. The pharmacy dispenses a ceftriaxone vial reconstituted to a concentration of $1\text{ g}$ per $10\text{ mL}$. How many milliliters ($\text{mL}$) should the nurse administer for a single dose? Record your answer to one decimal place.

A client is receiving a continuous intravenous heparin infusion for a deep vein thrombosis. The nurse suspects the client may be experiencing covert internal bleeding leading to early hypovolemic shock. Which clinical manifestations support this physiological adaptation? (Select all that apply)

During the afternoon clinical rounds, the nurse evaluates a client recently admitted with severe acute pancreatitis. The nurse reviews the latest diagnostic data and physical assessment findings. Which specific observations indicate the onset of physiological decompensation requiring immediate medical intervention? Select all that apply.