Physiological Integrity

During mealtime on a medical-surgical unit, an elderly client with a known history of dysphagia requires assistance. What is the most appropriate action by the registered nurse to ensure safe ingestion and comfort?

A nurse is instructing a client who has a cast on the right lower extremity and is prescribed non-weight-bearing status. The client is learning to ascend stairs using axillary crutches. Arrange the following actions in the correct sequence from first to last.

A nurse is preparing to administer an initial loading dose of $1000$ mg of intravenous phenytoin to an adult client experiencing continuous seizure activity. The client has a single peripheral intravenous catheter currently infusing 5% dextrose in water (D5W) at $100$ mL/hr. Which sequence of actions is the most appropriate for safe parenteral administration of this medication?

A nurse is providing morning hygiene and nutritional support for an older adult client who underwent a right total hip arthroplasty via a posterior approach on the previous day. Which of the following actions should the nurse take?

A nurse is assessing a client who experienced an acute anterior myocardial infarction $24$ hours ago. Which of the following clinical findings indicate that the client is developing cardiogenic shock? Select all that apply.

A registered nurse is assigned to care for a client who is receiving a continuous intravenous infusion of $0.45\%$ sodium chloride. The healthcare provider prescribes a new intravenous (IV) push medication for the client. Which action represents the most critical safety check before injecting the medication into the existing IV line?

A nurse is evaluating the arterial blood gas (ABG) results of an adult client admitted with an acute asthma exacerbation. Which of the following laboratory values indicate that the client is experiencing uncompensated respiratory acidosis? Select all that apply.

A nurse is preparing to feed a client who has dysphagia and left-sided facial weakness following the surgical resection of a brain tumor. Arrange the following nursing actions in the correct chronological sequence to prevent aspiration and promote safe swallowing. All options must be used.

A nurse is caring for a client with a central venous access device (CVAD) that is completely occluded. The healthcare provider has prescribed alteplase to declot the line. Arrange the following steps for administering this thrombolytic agent in the correct chronological sequence. All steps must be used.

A client weighing $198\text{ lb}$ is receiving a continuous intravenous (IV) heparin infusion for the treatment of a deep vein thrombosis. The client's morning activated partial thromboplastin time (aPTT) is reported as $42\text{ seconds}$. According to the facility's weight-based heparin protocol, for this aPTT result, the nurse must administer an IV push bolus of $40\text{ units/kg}$ and increase the continuous infusion rate by $2\text{ units/kg/hr}$. The continuous IV infusion is currently running at $14\text{ units/kg/hr}$. The pharmacy provides a premixed heparin bag containing $25,000\text{ units}$ in $250\text{ mL}$ of $0.9\%$ sodium chloride, and a separate heparin vial containing $1,000\text{ units/mL}$ for the bolus dose.

After administering the required bolus, at what rate in $\text{mL/hr}$ should the nurse set the IV pump for the new continuous infusion? (Record your answer to the nearest tenth.)

A nurse is preparing to administer a large-volume cleansing enema to an adult client who is experiencing severe constipation. Arrange the following steps of the procedure in the correct chronological order.

A nurse is preparing to assess an adult client for orthostatic hypotension to determine their risk for falls. In what order should the nurse perform the following actions to ensure accurate results?

A 68-year-old client with severe osteoarthritis arrives on the orthopedic unit after undergoing a right total hip arthroplasty using a posterior surgical approach. The client is drowsy but responsive, with stable vital signs. Which action must the nurse prioritize to prevent dislocation of the new joint prosthesis?

A nurse is evaluating a newly hired colleague who is preparing to administer an intravenous (IV) push medication into a client's existing primary IV line. Which actions by the newly hired colleague demonstrate safe parenteral medication administration? (Select all that apply.)

A nurse is caring for a client who is receiving intravenous fluid therapy via a subclavian central venous catheter. The nurse enters the room and observes that the intravenous tubing has disconnected from the catheter hub. The client is suddenly grasping their chest, gasping for air, and appears cyanotic. Arrange the following nursing interventions in the priority sequence they should be performed, from first to last.

A client receiving continuous enteral nutrition via a nasogastric (NG) tube has just returned to the medical-surgical unit following a diagnostic lumbar puncture. The healthcare provider has prescribed strict flat bed rest for 6 hours to minimize the risk of a post-dural puncture headache. Which nursing action safely integrates the client's continuous nutritional requirements with the prescribed post-procedure positioning?

A client on a medical-surgical unit has a hemoglobin level of 6.8 g/dL (68 g/L) and is prescribed a transfusion of packed red blood cells (PRBCs). The client has a single 20-gauge peripheral intravenous (IV) catheter, which is currently infusing a continuous maintenance fluid of 5% dextrose in water (D5W) at 75 mL/hr. What is the most appropriate action by the nurse?

A nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation. The ventilator settings include a positive end-expiratory pressure (PEEP) of 15 cm $H_2O$. The most recent arterial blood gas (ABG) analysis indicates a pH of $7.29$, $PaCO_2$ of $54$ mm Hg, $HCO_3^-$ of $25$ mEq/L, and $PaO_2$ of $62$ mm Hg. Over the last $10$ minutes, the client's blood pressure drops rapidly from $115/72$ mm Hg to $82/48$ mm Hg, and the heart rate increases from $95$ to $132$ bpm. Which action should the nurse implement first to reduce the client's risk of imminent physiological collapse?

A client admitted with severe sepsis is receiving a continuous intravenous (IV) infusion of piperacillin/tazobactam through a peripheral IV catheter. The healthcare provider prescribes a scheduled dose of IV vancomycin $1,500\text{ mg}$. The pharmacy dispenses the vancomycin in a $300\text{ mL}$ bag of $0.9\%$ sodium chloride. Institutional protocol requires vancomycin doses greater than $1,000\text{ mg}$ to be infused over a minimum of $90\text{ minutes}$ to prevent adverse infusion reactions. The client has only one patent peripheral IV line. Which of the following is the most appropriate nursing action?

During the management of a critically ill adult in the intensive care unit, a triple-lumen central venous catheter (CVC) is utilized for multiple continuous infusions. The client's distal lumen is infusing epinephrine to maintain hemodynamic stability, the medial lumen is reserved for continuous total parenteral nutrition (TPN), and the proximal lumen is delivering a standard heparin protocol. Suddenly, the cardiac monitor displays symptomatic supraventricular tachycardia (SVT), and the healthcare provider prescribes an immediate dose of adenosine via rapid intravenous push. Which parenteral administration technique represents the safest clinical judgment?