Physiological Integrity

A nurse is preparing to administer an intermittent bolus enteral feeding via a percutaneous endoscopic gastrostomy (PEG) tube to a client. In what order should the nurse perform the following actions? Arrange the steps in the correct sequence.

Following a diagnostic lumbar puncture, a client is transferred back to the acute care unit. The client reports mild tenderness at the lower back puncture site but is currently alert with stable vital signs. Which of the following actions is the most appropriate for the registered nurse to implement?

A client with mild cognitive impairment returned to the medical-surgical unit following a diagnostic lumbar puncture. The client is visibly restless, continuously attempts to sit up on the edge of the bed, and grasps at the bed linens. Which intervention is most appropriate to manage this client's care and comfort?

A nurse is preparing to administer a prescribed dose of intravenous (IV) ondansetron to a client who is recovering from a laparoscopic cholecystectomy and reporting nausea. The client has a peripheral saline lock in place on the right forearm. Arrange the following steps for administering the IV push medication in the correct sequence.

During morning rounds, the nurse notes that a client with severe malnutrition has total parenteral nutrition (TPN) infusing through a single-lumen peripherally inserted central catheter (PICC). A new prescription for intermittent intravenous (IV) ceftriaxone is ordered for a suspected infection. Which action is the most appropriate method to deliver the antibiotic?

The nurse is preparing to safely transfer a client with right-sided hemiparesis from the bed to a wheelchair. In which order should the nurse perform the following actions? (Arrange the steps in the correct sequence from first to last.)

A client who has difficulty swallowing is receiving a continuous enteral feeding via a nasogastric tube. Which actions are appropriate to include in the client's plan of care to maintain safety and comfort? (Select all that apply)

An intensive care nurse is initiating a heparin protocol for a client weighing $80 \text{ kg}$ who was recently diagnosed with a pulmonary embolism. The medical prescription indicates a continuous intravenous infusion at $18 \text{ units/kg/hr}$. The pharmacy delivers a premixed bag labeled 'Heparin sodium $25,000 \text{ units}$ in $500 \text{ mL}$ of $0.45\% \text{ NaCl}$'. Based on these parameters, how many $\text{mL/hr}$ will the infusion pump be programmed to deliver? (Round the final answer to the nearest tenth.)

An adult client who has severe osteoarthritis of the left knee is receiving education from the nurse on how to navigate a staircase at home using a standard single-point cane. Which statement by the client demonstrates a correct understanding of ascending the stairs?

A nurse is preparing to administer an intermittent intravenous (IV) antibiotic via a secondary line (piggyback) to a client who is currently receiving a continuous primary IV fluid infusion. Arrange the following steps for setting up and initiating the secondary infusion in the correct chronological order.

A nurse is reviewing prescriptions for a client admitted with muscle weakness and a serum potassium level of 2.4 mEq/L. The healthcare provider has prescribed 40 mEq of intravenous potassium chloride (KCl) in 100 mL of 0.9% sodium chloride to be infused over 1 hour. The client currently has a 22-gauge peripheral intravenous (IV) catheter in the right forearm. Which action should the nurse take first?

During morning rounds on the orthopedic unit, a clinical team coordinates the daily care for a client who is on their third day of recovery following a right total hip arthroplasty (posterior approach). Which intervention demonstrates correct adherence to post-operative safety and comfort guidelines?

A nurse in the emergency department is caring for a client who is experiencing continuous tonic-clonic seizures. The healthcare provider prescribes intravenous phenytoin. The client currently has an ongoing peripheral intravenous infusion of 5% dextrose in water (D5W). Which of the following is the most appropriate action by the nurse?

A nurse is preparing to draw a blood specimen from a client's multi-lumen central venous catheter (CVC). A continuous intravenous infusion of 0.9% sodium chloride is currently running through a different lumen of the catheter. Arrange the following steps in the correct chronological order to obtain the blood sample safely and prevent laboratory result contamination.

A nurse is developing a plan of care for a client who recently sustained a severe traumatic brain injury and is at high risk for increased intracranial pressure (ICP). Which of the following basic care and comfort interventions should the nurse include? Select all that apply.

A critical care nurse is preparing to initiate a continuous IV infusion of dobutamine for a client with severe heart failure. The healthcare provider has prescribed dobutamine at $5 \text{ mcg/kg/min}$. The client weighs $198 \text{ lb}$. The medication is supplied as dobutamine $500 \text{ mg}$ in $250 \text{ mL}$ of 5% dextrose in water (D5W). At what rate, in $\text{mL/hr}$, should the nurse set the IV infusion pump? (Record your answer using one decimal place.)

A 68-year-old client is 24 hours post-operative following an open cholecystectomy. The client has been guarding the abdomen and is reluctant to use the incentive spirometer due to incisional pain. The nurse notes shallow respirations at $26$ breaths/min and an oxygen saturation ($SpO_2$) of $89\%$ on room air. A newly drawn arterial blood gas (ABG) reveals the following: pH $7.29$, $PaCO_2$ $56$ mmHg, $HCO_3^-$ $24$ mEq/L, and $PaO_2$ $62$ mmHg. Which immediate action should the nurse implement to reduce the risk of further physiological deterioration?

During morning rounds, a nurse notes that a client has an active peripheral venous catheter infusing lactated Ringer's solution at $100\text{ mL/hr}$. The pharmacy has just delivered a newly prescribed dose of intravenous ceftriaxone. Which action represents the most critical safety step the nurse must perform prior to connecting the medication?

A client is admitted to the emergency department in status epilepticus. The healthcare provider prescribes a loading dose of phenytoin 1,000 mg intravenously STAT. The client has a single 20-gauge peripheral intravenous (IV) catheter, which is currently infusing a primary solution of 5% Dextrose in Water (D5W) at 100 mL/hr. Which sequence of actions by the nurse demonstrates safe administration of this medication?

A nurse is planning care for a client who sustained deep partial-thickness burns to the anterior neck, bilateral axillae, and chest 24 hours ago. The client is experiencing severe discomfort and persistently requests to rest in a curled, fetal position with multiple pillows placed under the head and knees. Which nursing action is the most appropriate to ensure physiological integrity while managing the client's basic care?