Physiological Integrity

A nurse is caring for an older adult client who underwent a right total hip arthroplasty 12 hours ago. During the assessment, the nurse notes the client is increasingly restless and confused. Vital parameters are: heart rate 118 beats per minute, blood pressure 92/60 mm Hg, and respiratory rate 28 breaths per minute. A point-of-care arterial blood sample reveals a pH of 7.28, PaCO2 of 56 mm Hg, and HCO3- of 24 mEq/L. Which initial action should the nurse take to minimize the risk of further clinical deterioration?

An emergency department nurse is managing the care of a client who presents with suspected septic shock secondary to pneumonia. Initial vital signs include a blood pressure of 88/54 mmHg, heart rate of 112 beats/min, respiratory rate of 22 breaths/min, and an oral temperature of 39.1 °C (102.4 °F). A peripheral intravenous (IV) line is currently infusing 0.9% sodium chloride. After reviewing the newly prescribed parenteral therapies, which of the following actions indicate safe pharmacological practice? Select all that apply.

A nurse is caring for a client with a T3 spinal cord injury who suddenly reports a severe, throbbing headache. The client presents with facial erythema, diaphoresis above the level of the lesion, and a blood pressure of 215/115 mmHg. Arrange the following nursing actions in the correct priority sequence from first to last.

An emergency department nurse is evaluating a client with type 1 diabetes mellitus who was brought in with pronounced weakness, altered mental status, and a two-day history of a gastrointestinal viral infection. The client's initial arterial blood gas (ABG) analysis reveals a pH of 7.22, PaCO2 of 28 mm Hg, and HCO3 of 13 mEq/L. Based on these physiological parameters and the suspected underlying condition, which of the following assessment findings should the nurse expect? (Select all that apply.)

During the management of a client with diabetic ketoacidosis, a continuous intravenous infusion of regular insulin is running via a dedicated peripheral catheter. A new prescription for an intermittent intravenous antibiotic must be initiated promptly. The drug reference manual indicates that this specific antibiotic is physically incompatible with regular insulin. Which intervention ensures safe parenteral administration?

A client is receiving treatment in the emergency department for a severe asthma exacerbation. The client's initial presentation included marked restlessness, a respiratory rate of 34 breaths/min, and an arterial blood gas (ABG) revealing a pH of 7.49 and a PaCO₂ of 27 mm Hg. After two hours of therapy, the nurse observes that the client has become profoundly lethargic and the respiratory rate has decreased to 14 breaths/min. A follow-up ABG shows a pH of 7.28 and a PaCO₂ of 62 mm Hg. Which of the following is the priority nursing action?

A nurse is preparing to draw a diagnostic blood specimen from a client's central venous catheter (CVC) using the syringe method. Arrange the following actions in the correct procedural sequence. All options must be used.

A client is receiving continuous bladder irrigation (CBI) following a transurethral resection of the prostate (TURP). The client suddenly reports severe lower abdominal cramping, and the nurse observes that the outflow drainage has significantly decreased. Arrange the following nursing actions in the correct priority sequence to manage this complication.

A client admitted with acute decompensated heart failure requires hemodynamic support. The prescribed treatment plan includes dobutamine to be administered at $7.5 \text{ mcg/kg/min}$. The client's current weight is $198 \text{ lbs}$. The medication is supplied as $500 \text{ mg}$ of dobutamine mixed in $250 \text{ mL}$ of $5\% \text{ dextrose in water}$ ($D_5W$). What is the required infusion pump rate in $\text{mL/hr}$? (Round the final answer to the nearest tenth.)

A nurse evaluates a client four hours after a subtotal thyroidectomy. Which assessment findings indicate a developing physiological complication that requires immediate intervention? Select all that apply.

A client admitted with an active upper gastrointestinal bleed is receiving a continuous intravenous (IV) infusion of pantoprazole. The healthcare provider prescribes a scheduled dose of IV ciprofloxacin for a concurrent urinary tract infection. The client has a single peripheral IV catheter. The nurse consults the facility's drug compatibility reference and notes that pantoprazole and ciprofloxacin are physically incompatible. Which action by the nurse is the most appropriate?

A nurse is preparing to administer a prescribed intravenous (IV) push medication through a client's dedicated peripheral IV line, which currently has a continuous infusion of 5% dextrose in water (D5W) running. Which of the following actions must the nurse take to ensure safe medication administration? Select all that apply.

During a routine assessment on a medical-surgical unit, a nurse evaluates a client who is 15 minutes into a transfusion of packed red blood cells (PRBCs). The client suddenly reports severe flank pain, chills, and an impending sense of doom. Vital signs reveal a temperature of 38.8°C (101.8°F) and a blood pressure of 88/50 mm Hg. The nurse immediately stops the transfusion. Which of the following actions should the nurse take next?

Following a closed reduction and synthetic cast application for a fractured right tibia, a 35-year-old client is admitted to the orthopedic unit. Several hours into the shift, the client complains of a deep, relentless ache in the right calf that remains severe despite receiving a recent dose of intravenous hydromorphone. Assessment reveals a heart rate of 110 beats/min, blood pressure of 142/88 mm Hg, and sluggish capillary refill in the right toes. Which intervention must the nurse execute promptly to prevent a limb-threatening complication?

During bedside handoff on a progressive care unit, a client who sustained an anterior myocardial infarction the previous day becomes extremely restless. The assessment reveals pale, diaphoretic skin and a weak radial pulse of 118 beats per minute. The current blood pressure measurement is 84/60 mm Hg, and the client's urine output has been 15 mL over the last hour. Which action is the priority for this client?

A nurse is caring for a client who is receiving intravenous fluids via a central venous catheter. The nurse notices that the IV tubing has accidentally disconnected from the catheter hub. The client suddenly reports severe shortness of breath and exhibits cyanosis, tachycardia, and a loud, churning murmur over the precordium. Suspecting an air embolism, arrange the following nursing actions in the priority order they should be performed, from first to last.

A client admitted with a deep vein thrombosis is prescribed a continuous intravenous (IV) infusion of heparin. The client weighs $209 \text{ lbs}$. The prescribed protocol dictates an initial infusion rate of $18 \text{ units/kg/hr}$. The pharmacy supplies a premixed IV bag containing $25,000 \text{ units}$ of heparin in $250 \text{ mL}$ of $0.45\%$ sodium chloride. At what rate in mL/hr should the nurse program the infusion pump? Record your answer to one decimal place.

A client hospitalized with acute heart failure exacerbation and severe pulmonary congestion receives a stat prescription for 80 mg of intravenous furosemide. The pharmacy provides the medication in vials with a concentration of 10 mg/mL. To prevent a known irreversible sensory complication associated with this therapy, which administration technique should be utilized?

A nurse is caring for a client who underwent a partial bowel resection 12 hours ago. The client's baseline vital signs were temperature 37.0°C (98.6°F), heart rate 78 beats/min, respiratory rate 14 breaths/min, and blood pressure 124/76 mm Hg. Which of the following new assessment findings should the nurse identify as the earliest indicator that the client is developing hypovolemic shock?

A nurse is assessing a client who is 3 days postoperative following an abdominal laparotomy. The client coughs forcefully and suddenly states, "I feel like something just popped open." The nurse inspects the surgical site and observes a loop of bowel protruding through the incision. Arrange the following nursing actions in the correct priority order from first to last.