Physiological Integrity

A client with a deep vein thrombosis is receiving a continuous intravenous (IV) infusion of heparin through a single-lumen peripheral IV catheter. The healthcare provider prescribes a new order for intermittent IV vancomycin to treat a concurrent soft tissue infection. Which action by the nurse is most appropriate?

A client recovering from an ischemic stroke has residual dysphagia and requires assistance with oral intake. The nurse is planning interventions to prevent complications during feeding. Which of the following actions is the most appropriate for the nurse to implement?

A nurse is caring for a client who is receiving a packed red blood cell (PRBC) transfusion. Fifteen minutes after the transfusion begins, the client reports sudden chills and lower back pain. In what order should the nurse perform the following actions to minimize the client's risk of further injury? Arrange the steps from first to last.

An older adult client with advanced Parkinson's disease is receiving continuous enteral nutrition via a percutaneous endoscopic gastrostomy (PEG) tube. The client has a stage 2 sacral pressure injury and is exhibiting new-onset restlessness. The nurse needs to lower the head of the bed to reposition the client to a lateral position for pressure relief. Which action is the priority for the nurse to implement?

A rapid response team transfers an adult client with severe sepsis to the critical care unit. The client has a newly established multilumen central venous catheter (CVC) and is receiving a continuous intravenous (IV) infusion of norepinephrine. To safely manage this pharmacological therapy and the client's hemodynamic status, which interventions should the nurse implement? (Select all that apply.)

A nurse is preparing to collect a blood specimen for a comprehensive metabolic panel (CMP) from a patient's multi-lumen central venous catheter (CVC). The patient is currently receiving continuous total parenteral nutrition (TPN) through the distal lumen, and the nurse plans to use the proximal lumen for the blood draw. Arrange the following actions in the correct sequential order to ensure accurate laboratory results and maintain catheter patency.

Appropriate client positioning is crucial for minimizing physiological risks during and after clinical interventions. Which clinical situations are correctly paired with their required therapeutic position? Select all that apply.

A 45-year-old client arrives at the surgical step-down unit directly from the post-anesthesia care unit following a total thyroidectomy for hyperthyroidism. To effectively reduce the risk of postoperative complications, which actions are essential for the nurse to implement? Select all that apply.

A nurse is instructing a client with left-sided hemiparesis on how to safely descend stairs using a quad cane. The client holds the cane in the right hand. In what order should the nurse instruct the client to perform the following actions to step down?

During the admission assessment of a client with severe gastroenteritis, the laboratory reports a critically low serum potassium level of $2.2\text{ mEq/L}$. The electronic health record displays a stat prescription for $40\text{ mEq}$ of potassium chloride in $100\text{ mL}$ of $0.9\%$ sodium chloride, to be infused intravenously over $60\text{ minutes}$. The client is connected to continuous cardiac monitoring and has a 20-gauge peripheral intravenous catheter in the right forearm. Which clinical action should the nurse take next?

A nurse is continuously monitoring a client who is receiving an intravenous infusion of doxorubicin, a known vesicant, via a peripheral catheter. The client suddenly reports severe burning pain at the insertion site, and the nurse observes localized swelling and erythema. To reduce the risk of severe tissue necrosis, in what order should the nurse perform the following interventions?

A nurse is assessing a client who is 4 hours postoperative following an abdominal hysterectomy. Which of the following findings is the earliest indicator that the client may be developing hemorrhagic shock?

A nurse is planning care for a client who is $2$ days postoperative following a right total hip arthroplasty (posterior approach). Which positioning intervention should the nurse implement to prevent surgical complications?

A nurse is preparing to obtain a sterile urine specimen for culture and sensitivity from a client who has a continuous indwelling urinary catheter. Arrange the following steps in the correct order to minimize the risk of infection and ensure an accurate sample.

A patient with septic shock, weighing $165\text{ lbs}$, is receiving a continuous intravenous infusion of norepinephrine via a dedicated central venous catheter to minimize the risk of extravasation. The current infusion rate delivers $0.05\text{ mcg/kg/min}$. The patient's mean arterial pressure (MAP) is currently $58\text{ mmHg}$. The hemodynamic titration protocol prescribes increasing the dose by $0.02\text{ mcg/kg/min}$ every $5\text{ minutes}$ until the MAP is $\ge 65\text{ mmHg}$. The medication is supplied as $4\text{ mg}$ of norepinephrine in $250\text{ mL}$ of 5% dextrose in water (D5W). The nurse prepares to initiate the first titration increment. What should the new infusion pump rate be set at in $\text{mL/hr}$? (Round to the nearest tenth)

A nurse is caring for a client with decompensated heart failure who weighs $187\text{ lb}$. The healthcare provider prescribes a continuous IV infusion of dobutamine at $7.5\text{ mcg/kg/min}$. The pharmacy dispenses a premixed IV bag containing dobutamine $500\text{ mg}$ in $250\text{ mL}$ of $5\%\text{ dextrose in water}$. At what rate, in $\text{mL/hr}$, should the nurse set the IV infusion pump? (Record your answer to the nearest tenth.)

A client receiving a transfusion of packed red blood cells (PRBCs) suddenly reports severe lower back pain, chills, and shortness of breath. Suspecting an acute hemolytic transfusion reaction, the nurse must intervene immediately. Arrange the following nursing actions in the correct chronological sequence.

An older adult client with advanced Alzheimer's disease is receiving acute care for pneumonia. The client becomes intensely agitated and physically combative during attempts to provide morning hygiene. Which actions should the nurse include in the client's care plan to safely promote basic hygiene and comfort? (Select all that apply.)

An older adult client with a history of mild dementia has just returned to the unit following a diagnostic lumbar puncture. The client is restless, repeatedly attempts to sit up in bed, and verbally reports a throbbing headache. Which of the following basic care and comfort interventions should the nurse implement? (Select all that apply.)

A nurse is establishing a basic care regimen for an older adult client who is bedbound with right-sided flaccid paralysis and altered sensory perception due to a recent traumatic brain injury. To optimize comfort, prevent contractures, and protect skin integrity, which combination of nursing actions is most appropriate?