Physiological Integrity

An orthopedic unit nurse is evaluating a client 36 hours after a closed reduction and intramedullary nailing of a right femoral shaft fracture. The client suddenly exhibits profound agitation, dyspnea, and a feeling of impending doom. Physical assessment reveals a petechial rash on the anterior chest, distended neck veins, and severe diaphoresis. Vital signs are: blood pressure 86/52 mm Hg, heart rate 134 bpm, respiratory rate 36/min, and SpO2 84% on room air. Arterial blood gas (ABG) analysis indicates a pH of 7.54, PaCO2 of 25 mm Hg, HCO3 of 22 mEq/L, and PaO2 of 52 mm Hg. Based on this clinical presentation, which action should the nurse perform immediately?

A nurse is preparing to administer an intravenous (IV) push medication through a Y-site port on a client's active continuous IV infusion line. Which of the following is the priority nursing action before proceeding with the administration?

A client diagnosed with severe sepsis has a double-lumen central venous catheter (CVC). The proximal lumen is dedicated to a continuous infusion of total parenteral nutrition (TPN). The distal lumen is delivering a continuous infusion of norepinephrine to maintain systemic vascular resistance. During the shift, the client's mean arterial pressure drops to $54\text{ mm Hg}$. The provider verbally prescribes an immediate $500\text{ mL}$ intravenous bolus of lactated Ringer's solution and $100\text{ mg}$ of hydrocortisone sodium succinate via intravenous push. Which action by the nurse demonstrates the safest administration of these prescribed therapies?

A registered nurse is planning care for a 78-year-old client who is 1 day post-operative following a right total hip arthroplasty (posterior approach). Which basic care and comfort interventions should the nurse include in the client's plan of care? Select all that apply.

A client arrives at the cardiac step-down unit after a diagnostic cardiac catheterization accessed through the right femoral artery. Which intervention must the nurse implement to reduce the risk of hemorrhage at the access site?

A $28$-year-old client is admitted to the intensive care unit following a high-speed motor vehicle collision. The client sustained a severe pelvic fracture and a right-sided pulmonary contusion. The client is intubated, mechanically ventilated, and sedated. The nurse evaluates the following clinical data:

Which of the following interventions should the nurse implement to mitigate the risk of severe physiological deterioration? (Select all that apply.)

A bedside liver biopsy has just been completed for a client on the medical-surgical unit. Which position should the nurse assist the client into immediately after the procedure to minimize the risk of hemorrhage from the puncture site?

A client recovering from abdominal surgery reports a pain level of 8 on a 0-to-10 scale. The healthcare provider has ordered $2 \text{ mg}$ of morphine sulfate to be administered via intravenous push over 4 minutes. The client currently has a continuous infusion of $0.9\% \text{ sodium chloride}$ running at $75 \text{ mL/hr}$ through a peripheral catheter. The nurse accesses the injection port closest to the client. Which technique represents the safest method for administering this medication?

A young adult client is brought to the emergency department experiencing a severe asthma exacerbation. Initially, the client is restless, using accessory muscles to breathe, and has loud, widespread expiratory wheezes. The initial arterial blood gas (ABG) reveals a pH of $7.48$, $\text{PaCO}_2$ of $30\text{ mm Hg}$, and $\text{PaO}_2$ of $64\text{ mm Hg}$. One hour later, following continuous bronchodilator therapy, the nurse notes that the client has become drowsy and the wheezing is now barely audible. A repeat ABG shows a pH of $7.31$, $\text{PaCO}_2$ of $54\text{ mm Hg}$, and $\text{PaO}_2$ of $56\text{ mm Hg}$. Which of the following interventions should the nurse anticipate implementing? Select all that apply.

An older adult client is recovering on the surgical unit 48 hours after a right below-the-knee amputation. The nurse is updating the client's daily care plan. Which interventions should be included to promote comfort and prevent complications? Select all that apply.

A nurse is receiving a handoff report for a client who is receiving total parenteral nutrition (TPN) via a dedicated lumen of a central venous catheter (CVC). Which of the following actions should the nurse include in the client's plan of care? (Select all that apply)

A nurse is caring for a client who sustained a severe traumatic brain injury and is receiving mechanical ventilation. The client's continuous intracranial pressure (ICP) reading is $24\text{ mm Hg}$. The most recent arterial blood gas (ABG) results reveal a $\text{pH}$ of $7.31$, a $\text{PaCO}_2$ of $56\text{ mm Hg}$, a $\text{PaO}_2$ of $88\text{ mm Hg}$, and an $\text{HCO}_3^-$ of $24\text{ mEq/L}$. To reduce the risk of secondary brain injury, which action should the nurse implement first?

A nurse is reviewing safety protocols for the administration of intravenous (IV) medications and continuous infusions. Which of the following practices should the nurse implement to ensure client safety? Select all that apply.

An ambulatory client who recently started taking oral lisinopril for hypertension contacts the clinic to report several new symptoms. Which of the following client reports requires the most immediate intervention by the nurse?

A client requires a large-volume cleansing enema to relieve severe constipation. In what chronological sequence should the nurse perform the steps of this procedure?

A nurse is caring for a client who is receiving continuous total parenteral nutrition (TPN) via a multilumen central venous catheter. Which of the following actions should the nurse include in the client's plan of care? Select all that apply.

An adult client is transferred to the medical-surgical unit immediately after a percutaneous liver biopsy. To mitigate the risk of internal bleeding from the puncture site, which positioning strategy is most appropriate for this client?

An older adult client with a history of severe bilateral peripheral arterial disease (PAD) reports intense, burning pain in the lower extremities that wakes them during the night. The client's lower extremities are hairless, with thin, dry skin that is cool to the touch. The nurse is planning basic care to promote comfort and sleep. Which nursing action is most appropriate?

A nurse is preparing to remove a client's non-tunneled percutaneous central venous catheter (CVC). To minimize the risk of an air embolism, in what order should the nurse perform the following actions? Arrange the steps in the correct sequence from first to last.

A client weighing $105\text{ kg}$ is admitted to the emergency department with an acute ischemic stroke. The healthcare provider prescribes intravenous alteplase therapy at $0.9\text{ mg/kg}$. Which of the following nursing actions are required for the safe administration and monitoring of this pharmacological therapy? (Select all that apply.)