Physiological Integrity

A nurse is planning care for a client who is receiving continuous total parenteral nutrition (TPN) via a peripherally inserted central catheter (PICC). Which of the following interventions should the nurse include in the client's plan of care? (Select all that apply.)

A nurse is evaluating the condition of a client admitted to the intensive care unit with severe diabetic ketoacidosis (DKA). The client is lethargic and exhibiting deep, rapid respirations. Based on the client's clinical presentation, which of the following arterial blood gas (ABG) values are consistent with the expected acid-base imbalance and physiological compensation? Select all that apply.

A telemetry nurse is called to the room of a client who suffered a comminuted pelvic fracture seventy-two hours prior. The client is suddenly grasping their chest, expressing a severe feeling of doom, and sweating profusely. Assessment reveals a heart rate of $138$ beats per minute, a respiratory rate of $34$ breaths per minute, and a blood pressure of $98/76 \text{ mm Hg}$. Room air pulse oximetry displays an oxygen saturation of $85\%$. The rapid arterial blood gas (ABG) results are as follows: $\text{pH} = 7.53$, $\text{PaCO}_2 = 29 \text{ mm Hg}$, $\text{HCO}_3^- = 24 \text{ mEq/L}$, and $\text{PaO}_2 = 56 \text{ mm Hg}$. Which of the following conclusions accurately reflects this client's current physiological derangement?

A nurse in the emergency department receives a client who sustained full-thickness thermal burns to the face, neck, and anterior chest from a house fire. Arrange the following nursing interventions in the priority order they should be performed. All options must be used.

A laboratory technician urgently reports that a client's serum potassium level is $2.6 \text{ mEq/L}$. The healthcare provider immediately prescribes an intravenous (IV) infusion of $40 \text{ mEq}$ of potassium chloride in $100 \text{ mL}$ of 0.9% sodium chloride to be infused over 30 minutes. Which of the following is the priority nursing action before administering this medication?

A nurse is preparing to initiate a continuous intravenous (IV) infusion of dopamine for a client who weighs $85 \text{ kg}$. The healthcare provider prescribes dopamine to infuse at $5 \text{ mcg/kg/min}$. The available premixed IV solution contains $400 \text{ mg}$ of dopamine in $250 \text{ mL}$ of $5\%$ dextrose in water. How many $\text{mL/hr}$ should the nurse program the infusion pump to deliver? (Record the answer to the nearest whole number).

A client with a closed head injury is being continuously monitored in the neuro-intensive care unit. The nurse suspects the client's intracranial pressure (ICP) is rising to a critical level, initiating the physiological adaptation known as Cushing's triad. Which of the following vital sign trends support this clinical deterioration? (Select all that apply)

A client on the cardiac step-down unit suddenly develops severe dyspnea, audible wheezing, and expectorates pink, frothy sputum. The vital signs monitor shows an oxygen saturation of 84% on room air and a heart rate of 122 beats/min. Arrange the following nursing interventions in the most appropriate sequential order from first to last.

A nurse is caring for an older adult client who is receiving intravenous antibiotics for complicated pyelonephritis. During the mid-shift assessment, the client is restless and mildly confused. The nurse obtains the following vital signs:

Which of the following actions is the priority for the nurse to implement?

A client is admitted to the emergency department with an acute severe asthma exacerbation. Upon admission, the client is extremely restless, tachypneic with a respiratory rate of 34 breaths/min, and exhibiting loud, bilateral expiratory wheezes. The baseline arterial blood gas (ABG) on room air is obtained. Two hours later, after continuous bronchodilator therapy, the client becomes lethargic. The respiratory rate decreases to 14 breaths/min, and breath sounds are significantly diminished with minimal audible wheezing. A repeat ABG is drawn while the client is on a non-rebreather mask. The results are as follows:

Based on these findings, which action should the nurse take first?

A nurse is preparing to perform a routine scheduled dressing change for a client's central venous catheter (CVC). In what order should the nurse perform the following actions? Arrange the steps in the correct chronological sequence.

The nurse is reviewing the status of four clients on a medical-surgical step-down unit. Which client requires the most immediate assessment by the nurse?

A nurse is preparing to administer intermittent intravenous (IV) vancomycin to a client who has a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which of the following actions should the nurse include in the medication administration process? (Select all that apply)

During a shift assessment, the nurse receives a new prescription for 300 mg of phenytoin via intravenous (IV) push for a client with seizure activity. The client has a single peripheral IV access site currently infusing a continuous solution of 5% dextrose in 0.45% sodium chloride at 100 mL/hr. Which method of administration demonstrates the safest practice by the nurse?

A nurse is caring for a client who is 6 hours postoperative following a coronary artery bypass graft (CABG). The nurse notes that the client's mediastinal chest tube drainage has abruptly stopped over the past hour. Which of the following assessment findings indicate the client is developing cardiac tamponade? Select all that apply.

A nurse is evaluating a client who is being managed for septic shock. The client presents with cool, pale extremities, a respiratory rate of 28 breaths/minute, and a serum lactate level of 6.2 mmol/L. Based on this clinical presentation, which arterial blood gas (ABG) result should the nurse anticipate?

A critical care team is managing a client with a severe hypertensive emergency, presenting with a blood pressure of $210/120 \text{ mm Hg}$. Because sodium nitroprusside can cause profound hypotension, it must be administered via a controlled infusion pump. The primary healthcare provider orders a continuous intravenous infusion starting at $4 \text{ mcg/kg/min}$. The medication arrives from the pharmacy as a solution containing $100 \text{ mg}$ of sodium nitroprusside diluted in $100 \text{ mL}$ of normal saline. The client weighs $87 \text{ kg}$.

Calculate the infusion pump rate in $\text{mL/hr}$. Round the final answer to the nearest tenth.

A client admitted with severe sepsis is receiving a continuous intravenous (IV) infusion of norepinephrine through a peripheral IV catheter. The client's current blood pressure is $88/54 \text{ mm Hg}$ and heart rate is $112 \text{ beats/min}$. The healthcare provider prescribes a scheduled dose of IV pantoprazole. After consulting a drug reference, the nurse determines that norepinephrine and pantoprazole are incompatible. Which action should the nurse take?

A nurse is administering a prescribed intravenous medication to a client via an electronic infusion pump. Shortly after the medication is initiated, the client suddenly reports a severe headache, a tight feeling in the chest, and dizziness. The nurse observes intense facial flushing and notes a rapid, irregular pulse. Recognizing these manifestations as speed shock, in what chronological order should the nurse perform the following interventions? Arrange the actions from first to last.

A nurse is receiving shift report for a client with severe Crohn's disease who is malnourished and has just been started on continuous total parenteral nutrition (TPN) via a newly placed peripherally inserted central catheter (PICC). Which of the following nursing interventions should the nurse include in the client's daily plan of care? (Select all that apply.)