Physiological Integrity

A nurse in a neurology unit is developing a plan of care for a client who is scheduled for a lumbar puncture to rule out meningitis. To reduce the risk of procedural and post-procedural complications, which of the following actions should the nurse include? Select all that apply.

A client admitted with severe dehydration and hypokalemia has a prescription for an intravenous (IV) infusion of 40 mEq of potassium chloride (KCl) mixed in 1000 mL of 0.9% sodium chloride. Which action is essential for the nurse to perform when administering this parenteral therapy?

A nurse is caring for a client who sustained deep partial-thickness and full-thickness burns over 45% of their total body surface area (TBSA) 8 hours ago. Based on the physiological adaptations occurring during this emergent (resuscitative) phase, which of the following assessment findings should the nurse expect? Select all that apply.

A nurse is reviewing diagnostic data for a 72-year-old client admitted with a severe exacerbation of chronic obstructive pulmonary disease (COPD). The client is currently receiving continuous oxygen therapy. Which of the following arterial blood gas (ABG) results represents an acute physiological decompensation that requires the most immediate intervention by the nurse?

An adult client who underwent an open reduction and internal fixation of the right femur 48 hours ago suddenly develops extreme restlessness and shortness of breath. The nurse assesses the client and records the following vital signs: temperature 37.4°C (99.3°F), heart rate 126 beats/min, respirations 32 breaths/min, and blood pressure 114/72 mm Hg. The oxygen saturation is 85% on room air. A stat arterial blood gas (ABG) reveals a pH of 7.52, PaCO2 of 28 mm Hg, PaO2 of 53 mm Hg, and HCO3- of 23 mEq/L. Based on these findings, what is the priority nursing action?

A nurse is preparing to perform a sterile dressing change on a client's central venous catheter (CVC). To reduce the risk of a central line-associated bloodstream infection (CLABSI) and prevent catheter dislodgment, place the following steps in the correct chronological order.

During a routine intravenous (IV) tubing change for a client's central venous catheter (CVC), the catheter hub accidentally becomes disconnected and is left open to room air. The client abruptly gasps for breath, begins coughing violently, and reports acute, sharp chest pain. The client's lips appear cyanotic and oxygen saturation drops to 81%. What is the priority nursing action?

During afternoon rounds on a surgical unit, a client who had a partial colectomy two days ago reports feeling increasingly restless and unable to get comfortable. The assessment reveals a temperature of 98.4°F (36.9°C), a heart rate of 114 beats per minute, a blood pressure of 104/84 mm Hg, and a respiratory rate of 22 breaths per minute. The client's skin is cool to the touch and peripheral pulses are weak. Which of the following is the priority nursing action?

A nurse is preparing to administer prescribed intravenous (IV) push ondansetron to a client experiencing postoperative nausea. The client has a dedicated peripheral IV saline lock in place. Arrange the following actions in the correct sequence for safe administration.

A nurse is caring for a client admitted with an exacerbation of heart failure. The client suddenly develops severe dyspnea, extreme anxiety, and begins coughing up pink, frothy sputum. Arrange the following nursing actions in the priority order they should be performed.

A nurse is caring for a client who is receiving continuous total parenteral nutrition (TPN) through a dedicated lumen of a multi-lumen central venous catheter (CVC). The healthcare provider prescribes a scheduled dose of an intravenous (IV) antibiotic. Which of the following actions is the most appropriate for the nurse to take when administering the medication?

A nurse is preparing to perform open-system suctioning for a client with a tracheostomy tube. To reduce the risk of hypoxia and mucosal trauma, in which order should the nurse perform the following actions? Arrange the steps in the correct sequence from first to last.

An emergency department triage nurse assesses a young adult who sustained blunt abdominal trauma after striking a bicycle handlebar. Over the past 45 minutes, the client's heart rate has trended from 86 to 116 beats per minute, and their blood pressure has shifted from 120/72 mm Hg to 108/86 mm Hg. Based on these physiological changes, what is the priority nursing action?

A nurse is assessing a client who is 2 hours post-cardiac catheterization via the right femoral artery. Which assessment finding is the priority and requires immediate intervention to reduce the risk of a severe complication?

A client on an orthopedic unit is three days postoperative following a unilateral knee replacement. The client suddenly reports sharp, localized chest pain upon inspiration accompanied by a feeling of impending doom. Current vital signs reveal a respiratory rate of 32 breaths per minute and an oxygen saturation of 85% on room air. Which of the following concurrent nursing actions are appropriate? Select all that apply.

Upon evaluating a client recovering from an extensive small bowel resection, the assigned nurse notes a scheduled order for intravenous pantoprazole. The client's only vascular access is a single-lumen peripherally inserted central catheter (PICC) that is currently delivering total parenteral nutrition (TPN) at 90 mL/hr. How should the nurse proceed with administering the prescribed gastrointestinal protectant?

A nurse is evaluating a client who is $1$ hour post-percutaneous liver biopsy. The nurse is monitoring the client to reduce the risk of potential complications. Which of the following assessment findings or client actions require IMMEDIATE nursing intervention? (Select all that apply.)

While monitoring a client receiving an initial unit of packed red blood cells, the nurse notes that 15 minutes into the infusion, the client abruptly reports severe lower back pain, chills, and a sensation of shortness of breath. The client's vital signs reveal a blood pressure of 90/60 mmHg, a heart rate of 116/min, a respiratory rate of 24/min, and a temperature of 101.2°F (38.4°C). Arrange the following nursing actions in the correct order of priority.

A nurse is managing the parenteral therapies for several clients on a medical-surgical unit. Which of the following nursing actions indicate safe and appropriate practice? (Select all that apply.)

A client with a mechanical small bowel obstruction has been on low continuous nasogastric (NG) wall suction for the past $48$ hours. The client begins to report numbness and tingling around the mouth and muscle cramping in the calves. Morning arterial blood gas (ABG) results are: pH $7.51$, PaCO $_2$ $43$ mm Hg, HCO $_3^-$ $32$ mEq/L. To reduce the risk of a severe complication associated with these findings, which focused assessment should the nurse perform next?