Physiological Integrity

A client who recently underwent a mechanical aortic valve replacement is receiving a continuous intravenous infusion of unfractionated heparin via a single-lumen peripherally inserted central catheter (PICC). The client is diagnosed with a healthcare-associated systemic infection, and the healthcare provider prescribes an intermittent intravenous infusion of vancomycin $1,000\text{ mg}$ to run over $90$ minutes. The nurse notes from the pharmacological reference that heparin and vancomycin are physically incompatible at the Y-site. What is the priority nursing action to safely administer the prescribed vancomycin?

A client who has been experiencing constipation for several days is prescribed a large-volume cleansing enema. To best facilitate the flow of the enema solution by gravity into the descending colon, which position should the nurse assist the client into?

The healthcare provider prescribes a continuous intravenous infusion of sodium nitroprusside at a rate of $3 \text{ mcg/kg/min}$ for a client experiencing a hypertensive crisis. The client weighs $198 \text{ lbs}$. The medication is supplied as $50 \text{ mg}$ of sodium nitroprusside mixed in $250 \text{ mL}$ of 5% dextrose in water (D5W). What is the appropriate infusion rate in $\text{mL/hr}$? (Record your answer as a whole number.)

A nurse is preparing to administer a scheduled intravenous (IV) antibiotic via a secondary line. The client currently has a continuous primary IV infusion of 0.45% sodium chloride with 20 mEq of potassium chloride running. Which action must the nurse prioritize before attaching the secondary tubing to the primary IV line?

A client in cardiogenic shock is prescribed a continuous intravenous (IV) infusion of dobutamine at a rate of $5 \text{ mcg/kg/min}$. The client weighs $80 \text{ kg}$. The pharmacy provides a premixed IV bag containing $500 \text{ mg}$ of dobutamine in $250 \text{ mL}$ of $5\%$ dextrose in water (D5W). At what rate, in $\text{mL/hr}$, should the nurse program the electronic infusion pump?

A nurse is preparing to administer a new intravenous (IV) push medication to a client who is already receiving a continuous IV fluid infusion. To ensure client safety and reduce the risk of an adverse event, which action must the nurse take before administering the medication?

A client with acute decompensated heart failure is receiving a continuous intravenous (IV) infusion of milrinone through a dedicated 20-gauge peripheral catheter. The healthcare provider prescribes a STAT dose of furosemide 40 mg IV push. The client currently has no other venous access. Which action by the nurse is the safest and most appropriate?

A nurse is directing the care of an 80-year-old client who is 48 hours post-operative following a right total hip arthroplasty (posterior approach). The client, who has no history of cognitive impairment, has become increasingly restless, is pulling at their indwelling urinary catheter, and has had two episodes of bowel incontinence. Which intervention is most appropriate for the nurse to include in the client's basic care and comfort plan?

A nurse is planning care for an older adult client who is completely bedridden following an ischemic stroke. The plan includes interventions to maintain skin integrity, promote comfort, and ensure proper body alignment. Which of the following nursing actions are appropriate to include in the client's care plan? Select all that apply.

An intensive care nurse is managing the basic care needs of an adult client who is mechanically ventilated for severe acute respiratory distress syndrome (ARDS). The client is currently placed in the prone position to optimize oxygenation and is receiving continuous enteral nutrition via an orogastric tube. To provide safe and effective basic care, which combination of interventions is most appropriate for the nurse to implement?

A nurse on a medical-surgical unit has received the shift report for four clients. Which client should the nurse assess first to reduce the risk of a potential life-threatening complication?

A healthcare provider prescribes ceftriaxone $1 \text{ gram}$ in $50 \text{ mL}$ of $0.9\%$ sodium chloride to be infused intravenously over $30 \text{ minutes}$. The nurse will use an electronic infusion pump. At what rate, in $\text{mL/hr}$, should the nurse set the infusion pump? Record your answer as a whole number.

A client admitted with bacterial pneumonia is prescribed an intermittent intravenous (IV) antibiotic. The client currently has a continuous peripheral IV infusion of dextrose 5% in water (D5W) running at a low rate. Which actions are required by the nurse to ensure safe administration of the medication? Select all that apply.

A registered nurse is planning oral care for an unresponsive elderly client admitted with a severe ischemic stroke. To promote comfort and minimize physiological risk, which intervention is most appropriate for the nurse to implement?

A client is in the post-anesthesia care unit (PACU) following an open abdominal surgery under general anesthesia utilizing desflurane and succinylcholine. The nurse notes new-onset masseter muscle rigidity, tachycardia of $145 \text{ beats/minute}$, tachypnea, and an end-tidal carbon dioxide ($EtCO_2$) level of $65 \text{ mm Hg}$. The client's temperature is rapidly rising. Based on these findings, which of the following pharmacological and parenteral interventions should the nurse anticipate implementing? (Select all that apply)

A nurse is preparing to transfer a client from the bed to a wheelchair. The client has a history of severe orthostatic hypotension and right-sided hemiparesis following a cerebrovascular accident. Arrange the following steps in the correct chronological order to ensure a safe and hemodynamically stable transfer.

An adult client is receiving total parenteral nutrition (TPN) via a single-lumen peripherally inserted central catheter (PICC). The healthcare provider prescribes a scheduled dose of intravenous (IV) famotidine. Which action is most appropriate for the nurse to take?

A nurse is creating a care plan for a client with an acute exacerbation of multiple sclerosis who has bilateral lower extremity paralysis and frequent bowel incontinence. Which interventions should the nurse include to maintain skin integrity and promote basic comfort? Select all that apply.

A nurse is caring for a client who has just returned to the medical-surgical unit following an esophagogastroduodenoscopy (EGD) performed with a topical anesthetic spray to the throat. Which action is the priority for the nurse to take to reduce the client's risk of a potential complication?

A client is recovering on the surgical unit 24 hours after a right-sided modified radical mastectomy with an axillary lymph node dissection. The client has a closed-suction drain in place and reports incisional pain. What actions should the nurse implement to optimize the client's basic care and comfort? Select all that apply.