Physiological Integrity

An oncology client with severe mucositis has developed distributive shock secondary to a suspected bloodstream infection. The client has a double-lumen peripherally inserted central catheter (PICC) in place with the following active infusions:

- Distal port: Continuous infusion of norepinephrine to sustain a mean arterial pressure (MAP) above 65 mm Hg.
- Proximal port: Continuous infusion of total parenteral nutrition (TPN) with added regular insulin.

The provider issues a stat order to administer a 100 mL intravenous bag of a broad-spectrum antibiotic over 30 minutes. Which intervention demonstrates the most appropriate clinical judgment regarding the administration of this antibiotic?

A client who underwent a cardiac catheterization via the right femoral artery is currently on strict bed rest. The nurse observes that the client has been incontinent of urine and needs immediate perineal care and a linen change. Which of the following is the most appropriate action for the nurse to take?

A nurse is preparing to administer an intravenous (IV) push medication through a client's established peripheral intermittent infusion device (saline lock). Arrange the following actions in the correct chronological sequence from first to last.

A nurse is caring for a client who is receiving continuous enteral nutrition via a nasogastric tube. Which of the following positions is the most appropriate for this client to prevent complications?

An adult client is currently receiving a transfusion of packed red blood cells (PRBCs) through a 20-gauge peripheral intravenous catheter to treat acute blood loss anemia following a surgical procedure. During the transfusion, the client experiences a sudden episode of severe post-operative nausea and vomiting. The healthcare provider prescribes an immediate dose of intravenous ondansetron. The client currently has no other vascular access. Which of the following actions is the most appropriate way to safely administer the medication?

A client who recently experienced a cerebrovascular accident has dense left-sided hemiplegia. The nursing team is establishing a schedule to maintain body alignment, prevent joint deformities, and ensure skin integrity. Which action is the most appropriate to include in this client's daily care?

A nurse is preparing to assist a healthcare provider with a bedside thoracentesis for an adult client with a large pleural effusion. To ensure client safety and reduce the risk of procedural complications, arrange the following nursing actions in the correct chronological order.

A nurse is preparing to initiate a continuous enteral tube feeding for an immobile client. To effectively reduce the risk of potentially life-threatening respiratory complications, which action must the nurse take?

A nurse is caring for a hemodynamically unstable client with severe sepsis who has a blood pressure of 82/40 mm Hg. The client is receiving a continuous intravenous (IV) infusion of norepinephrine through the distal port of a newly placed triple-lumen central venous catheter (CVC). The provider prescribes a 500 mL bolus of 0.9% sodium chloride and pantoprazole 40 mg IV push. Which of the following actions represent safe parenteral medication administration and physiological management for this client? (Select all that apply.)

A nurse is formulating a plan of care for a client who has just returned to the nursing unit following a bronchoscopy with a transbronchial lung biopsy under conscious sedation. Which nursing interventions should be included in the plan of care to reduce the risk of post-procedure complications? Select all that apply.

During a clinical shift, a registered nurse is responsible for a patient receiving continuous hydration via a peripheral venous access device with $0.9\%$ sodium chloride. The provider orders multiple new intravenous pharmacological treatments. To maintain patient safety and adhere to standard parenteral protocols, which interventions must the nurse execute? Select all that apply.

A client is recovering on the surgical unit 48 hours after undergoing a right above-the-knee amputation. Which basic care and comfort interventions should the nurse incorporate into the client's daily routine? Select all that apply.

A pediatric nurse is caring for a toddler who weighs $16 \text{ kg}$ and is receiving treatment for bacterial meningitis. The client's current temperature is $38.9^\circ\text{C}$ ($102^\circ\text{F}$), heart rate is $135 \text{ bpm}$, and respiratory rate is $28 \text{ breaths/min}$. The client has a single-lumen peripheral intravenous (IV) catheter. The healthcare provider prescribes ampicillin $500 \text{ mg}$ IV and gentamicin $2.5 \text{ mg/kg}$ IV. Both intermittent medications are scheduled to be administered at 09:00. The pharmacy supplies gentamicin in a multiple-dose vial labeled $20 \text{ mg/mL}$. Which of the following is the most appropriate action by the nurse?

A client hospitalized with a bacterial infection has a continuous peripheral intravenous (IV) infusion of normal saline. The healthcare provider prescribes a scheduled dose of IV ciprofloxacin. Which safety check is the most critical for the nurse to perform before connecting the new medication to the primary line?

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

A nurse is teaching a client who has left leg weakness how to ambulate safely using a straight cane. Arrange the following actions in the correct sequence from first to last to ensure a safe gait.

A nurse is preparing to administer a prescribed dose of cefepime 1 gram in $50\text{ mL}$ of $0.9\%$ sodium chloride intravenously over $30\text{ minutes}$ to a client with a respiratory tract infection. At what rate in $\text{mL/hr}$ should the nurse set the intravenous infusion pump? Record your answer as a whole number.

A nurse is preparing to administer 40 mEq of intravenous (IV) potassium chloride (KCl) to a client with a serum potassium level of 2.8 mEq/L (2.8 mmol/L). Which of the following actions demonstrates the safest method for administering this parenteral therapy?

A 58-year-old client with end-stage cirrhosis and severe ascites is scheduled to undergo a bedside paracentesis. Which of the following nursing actions is the priority to reduce the risk of a serious complication during this procedure?

A nurse is teaching basic mobility techniques to an older adult client who is 2 days post-operative following a right total hip arthroplasty (posterior approach). The client is preparing to transfer from a standing position using a standard walker to a sitting position in an armchair. Which instruction should the nurse provide to ensure client safety and comfort?