Physiological Integrity

A client diagnosed with bacterial pneumonia is prescribed intravenous ceftriaxone. While completing the admission history, the nurse discovers that the client has a documented history of anaphylaxis following amoxicillin administration. Which action is the priority for the nurse to take?

A nurse is providing care for a client who had a right below-the-knee amputation 36 hours ago. The client reports mild discomfort and stiffness in the affected leg. Which nursing action is the most appropriate?

A newly admitted adult client is recovering from a prolonged tonic-clonic seizure. The client has a peripheral venous catheter in the right forearm, which is currently infusing a maintenance solution of 5% dextrose in water at $80\text{ mL/hr}$. The nurse must deliver a stat order of intravenous phenytoin. Which procedural approach ensures safe administration of this medication?

An intensive care nurse evaluates a critically ill client being treated for severe viral pneumonia. Over the past 30 minutes, the client has become increasingly agitated and disoriented. Current vital signs reveal a heart rate of 126 beats/min, a respiratory rate of 34 breaths/min, and a blood pressure of 98/78 mm Hg. Stat arterial blood gas (ABG) analysis on a non-rebreather mask demonstrates a pH of 7.26, $PaCO_2$ of 64 mm Hg, $PaO_2$ of 52 mm Hg, and $HCO_3^-$ of 24 mEq/L. What is the most appropriate action by the nurse to mitigate the risk of immediate cardiorespiratory arrest?

A $72$-year-old client with a history of dysphagia is receiving continuous enteral nutrition via a nasogastric tube. The client suddenly exhibits severe shortness of breath, use of accessory muscles, and a pulse oximetry reading of $84\%$ on room air. A stat arterial blood gas (ABG) analysis shows a pH of $7.26$, PaCO $_2$ of $64$ mm Hg, and HCO $_3^-$ of $24$ mEq/L. The nurse suspects acute pulmonary aspiration. Which of the following immediate interventions should the nurse implement? Select all that apply.

A nurse is caring for a client who is receiving intravenous fluids through a central venous catheter. The client suddenly gasps, reports severe chest pain, and becomes extremely short of breath. The nurse notes a heart rate of 124 beats/min, a blood pressure of 82/50 mm Hg, and auscultates a loud, churning "mill-wheel" murmur over the precordium. Suspecting a venous air embolism, arrange the following nursing actions in the correct priority order.

A nurse is assessing a client who is receiving continuous intravenous opioid analgesia. The client is difficult to arouse and has a respiratory rate of 8 breaths per minute. The nurse anticipates the client is developing respiratory acidosis. What arterial blood gas (ABG) findings would confirm this complication? Select all that apply.

An adolescent client is brought to the emergency department after ingesting a toxic amount of acetylsalicylic acid (aspirin) 6 hours ago. The client is confused, diaphoretic, and reports tinnitus. Vital signs are: heart rate 124 beats/min, respiratory rate 34 breaths/min and deep, and blood pressure 102/64 mm Hg. Arterial blood gas (ABG) analysis reveals: pH 7.31, PaCO2 24 mm Hg, HCO3 12 mEq/L, and PaO2 96 mm Hg. Which physiological interpretation and corresponding priority action is most appropriate for this client?

A nurse in the cardiovascular intensive care unit is caring for a client with acute decompensated heart failure. The client weighs $209\text{ lbs}$.

The client is receiving a continuous intravenous infusion of dobutamine. The standard hospital mixture contains $500\text{ mg}$ of dobutamine in $250\text{ mL}$ of $5\%$ dextrose in water (D5W). The infusion pump is currently running at $17.1\text{ mL/hr}$.

The provider's order reads: 'Titrate dobutamine by $1.5\text{ mcg/kg/min}$ every $15\text{ minutes}$ to achieve a cardiac index $\geq 2.2\text{ L/min/m}^2$.'

The latest hemodynamic assessment reveals a cardiac index of $1.8\text{ L/min/m}^2$. The nurse prepares to perform the next titration step according to the protocol.

At what value in $\text{mL/hr}$ will the nurse program the infusion pump for the new dose? (Round the final answer to the nearest tenth.)

