Physiological Integrity

An older adult client with advanced Parkinson's disease is admitted for the management of severe dysphagia and a new sacral pressure injury. The client is receiving continuous enteral nutrition via a gastrostomy tube. During the shift, the client becomes restless, repeatedly attempts to pull on their medical tubing, and experiences sudden new-onset urinary incontinence. Which basic care and comfort interventions should the nurse include in the client's plan of care? Select all that apply.

A nurse is planning care for a client who is postoperative following a right total hip arthroplasty via a posterior approach. Which action regarding the client's positioning and basic care is correct?

During morning rounds, a client who underwent a right total hip arthroplasty with a posterior approach the previous day informs the nurse of the need to have a bowel movement. The client is currently restricted to bed rest. Which intervention should the nurse implement to safely facilitate elimination?

A 14-day-old neonate is admitted to the neonatal intensive care unit with suspected bacterial meningitis. The neonate has a single peripheral intravenous (IV) catheter infusing Lactated Ringer's solution at $10 \text{ mL/hr}$. The healthcare provider prescribes a stat dose of intravenous ceftriaxone $50 \text{ mg/kg}$. Which of the following is the priority nursing action?

A client with a complete T4 spinal cord injury suddenly reports a severe, pounding headache and profound nasal congestion. The nurse observes profuse diaphoresis above the level of the injury and a suddenly elevated blood pressure of 218/114 mm Hg. Arrange the following nursing actions in the priority order they should be performed. (Place the first action at the top and the final action at the bottom.)

While conducting a shift assessment on a surgical unit, the nurse evaluates a client who is 6 hours post-operative following a total abdominal hysterectomy. The electronic health record shows the client's blood pressure was 134/76 mm Hg two hours ago, but it is currently 112/88 mm Hg. The apical pulse has risen from 82 to 116 beats per minute, and respirations are 26 per minute. The client's skin is cool to the touch, and they report feeling unusually anxious. What is the priority nursing intervention?

A 71-year-old client with a history of early-stage vascular dementia is 4 hours post-percutaneous coronary intervention (PCI) via the right femoral artery. The client suddenly becomes highly agitated, reports vague lower abdominal pressure, and repeatedly attempts to sit upright and pull at the groin dressing. The client has not voided since before the procedure. Which action should the nurse take to safely address the client's basic care and comfort needs?

A client on a medical-surgical unit is receiving a continuous peripheral infusion of 0.9% sodium chloride with added potassium chloride. The client's electronic health record indicates that a scheduled dose of intravenous famotidine is currently due. Which step is essential for the nurse to take before proceeding with the medication administration?

A client is 4 hours postoperative following a bowel resection. The surgical dressing is saturated with bright red blood, and the hemovac drain contains 300 mL of fresh sanguineous fluid. Which assessment findings indicate the client is developing early hypovolemic shock? Select all that apply.

During afternoon rounding on the cardiovascular progressive care unit, the charge nurse evaluates the status of a client who underwent a right femoral percutaneous coronary intervention (PCI) two hours ago. Which specific finding necessitates an immediate interruption by the charge nurse to mitigate a severe physiological risk?

A client weighing $76 \text{ kg}$ is receiving a continuous intravenous (IV) infusion of unfractionated heparin for a deep vein thrombosis. The current infusion rate is $16 \text{ units/kg/hr}$. The IV bag is labeled "Heparin sodium $25,000 \text{ units}$ in $500 \text{ mL}$ $0.45\% \text{ NaCl}$". The client's morning activated partial thromboplastin time (aPTT) result is $112 \text{ seconds}$ (reference range: $30-40 \text{ seconds}$).

The facility's heparin titration protocol specifies the following actions based on aPTT results:
- aPTT $71-90 \text{ seconds}$: Decrease infusion rate by $2 \text{ units/kg/hr}$.
- aPTT $> 90 \text{ seconds}$: Stop the infusion for $1$ hour, then decrease the rate by $3 \text{ units/kg/hr}$.

Based on the protocol, which sequence of actions and newly programmed IV pump rate should the nurse implement? (Round the final pump rate to the nearest tenth).

A nurse is planning care for a client who has just returned to the nursing unit following a lumbar puncture. Which of the following actions should the nurse take to reduce the risk of post-procedure complications?

A nurse is preparing to transfer a client who has right-sided weakness from the bed to a wheelchair. Arrange the following nursing actions in the correct sequence to ensure a safe transfer.

A 45-year-old client with acute necrotizing pancreatitis is being monitored in the high-acuity unit. Over a four-hour observation period, the client's serum calcium drops dramatically from 8.8 mg/dL to 6.5 mg/dL, accompanied by a rising heart rate of 118 bpm. The client reports a progressive 'pins and needles' sensation around the mouth and in the fingertips. As an unlicensed assistive personnel (UAP) approaches the bedside and begins wrapping a sphygmomanometer cuff around the client's upper arm, what represents the paramount risk reduction action?

An adult client is receiving care in the emergency department for a severe asthma exacerbation. Following one hour of continuous albuterol nebulization and intravenous corticosteroids, the client's respiratory rate is 32 breaths per minute, and auscultation reveals that the previously loud, bilateral expiratory wheezes are now significantly diminished. The most recent arterial blood gas (ABG) analysis on room air reveals a pH of 7.36, a PaCO2 of 44 mm Hg, and a PaO2 of 61 mm Hg. Which action should the nurse take to reduce the client's immediate risk of physiological deterioration?

A client with short bowel syndrome is receiving continuous total parenteral nutrition (TPN) through a single-lumen central venous catheter. The electronic health record indicates a new prescription for an intermittent intravenous antibiotic. Upon assessment, the nurse notes the client does not have any other established venous access. What is the most appropriate action by the nurse?

A nurse is developing a care plan for a client who is 48 hours postoperative following a right above-the-knee amputation. Which interventions should the nurse include to promote comfort, mobility, and proper positioning? Select all that apply.

An intensive care nurse is caring for a client who is receiving positive pressure mechanical ventilation. The ventilator's high-pressure alarm suddenly sounds, and the client's oxygen saturation drops to 84%. Assessment reveals absent breath sounds over the right lung field, a blood pressure of 82/40 mm Hg, and the trachea deviated toward the left. Which of the following interventions should the nurse anticipate performing immediately?

A nurse is preparing to administer a primary intravenous infusion of $1,000$ mL of $0.9\%$ sodium chloride over $8$ hours. At what rate should the nurse program the electronic infusion pump in mL/hr? (Record your answer as a whole number.)

A rapid response team is called to an inpatient unit for a client who is experiencing a generalized tonic-clonic seizure. The seizure activity has been continuous for 12 minutes without the client regaining consciousness. Upon arrival, the nurse notes circumoral cyanosis and audible gurgling respirations. Arrange the following emergent interventions in the priority sequence they must be executed.