Physiological Integrity

A nurse is assessing a client who has been receiving a continuous intravenous infusion of unfractionated heparin for four days to treat a deep vein thrombosis. The client's most recent laboratory results reveal a platelet count that has decreased from an admission baseline of $240,000/\text{mm}^3$ to $95,000/\text{mm}^3$. The nurse suspects the client is developing heparin-induced thrombocytopenia (HIT). Based on this clinical presentation, which of the following actions should the nurse take? Select all that apply.

A nurse is caring for a client who is 12 hours postoperative following an abdominal surgery and is receiving intravenous morphine via a patient-controlled analgesia (PCA) pump. Which of the following nursing actions are appropriate for the safe administration and monitoring of this therapy? (Select all that apply.)

A nurse is performing a postoperative assessment on a client who is utilizing a patient-controlled analgesia (PCA) pump with morphine following a right total knee arthroplasty. The client is lethargic, difficult to arouse, and has a respiratory rate of 8 breaths per minute with shallow chest excursion. Based on these assessment findings, which arterial blood gas (ABG) result should the nurse anticipate?

A nurse is preparing to draw up a prescribed intravenous medication from a glass ampule. Arrange the following steps in the correct chronological order to ensure safe preparation.

During a morning assessment, a nurse evaluates a client who has been suffering from frequent, severe vomiting for the past 48 hours. Which of the following acid-base imbalances is the client at greatest risk for developing as a direct result of this fluid loss?

A nurse is caring for a client with a hypertensive crisis. The provider prescribes a continuous intravenous (IV) infusion of sodium nitroprusside at $3 \text{ mcg/kg/min}$. The client weighs $176 \text{ lbs}$. The medication is supplied as $50 \text{ mg}$ of sodium nitroprusside in $250 \text{ mL}$ of $5\% \text{ Dextrose}$ in water ($D_5W$). At what rate should the nurse set the IV infusion pump in $\text{mL/hr}$? (Round the answer to the nearest whole number.)

A nurse is caring for a client with cardiogenic shock who weighs $176 \text{ lbs}$. The healthcare provider prescribes a continuous intravenous (IV) infusion of dopamine at $5 \text{ mcg/kg/min}$. The pharmacy dispenses a premixed dopamine solution of $400 \text{ mg}$ in $250 \text{ mL}$ of $5\% \text{ dextrose in water}$ (D5W). What rate should the nurse program the IV infusion pump to deliver the prescribed dose? Record your answer as a whole number.

A registered nurse is preparing to safely move a client who has right-sided hemiparesis from the hospital bed into a wheelchair. In what sequence should the nurse perform the following interventions?

A client is recovering on the surgical unit 24 hours after a right-sided modified radical mastectomy with axillary lymph node dissection. The client reports mild incisional pain and a feeling of "heaviness" in the right arm. Which nursing intervention is most appropriate to promote comfort and minimize postoperative complications?

Following a major abdominal surgery, a client is being monitored closely for potential hemorrhagic complications. Which of the following vital sign trends should the nurse identify as the most reliable early indicator of developing hypovolemic shock?

A nurse is preparing to remove a non-tunneled central venous catheter (CVC) from the subclavian vein of an alert, cooperative adult client. Arrange the following actions in the correct chronological order to minimize the risk of a venous air embolism and bleeding. (First action to last action)

A nurse is preparing to administer an intramuscular (IM) injection of iron dextran using the Z-track method to an adult client. Arrange the following steps of the procedure in the correct chronological order.

An older adult client is admitted to the medical-surgical unit with generalized weakness, poor oral intake, and frequent episodes of fecal incontinence. The client occasionally exhibits periods of confusion and is currently bed-bound. Which interventions should the nurse include in the client's plan of care to promote comfort and prevent skin breakdown? Select all that apply.

A nurse is caring for a 65-year-old client who is receiving an intravenous infusion of alteplase (rtPA) for an acute ischemic stroke. Thirty minutes into the infusion, the client reports a sudden, severe headache, becomes intensely nauseous, and exhibits a new unilateral pupillary dilation. To reduce the risk of catastrophic neurological deterioration, arrange the following nursing actions in the correct priority order from first to last.

A client is brought to the emergency department experiencing a severe panic attack. The client is visibly anxious, diaphoretic, and breathing rapidly at a rate of 34 breaths per minute. Which of the following arterial blood gas (ABG) values would the nurse anticipate for this client? Select all that apply.

The nurse receives a client who has just returned to the nursing unit following a diagnostic cardiac catheterization performed via the right femoral artery. Which of the following positioning interventions is most important for the nurse to implement to reduce the risk of postoperative bleeding?

A nurse is preparing to assist a client who has dysphagia and right-sided facial weakness with a meal. Arrange the following nursing actions in the correct chronological sequence to ensure safe oral intake and prevent aspiration. All options must be used.

A nurse is preparing to administer a prescribed intravenous (IV) antibiotic intermittent infusion (piggyback) to a client who is currently receiving a continuous IV infusion of 0.9% sodium chloride. Which of the following is the priority nursing action before initiating the antibiotic infusion?

An intensive care nurse is caring for a hemodynamically unstable client who has a triple-lumen central venous catheter. The current continuous intravenous (IV) infusions are:

* Proximal port: Total parenteral nutrition (TPN)
* Medial port: 0.45% sodium chloride with 20 mEq/L of potassium chloride at 75 mL/hr
* Distal port: Propofol emulsion for continuous sedation

The client's mean arterial pressure abruptly drops to 54 mmHg. The healthcare provider prescribes an immediate 500 mL IV bolus of 0.9% sodium chloride and a continuous infusion of norepinephrine. Which action demonstrates the safest administration of these new prescriptions?

A nurse is caring for a client weighing $80\text{ kg}$ who is admitted with acute decompensated heart failure. The client is receiving a continuous intravenous infusion of milrinone at $0.5\text{ mcg/kg/min}$ via a single patent 20-gauge peripheral IV line in the left forearm.

The client's respiratory status acutely worsens, with oxygen saturation dropping to 84% on room air and severe bilateral crackles present on auscultation. The healthcare provider prescribes a stat dose of furosemide $1\text{ mg/kg}$ IV push.

The available furosemide vial concentration is $10\text{ mg/mL}$. Facility policy mandates that IV furosemide must not be administered faster than $20\text{ mg/min}$ to prevent ototoxicity.

After multiple unsuccessful attempts to establish a second peripheral IV line by the vascular access team, which of the following is the most appropriate action by the nurse?