Physiological Integrity

During a routine shift, a nurse is assigned to a client who requires both nutritional support and antimicrobial therapy. The client currently has total parenteral nutrition (TPN) infusing continuously via a dedicated port of a multi-lumen central venous catheter. A new order is placed for an intermittent infusion of intravenous azithromycin. What is the safest method for the nurse to deliver the newly prescribed medication?

A client with hepatic cirrhosis has just returned to the medical-surgical unit following a percutaneous liver biopsy. The client is awake, alert, and reports mild tenderness at the biopsy site. To reduce the risk of the most significant immediate complication, which action is the priority for the nurse to implement?

A nurse is caring for a client who was admitted 12 hours ago with a pelvic fracture following a fall. The client is currently restless, frequently shifting in bed, and repeatedly asking for something to drink. The most recent vital signs reveal a blood pressure of 114/82 mm Hg, a heart rate of 118 beats/minute, and a respiratory rate of 24 breaths/minute. The client's admission heart rate was 84 beats/minute. Which of the following actions should the nurse take first?

Ten minutes after the initiation of an intravenous (IV) piperacillin-tazobactam infusion, a client develops audible inspiratory stridor, restlessness, and lightheadedness. The client's heart rate is $128\text{ bpm}$ and blood pressure is $84/50\text{ mmHg}$. Which of the following priority actions should the nurse implement? Select all that apply.

A nurse is preparing to discontinue a client's non-tunneled central venous catheter (CVC) from the internal jugular vein. In what order should the nurse perform the following actions to minimize the risk of complications? Arrange the steps in the correct sequence from first to last.

A nurse is caring for a client who is receiving a transfusion of packed red blood cells (PRBCs). Fifteen minutes into the transfusion, the client reports severe lower back pain, chills, and shortness of breath. Arrange the following nursing actions in the correct order of priority from first to last.

A nurse is assessing a client with diabetic ketoacidosis (DKA) who is receiving a continuous intravenous regular insulin infusion. The client is lethargic and has deep, rapid respirations at $28$ breaths/min. The most recent arterial blood gas (ABG) results are: pH $7.29$, PaCO $_2$ $30$ mm Hg, PaO $_2$ $94$ mm Hg, and HCO $_3^-$ $15$ mEq/L. Which of the following is the most appropriate action by the nurse?

A nurse is evaluating a client with acute kidney injury who is receiving a prescribed continuous intravenous infusion of regular insulin and 50% dextrose in water. To minimize the risk of a severe physiological complication, which of the following assessment findings demands the most immediate intervention by the nurse?

A client admitted with bacterial cellulitis is receiving a continuous primary infusion of normal saline at $125\text{ mL/hr}$. The nurse is ready to initiate a scheduled dose of intravenous ampicillin-sulbactam via a secondary piggyback line. Arrange the following steps in the correct order to safely set up the secondary infusion.

An emergency department nurse evaluates an older adult client brought in from a long-term care facility with altered mental status and a new-onset productive cough. Initial assessment reveals a blood pressure of 86/48 mm Hg, an apical pulse of 124 beats/min, and a respiratory rate of 26 breaths/min. The client's skin is warm and flushed. Serum laboratory results indicate a white blood cell count of 19,000/mm³ and a serum lactate level of 4.5 mmol/L. Which of the following priority actions should the nurse anticipate incorporating into the immediate plan of care? (Select all that apply)

A nurse is planning care for a client who is 6 hours post-operative following an exploratory laparotomy. Which of the following nursing actions are appropriate to reduce the risk of potential complications? (Select all that apply.)

A client with new-onset seizures is scheduled to receive a loading dose of intravenous (IV) phenytoin. The client currently has a continuous IV infusion of $5\%$ dextrose in water (D5W) running at $50\text{ mL/hr}$ through a single peripheral IV catheter. Which action should the nurse take to administer the phenytoin safely?

A nurse is monitoring a client who was admitted with severe acute pancreatitis. During the most recent assessment, the nurse notes the client is newly restless and reports intense thirst. Comparing the current vital signs to the baseline from four hours ago, the blood pressure has changed from 132/78 mm Hg to 116/94 mm Hg, the heart rate has increased from 84 to 118 beats per minute, and the respiratory rate has increased from 16 to 26 breaths per minute. Which conclusion should the nurse draw from these clinical findings?

A nurse in the intensive care unit is preparing to initiate a continuous intravenous (IV) infusion of norepinephrine for a client experiencing severe hypotension. The prescribed dose is $0.06\text{ mcg/kg/min}$. The client weighs $78\text{ kg}$. The pharmacy provides a prediluted IV bag containing $8\text{ mg}$ of norepinephrine in $250\text{ mL}$ of $5\%$ dextrose in water ($D_5W$).

At what rate, in $\text{mL/hr}$, should the nurse program the infusion pump? (Record your answer using one decimal place.)

A nurse is evaluating a 54-year-old client who is 4 hours post-operative following a right partial nephrectomy for renal cell carcinoma. The client's baseline vital signs upon arrival to the surgical unit were: blood pressure 128/74 mm Hg, heart rate 76 beats/min, and respiratory rate 16 breaths/min. Which of the following assessment findings is the EARLIEST indicator that the client is developing hemorrhagic shock?

A nurse is caring for a client who is receiving a packed red blood cell (PRBC) transfusion. Fifteen minutes after the transfusion begins, the client reports severe lower back pain, shortness of breath, and chills. Arrange the following nursing actions in the correct priority order from first to last.

A nurse is caring for a client with a spinal cord injury at the T4 level. The client suddenly reports a severe, pounding headache and blurred vision. The nurse notes profuse diaphoresis and flushing above the level of the injury. The client's blood pressure is 210/115 mm Hg, and the heart rate is 52 beats/min. Arrange the following nursing actions in the correct priority order.

A client admitted with ventricular tachycardia is receiving a continuous intravenous (IV) infusion of amiodarone through a dedicated peripheral line. The healthcare provider prescribes a STAT dose of IV furosemide to treat a sudden onset of pulmonary edema. The nurse notes in the facility's drug reference guide that furosemide and amiodarone are incompatible at the Y-site. Which action should the nurse take?

A nurse is preparing to administer a unit of packed red blood cells (PRBCs) to an adult client with symptomatic anemia. Which of the following interventions should the nurse implement to ensure safe administration? Select all that apply.

A nurse is caring for a client who has been receiving continuous nasogastric (NG) tube suctioning for three days to treat a paralytic ileus. The client's most recent arterial blood gas (ABG) values are: $\text{pH} = 7.53$, $\text{PaCO}_2 = 47 \text{ mm Hg}$, and $\text{HCO}_3^- = 33 \text{ mEq/L}$. Which clinical manifestation is a direct physiological consequence of the client's current acid-base imbalance?