Physiological Integrity

A client in cardiogenic shock is receiving a continuous intravenous (IV) infusion of dopamine through a single-lumen peripheral IV line. The healthcare provider prescribes a stat dose of furosemide $120$ mg IV push for acute pulmonary edema. The facility protocol dictates that furosemide should not be administered faster than $20$ mg/minute to prevent adverse effects. Furosemide is physically incompatible with dopamine. Based on these parameters, which action by the nurse is the safest and most appropriate?

A nurse is planning basic care for an older adult client who is completely bedbound and requires assistance with all activities of daily living. Which interventions should the nurse include in the plan of care to maintain skin integrity and promote comfort? Select all that apply.

The healthcare provider prescribes a $100\text{ mL}$ intravenous piggyback infusion of ceftriaxone to run over $30\text{ minutes}$. At what rate, in $\text{mL/hr}$, will the nurse set the electronic infusion pump? (Record your answer as a whole number).

While managing a client in the intensive care unit who is in profound distributive shock, the nurse notes the client has developed severe, unsafe psychomotor agitation. The client's only vascular access is a single-lumen central venous catheter (CVC) currently infusing norepinephrine at $0.2 \text{ mcg/kg/min}$ to maintain a mean arterial pressure greater than $65 \text{ mm Hg}$. The provider prescribes a stat dose of intravenous (IV) midazolam $2 \text{ mg}$. Which of the following is the safest and most appropriate action for the nurse to take?

A nurse is monitoring a client who is receiving an intravenous (IV) transfusion of packed red blood cells (PRBCs). Fifteen minutes after the transfusion begins, the client reports sudden lower back pain and chills. The client's heart rate increases from 82 to 118 beats/min, and blood pressure drops from 124/76 mm Hg to 92/58 mm Hg. Which of the following is the priority nursing action?

A nurse is planning care for a 78-year-old client with Parkinson's disease and severe dysphagia who was recently admitted with aspiration pneumonia. The client is receiving continuous enteral feedings via a nasogastric tube and has a highly friable stage 3 sacral pressure injury. Upon assessment, the nurse notes the client is newly confused, restless, and repeatedly grasping at the nasogastric tube. Which comprehensive intervention is the most appropriate for the nurse to implement?

A nurse is assigned to care for a client with a mechanical bowel obstruction who has had a nasogastric (NG) tube connected to low intermittent suction for the past $48$ hours. The client's morning arterial blood gas (ABG) results reveal a pH of $7.52$, a PaCO $_2$ of $42$ mm Hg, and an HCO $_3^-$ of $34$ mEq/L. Which of the following nursing interventions should be implemented to reduce the risk of further physiological complications? Select all that apply.

A nurse is caring for a client who is 1 day postoperative following a total abdominal hysterectomy. Which of the following interventions should the nurse implement to reduce the risk of developing a deep vein thrombosis (DVT)? Select all that apply.

A nurse is preparing to initiate a transfusion of packed red blood cells (PRBCs) for a client with symptomatic anemia. Which intravenous (IV) fluid should the nurse use to prime the blood administration tubing?

A client is received on the medical unit directly after a percutaneous liver biopsy. To mitigate the primary risk associated with this procedure, which positioning strategy must the nurse implement?

A nurse is caring for a 45-year-old client who is 12 hours postoperative following an extensive small bowel resection for mesenteric ischemia. The client is intubated, receiving mechanical ventilation with a positive end-expiratory pressure (PEEP) of 10 cm $H_2O$, and has a central venous catheter. The nurse is evaluating the client to reduce the risk of potential complications. Which of the following findings or observed nursing actions indicate an imminent risk for physiological decompensation or client harm? Select all that apply.

A nurse is caring for a critically ill client who is experiencing septic shock and new-onset tonic-clonic seizures. The client has a double-lumen central venous catheter (CVC) in place. Lumen one is infusing continuous total parenteral nutrition (TPN), and lumen two is infusing continuous norepinephrine. The healthcare provider prescribes a stat dose of intravenous (IV) push phenytoin. Which of the following actions by the nurse demonstrate safe pharmacological and parenteral management? (Select all that apply)

A nurse is caring for a client who is receiving an infusion of packed red blood cells (PRBCs). Fifteen minutes after the transfusion begins, the client reports sudden lower back pain, chills, and shortness of breath. In which order should the nurse perform the following actions? Arrange the actions from first to last.

A 65-year-old client with osteomyelitis is receiving long-term antibiotic therapy. The nurse is preparing to administer the next dose of intermittent intravenous (IV) ceftriaxone through the client's open-ended central venous catheter (CVC). The designated lumen is currently capped and has not been used for 12 hours. Place the following steps in the correct chronological order to safely administer the medication and maintain catheter patency.

A nurse is preparing to safely transfer a client with right-sided hemiparesis (weakness) from the bed to a wheelchair. Arrange the following nursing actions in the correct chronological order.

A client who recently experienced a cerebrovascular accident has new-onset right-sided hemiparesis. The nurse is preparing to transfer the client from the bed to a wheelchair using a stand-and-pivot technique. The client is currently resting supine in bed. Place the following steps in the correct chronological order to ensure a safe transfer.

A registered nurse is caring for a client who is receiving a continuous maintenance intravenous (IV) fluid through a peripheral catheter. The provider prescribes a new intermittent IV antibiotic to be administered via the existing line. Which of the following safety measures must the nurse implement? Select all that apply.

A nurse is reviewing the electronic health record of a young adult client admitted with diabetic ketoacidosis. The client has been receiving a continuous regular insulin infusion and 0.9% sodium chloride for the past four hours.

Current clinical data:
- Vital signs: Heart rate 112/min, Blood pressure 108/65 mm Hg, Respiratory rate 22/min
- Cardiac monitor: Sinus tachycardia with frequent premature ventricular contractions
- Capillary blood glucose: 235 mg/dL
- Arterial Blood Gases: pH 7.31, PaCO2 36 mm Hg, HCO3 15 mEq/L
- Basic Metabolic Panel: Sodium 142 mEq/L, Potassium 3.1 mEq/L, Chloride 105 mEq/L

Which of the following is the priority nursing action to reduce the client's risk of a life-threatening complication?

A nurse is caring for a client who sustained a complete spinal cord injury at the T4 level three weeks ago. The client suddenly reports a severe, throbbing headache, blurred vision, and nasal congestion. The nurse observes profuse diaphoresis on the client's face and neck, with distinct piloerection below the nipple line. Vital signs reveal a blood pressure of 215/115 mmHg and a heart rate of 50 bpm. To immediately reduce the client's risk for a catastrophic physiological complication, which action should the nurse take first?

A client with a history of chronic obstructive pulmonary disease (COPD) presents with sudden, severe dyspnea and extreme agitation. Assessment reveals absent breath sounds over the right lung field, jugular venous distention, and a trachea deviated to the left. The client's blood pressure is $78/42$ mm Hg, and the heart rate is $136$ bpm. A rapid arterial blood gas (ABG) analysis shows a pH of $7.24$, $PaCO_2$ of $68$ mm Hg, and $HCO_3^-$ of $26$ mEq/L. Which of the following is the priority nursing action?