Physiological Integrity

A nurse is preparing to perform open suctioning for an adult client with a tracheostomy tube. To minimize the risk of complications such as hypoxia and mucosal trauma, in what order should the nurse perform the following actions? Arrange the steps in the correct sequence.

Following a motor vehicle collision, a young adult client is admitted to the neurosurgical unit with a traumatic brain injury. The latest assessment reveals a blood pressure of 172/68 mm Hg and a heart rate of 52 beats per minute. Previous vital signs were a blood pressure of 130/82 mm Hg and a heart rate of 88 beats per minute. What is the most appropriate initial action for the nurse to perform?

A nurse is reviewing the arterial blood gas (ABG) results for a client with a long history of severe chronic obstructive pulmonary disease (COPD). Which of the following ABG findings indicates that the client's body has physiologically compensated for the chronic respiratory condition?

A client with a history of severe chronic obstructive pulmonary disease (COPD) is receiving non-invasive positive pressure ventilation (NIPPV) for an acute exacerbation. The client's initial arterial blood gas (ABG) values on admission were pH $7.24$, PaCO $_2$ $76$ mm Hg, PaO $_2$ $52$ mm Hg, and HCO $_3^-$ $34$ mEq/L. After 90 minutes of continuous NIPPV therapy, a repeat ABG reveals pH $7.31$, PaCO $_2$ $64$ mm Hg, PaO $_2$ $62$ mm Hg, and HCO $_3^-$ $34$ mEq/L. Upon entering the room to review these results, the nurse observes that the client is now difficult to arouse, moans only in response to a sternal rub, and exhibits absent gag and swallow reflexes. Which action should the nurse take immediately?

While a nurse is changing the needleless connector caps on a 65-year-old client's right subclavian central venous catheter, the client suddenly gasps for air, reports sharp chest pain, and develops peripheral cyanosis. Recognizing the signs of a potential air embolism, in what order should the nurse perform the following emergency interventions? Arrange the steps from first priority to last priority.

A nurse is preparing to administer a unit of packed red blood cells (PRBCs) to a client with symptomatic anemia. Arrange the following actions in the correct chronological sequence to ensure safe administration.

A nurse is caring for a client who is receiving a transfusion of packed red blood cells. Fifteen minutes after the transfusion begins, the client suddenly reports severe lower back pain, chills, and dyspnea. Place the following nursing interventions in the correct order of priority from first to last.

A registered nurse is preparing to apply knee-length anti-embolism stockings to a client who is on strict bed rest. Place the following nursing actions in the correct order from first to last. (All steps are required.)

During the first post-surgical shift following an exploratory laparotomy, a client's clinical parameters demonstrate a subtle but continuous shift. The client's systolic blood pressure has drifted from $138$ mm Hg to $118$ mm Hg, while the diastolic pressure has climbed from $70$ mm Hg to $88$ mm Hg. Concurrently, the resting heart rate has accelerated from $78$ to $115$ beats per minute, and the respiratory rate is currently $28$ breaths per minute. The most recent hourly urine measurement yielded $15$ mL. Which underlying pathophysiological mechanism best accounts for this symptom complex?

A client with osteoarthritis is prescribed oral ibuprofen $600 \text{ mg}$ every 8 hours as needed for joint pain. The medication is available on the unit as an oral suspension with a concentration of $100 \text{ mg} / 5 \text{ mL}$. How many milliliters ($\text{mL}$) should the nurse administer for a single dose?

A nurse is assessing a postoperative client who recently underwent major abdominal surgery. Which clinical findings should indicate to the nurse that the client is experiencing the early, compensatory stage of hypovolemic shock? Select all that apply.

An emergency department nurse initiates a prescribed sodium nitroprusside continuous intravenous infusion for a patient presenting with acute hypertensive encephalopathy and underlying renal insufficiency. To ensure patient safety during this high-alert parenteral therapy, which interventions must the nurse implement? Select all that apply.

A nurse is caring for a client who is 12 hours postoperative following an open abdominal surgery. Which interventions should the nurse implement to reduce the client's risk of developing a venous thromboembolism (VTE)? Select all that apply.

An emergency department nurse is managing a client in a hypertensive crisis. The client weighs $85\text{ kg}$ and is currently receiving a continuous intravenous (IV) infusion of sodium nitroprusside at $25\text{ mL/hr}$. The IV bag contains $50\text{ mg}$ of sodium nitroprusside mixed in $250\text{ mL}$ of $5\%$ Dextrose in Water ($D_5W$). According to the facility protocol, the nurse must titrate the infusion upward by $0.5\text{ mcg/kg/min}$ if the mean arterial pressure (MAP) remains above $80\text{ mm Hg}$. The client's current MAP is $94\text{ mm Hg}$. After increasing the dosage by one increment, what will be the new infusion pump rate in $\text{mL/hr}$? Record your answer to the nearest tenth.

A client is prescribed an intravenous (IV) dose of phenytoin for seizure management. The client has a single peripheral IV access site with a continuous primary infusion of $5\%$ dextrose in water (D5W). Which action should the nurse take to safely administer the phenytoin?

A nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is receiving positive-pressure mechanical ventilation. The client's high-pressure ventilator alarm begins sounding continuously, and the nurse notes that the client has become highly agitated. The latest arterial blood gas (ABG) results show a pH of $7.21$, $\text{PaCO}_2$ of $72\text{ mm Hg}$, $\text{PaO}_2$ of $52\text{ mm Hg}$, and $\text{HCO}_3^-$ of $25\text{ mEq/L}$. Over the last 10 minutes, the client's blood pressure has dropped from $122/76\text{ mm Hg}$ to $84/42\text{ mm Hg}$, and the heart rate has increased from $98\text{ bpm}$ to $136\text{ bpm}$. Auscultation reveals absent breath sounds over the right lung field. Which action is the highest priority for the nurse to take to reduce the risk of cardiovascular collapse?

A nurse is formulating a basic care and comfort plan for an 82-year-old client who experienced a right hemispheric ischemic stroke 48 hours ago. The client exhibits left-sided hemiparesis, impulsive behavior, moderate dysphagia, and new-onset urinary incontinence. Which intervention is the most appropriate for the nurse to include in the plan of care?

A nurse is caring for a client newly admitted to the intensive care unit with diabetic ketoacidosis (DKA). The client is lethargic and exhibits deep, rapid respirations. Initial laboratory results reveal a serum blood glucose of 680 mg/dL (37.7 mmol/L), an arterial pH of 7.12, and a serum potassium of 2.7 mEq/L (2.7 mmol/L). In what order should the nurse implement the collaborative interventions? Arrange the actions from first to last.

A registered nurse (RN) is planning morning hygiene care for a client who has right-sided hemiparesis and is receiving continuous enteral nutrition. The RN is delegating parts of the care to an unlicensed assistive personnel (UAP). Which instruction provided by the RN is the most appropriate?

Following the removal of $1,500$ mL of pleural fluid via a right-sided thoracentesis, a client suddenly develops acute respiratory distress. The continuous monitor displays a heart rate of $128$ beats/minute and a blood pressure of $84/52$ mm Hg. Physical examination reveals absent breath sounds on the right side and a leftward tracheal shift. Which of the following is the priority nursing action?