Physiological Integrity

A nurse is caring for a client who is receiving intravenous fluids through a central venous catheter. The client suddenly develops severe dyspnea, chest pain, and a feeling of impending doom. The nurse suspects a central line-associated air embolism. In what order should the nurse take the following actions to reduce the risk of a life-threatening complication? Arrange the steps from first to last.

A client with end-stage renal disease misses two dialysis sessions and presents to the emergency department with profound muscle weakness. The initial serum potassium level is $7.6\text{ mEq/L}$ ($7.6\text{ mmol/L}$), and the 12-lead electrocardiogram (ECG) reveals absent P waves, a widened QRS complex, and tall, peaked T waves. The healthcare provider prescribes several emergency interventions. Arrange the following nursing actions in the correct priority order from first to last.

A medical-surgical nurse is monitoring a client who is undergoing conservative management for severe acute pancreatitis. The client is increasingly restless and reports persistent, agonizing pain in the left upper quadrant. Which subsequent assessment finding represents the highest priority and warrants immediate provider notification?

A client receiving care on an oncology unit has a newly inserted multi-lumen central venous catheter (CVC) for the administration of chemotherapy and total parenteral nutrition. The nurse is preparing to administer several prescribed intravenous medications. Which of the following actions indicate correct understanding of central line and parenteral therapy safety? Select all that apply.

A nurse is preparing to discontinue a non-tunneled central venous catheter (CVC) located in the right subclavian vein of a 68-year-old client who has completed a course of intravenous antibiotics for osteomyelitis. To strictly reduce the risk of a life-threatening physiological complication during this procedure, in what order should the nurse perform the following actions? Arrange the steps from first to last.

A nurse is assessing a client who was admitted 6 hours ago with severe acute pancreatitis. The client has become increasingly restless. Which of the following assessment findings indicate severe physiological decompensation requiring immediate intervention? Select all that apply.

A nurse is preparing to administer an intermittent intravenous (IV) piggyback medication using the backpriming method through an existing continuous primary IV infusion. Assuming hand hygiene and medication verification have been completed, place the following steps in the correct sequence for setting up the IV piggyback.

A nurse is conducting serial assessments on a client who sustained blunt abdominal trauma three hours ago. The client's initial vital signs and physical assessments were within normal limits. Based on the understanding of hemodynamic compensatory mechanisms, which of the following physiological changes should the nurse identify as the earliest indicator that the client is developing hemorrhagic shock?

Following a percutaneous liver biopsy, a client rests on their right side. As the nurse monitors the client for potential complications, which vital sign change provides the earliest indication of internal hemorrhage?

A nurse is caring for a client who recently experienced a right-hemisphere ischemic stroke. The client has developed left-sided hemiplegia, left homonymous hemianopsia, and mild dysphagia. Which of the following basic care interventions should the nurse implement during mealtime?

While conducting hourly rounds on a surgical unit, a nurse encounters a client who is two days post-operative from an open bowel resection. The client is extremely restless, clutching their chest, and gasping for air. The bedside monitor displays a heart rate of 124 beats/minute, a respiratory rate of 32 breaths/minute, a blood pressure of 90/62 mm Hg, and an oxygen saturation of 84% on room air. The rapid response team is activated, and immediate arterial blood gas (ABG) results show a pH of 7.52, PaCO2 of 28 mm Hg, PaO2 of 54 mm Hg, and HCO3 of 23 mEq/L. Which of the following actions should the nurse execute first to mitigate the risk of cardiopulmonary arrest?

A nurse is managing the care of a client admitted with diabetic ketoacidosis. The client is receiving a continuous intravenous (IV) infusion of regular insulin through a single peripheral IV catheter. The healthcare provider prescribes an intermittent IV infusion of a broad-spectrum antibiotic for a concurrent infection. The nurse consults a drug compatibility reference and discovers the antibiotic is chemically incompatible with regular insulin at the Y-site. Which of the following actions is the most appropriate for the nurse to take?

A healthcare provider prescribes a continuous intravenous dopamine infusion at $5\text{ mcg/kg/min}$ to support the blood pressure of a client in cardiogenic shock. The client's body weight is recorded as $176\text{ lb}$. The medication is supplied in an intravenous bag containing $400\text{ mg}$ of dopamine mixed in $250\text{ mL}$ of 5% dextrose in water (D5W). At what rate, in $\text{mL/hr}$, should the infusion pump be programmed? (Record your answer as a whole number)

A nurse is evaluating a client who was admitted following a severe pelvic crush injury. Which of the following assessment findings should the nurse identify as indicators that the client is in the early (compensatory) stage of hypovolemic shock? Select all that apply.

A nurse evaluates a client with a history of hepatic cirrhosis who is being monitored for a suspected gastrointestinal bleed. The client is alert but frequently shifts positions in bed and appears restless. The current vital signs are: blood pressure $114/86$ mm Hg (admission baseline $134/74$ mm Hg), heart rate $112$ beats/min, and respiratory rate $22$ breaths/min. The client repeatedly complains of severe thirst. Which action should the nurse take first?

A nurse is preparing a client with ascites for a bedside abdominal paracentesis. In which order should the nurse perform the following actions to ensure the client's safety and reduce the risk of physiological complications? Arrange the actions in the correct chronological sequence.

During a routine assessment of a client who underwent a right-sided thoracentesis 45 minutes ago, the nurse notes several clinical changes. Which observation represents the highest priority for immediate provider notification and intervention?

A nurse is caring for a client who is receiving an initial intravenous dose of ceftriaxone for a severe respiratory infection. Ten minutes after the infusion begins, the client develops sudden wheezing, facial swelling, and reports a feeling of impending doom. Which of the following nursing actions are appropriate? (Select all that apply.)

While caring for a client with a continuous intravenous (IV) infusion of normal saline, the nurse receives a new prescription for an IV push analgesic. Which action is the most critical for the nurse to perform before injecting the medication into the existing IV line?

A nurse is caring for a client who is in the immediate postoperative period following a total thyroidectomy. Which of the following actions should the nurse take to reduce the risk of complications? (Select all that apply.)