Physiological Integrity

A nurse is caring for a client who is receiving total parenteral nutrition via a central venous catheter. The nurse discovers that the catheter tubing has become disconnected. The client suddenly develops severe dyspnea, a cough, chest pain, and extreme tachycardia. Arrange the following nursing interventions in the most appropriate order of priority.

A nurse is caring for an older adult client who returned to the inpatient unit 1 hour ago following a left-sided cardiac catheterization accessed via the femoral artery. The client is experiencing lower back discomfort from prolonged immobility, has been incontinent of urine, and is intermittently reaching toward the groin dressing. Which of the following nursing interventions are appropriate? Select all that apply.

A 24-year-old client with type 1 diabetes mellitus is brought to the emergency department after a 2-day history of vomiting and omitting insulin doses. The triage nurse suspects diabetic ketoacidosis (DKA). Which of the following clinical findings should the nurse expect to assess? Select all that apply.

A client is being monitored on the medical-surgical unit shortly after a therapeutic thoracentesis that removed a large volume of pleural fluid. Upon entering the room, the nurse observes that the client is newly restless and confused. The client's respiratory rate is 28 breaths per minute, the apical pulse is 114 beats per minute, and the blood pressure has trended down to 88/64 mm Hg. Which of the following immediate nursing actions should be implemented? (Select all that apply)

A nurse is caring for a client at 34 weeks gestation who is receiving a continuous intravenous infusion of magnesium sulfate for severe preeclampsia. Which of the following nursing actions are appropriate to ensure safe administration and monitor for medication toxicity? Select all that apply.

A nurse is assessing a client admitted with acute hemorrhagic pancreatitis who is receiving continuous intravenous fluid resuscitation. Which of the following findings indicate the client is developing early hypovolemic shock? Select all that apply.

An adolescent client is brought to the emergency department exhibiting deep, rapid respirations, a fruity breath odor, and severe lethargy. The initial capillary blood glucose is $580 \text{ mg/dL}$ ($32.2 \text{ mmol/L}$). The healthcare provider diagnoses diabetic ketoacidosis (DKA). Arrange the following nursing actions in the priority order they should be performed.

A nurse is removing a central venous access device (CVAD) from a client's right subclavian vein. During the procedure, the client suddenly gasps for air, becomes profoundly dyspneic, and exhibits perioral cyanosis. The client's blood pressure drops to 72/40 mm Hg, and a loud 'churning' murmur is auscultated over the precordium. Arrange the following emergency nursing interventions in the correct physiological sequence from first to last.

A nurse is teaching a client who has a non-weight-bearing right leg fracture how to ascend stairs using axillary crutches. In what order should the nurse instruct the client to perform the following actions? Arrange the steps in the correct sequence.

A nurse is preparing to administer a prescribed intravenous (IV) push analgesic to a client. The client has a single peripheral IV line currently infusing a continuous medication. The drug reference guide indicates that the continuous infusion is physically incompatible with the prescribed IV push analgesic. Arrange the following nursing actions in the correct sequence to safely administer the medication.

An adult client admitted with suspected sepsis is receiving a continuous intravenous infusion of lactated Ringer's solution at $150\text{ mL/hr}$ through a single peripheral intravenous line. The healthcare provider prescribes a stat dose of intravenous ceftriaxone $1\text{ g}$ in $50\text{ mL}$ of 0.9% sodium chloride to be infused over 30 minutes. Which action is most appropriate for the nurse to take?

A nurse is caring for a client who has just returned to the medical-surgical unit following a percutaneous liver biopsy. Which of the following actions is the priority for the nurse to take to reduce the risk of a post-procedure complication?

An 82-year-old client with a history of vascular dementia and right-sided hemiparesis is receiving continuous enteral nutrition via a nasogastric (NG) tube. The client is currently positioned with the head of the bed elevated at 45 degrees. The nurse notes the client has become acutely restless, is repeatedly pulling at the NG tube, and has not voided in the past 8 hours. Which of the following nursing interventions best demonstrates appropriate management of this client's basic care and comfort needs?

A nurse is preparing to provide oral care to a client who is comatose. Which of the following actions is the most appropriate for the nurse to take to ensure the client's safety?

A healthcare provider prescribes oral amoxicillin $500\text{ mg}$ every $8$ hours for a client with a respiratory tract infection. The pharmacy dispenses an amoxicillin oral suspension labeled $250\text{ mg}/5\text{ mL}$. How many milliliters (mL) should the nurse administer for a single dose? (Record answer as a whole number.)

A nurse is preparing to administer a prescribed intravenous (IV) push medication through a client's peripheral IV line. The client currently has a continuous primary IV infusion of a solution that is physically incompatible with the ordered IV push medication. In what order should the nurse perform the following actions to safely administer the medication? Arrange the steps from first to last.

A nurse is reviewing the arterial blood gas (ABG) results for a client who is experiencing acute respiratory distress. The results show a pH of $7.25$, $\text{PaCO}_2$ of $60\text{ mm Hg}$, and $\text{HCO}_3^-$ of $24\text{ mEq/L}$. Based on these values, which acid-base imbalance is the client experiencing?

A nurse is caring for a client who is four hours post-operative following a total thyroidectomy. The client suddenly becomes highly agitated and reports a sensation of intense pressure and fullness in the neck. Upon inspection, the surgical dressing is dry and intact, but the nurse auscultates high-pitched, harsh respiratory sounds during inspiration. The client's voice has become noticeably muffled. Which action should the nurse take immediately?

A nurse is assessing a client who has a suspected proximal small bowel obstruction and has experienced severe, persistent vomiting for the past 24 hours. Which of the following clinical findings should the nurse identify as physiological complications associated with this condition? Select all that apply.

A nurse is assessing a client who is 4 hours post-admission for a severe pelvic fracture following a motor vehicle crash. The client's baseline vital signs upon admission were: blood pressure 130/76 mm Hg, heart rate 82/min, and respiratory rate 16/min. Which of the following current assessment findings indicate the client is entering the early (compensatory) stage of hypovolemic shock? Select all that apply.