An adult client admitted to the medical-surgical unit is currently receiving continuous enteral nutrition through a nasogastric tube. To actively reduce the risk of potential physiological complications associated with this therapy, which intervention is most appropriate for the nurse to implement?

A nurse is managing the care of a client who is receiving continuous total parenteral nutrition (TPN) via a peripherally inserted central catheter (PICC). Which of the following nursing actions are appropriate to include in the client's plan of care? (Select all that apply.)

A nurse is caring for a client with type 2 diabetes mellitus whose morning blood glucose level is $185 \text{ mg/dL}$. The healthcare provider has prescribed $10 \text{ units}$ of regular insulin and $20 \text{ units}$ of NPH insulin to be administered subcutaneously. The nurse is preparing to mix both insulins in a single syringe. Arrange the following steps in the correct sequence for this procedure.

A nurse is caring for a 62-year-old client who is 4 days post-operative following an open colon resection. While the nurse is assisting the client with coughing and deep breathing exercises, the client reports a sudden "popping" sensation in the abdomen. The nurse inspects the surgical site and observes a wound evisceration. Place the following nursing interventions in the correct order of priority to mitigate further physiological risk.

A nurse is evaluating a client who sustained a massive anterior wall myocardial infarction 24 hours ago. Which of the following clinical findings indicate the client is developing cardiogenic shock? Select all that apply.

A nurse is assessing a client who is 4 hours post-operative following a total thyroidectomy. Which of the following clinical observations and assessment findings require immediate intervention by the nurse? Select all that apply.

A client is recovering in the outpatient endoscopy unit after undergoing an esophagogastroduodenoscopy (EGD) with gastric biopsies. The client received intravenous midazolam and fentanyl for moderate sedation. Which assessment finding represents the highest priority physiological risk that the nurse must report immediately?

A nurse is evaluating a client who underwent a percutaneous coronary intervention (PCI) via the right femoral artery approach 4 hours ago. The femoral sheath has been removed and hemostasis was achieved. The client now reports a new onset of dull, aching pain in the right flank and lower back. Current vital signs are: blood pressure 96/60 mmHg, heart rate 114 bpm, and respiratory rate 20/min. The puncture site dressing is dry and intact, and the right pedal pulse is +2. Which of the following is the priority action by the nurse?

A client is 4 hours post-coronary artery bypass grafting (CABG) surgery with mediastinal and pleural chest tubes in place. The nurse notes that the previously steady dark red mediastinal drainage has abruptly stopped over the last hour. The client has become highly restless. Current vital signs are heart rate 118 bpm, blood pressure 92/76 mmHg, and respiratory rate 22 breaths/min. The latest arterial blood gas (ABG) on 40% FiO2 reveals: pH 7.32, PaCO2 37 mm Hg, PaO2 88 mm Hg, and HCO3 18 mEq/L. Which action should the nurse take FIRST to reduce the risk of imminent mortality?

A nurse is evaluating a client admitted 48 hours ago with severe acute pancreatitis. The client has become increasingly restless and confused. Current assessment findings include:

* Respiratory rate: 34 breaths/min and shallow
* Heart rate: 132 beats/min
* Blood pressure: 78/50 mm Hg
* **Oxygen saturation ($SpO_2$):** 84% on 4 L/min via nasal cannula
* Urine output: 10 mL over the last 2 hours
* Arterial Blood Gas (ABG): pH 7.25, $PaCO_2$ 58 mm Hg, $PaO_2$ 52 mm Hg, $HCO_3^-$ 24 mEq/L

Which of the following interventions should the nurse anticipate implementing? Select all that apply.

An adult client hospitalized with a deep vein thrombosis is receiving a continuous intravenous infusion of heparin. The healthcare provider prescribes a scheduled dose of intravenous vancomycin to treat a concurrent wound infection. The client currently has a single patent $20$-gauge peripheral venous catheter. Upon checking the facility drug reference, the nurse notes that heparin and vancomycin are physically incompatible at the Y-site. Which action by the nurse is the most appropriate?