Physiological Integrity

A clinical nurse is evaluating a client who underwent an open bowel resection with a temporary colostomy formation $48$ hours ago. The client has a nasogastric (NG) tube connected to low intermittent suction, which has drained $950$ mL of fluid over the past $12$ hours. Which cluster of clinical data indicates the highest risk for a physiological crisis and requires the most immediate intervention?

A nurse is preparing to administer intravenous (IV) ceftazidime to a pediatric client who weighs $24\text{ kg}$. The healthcare provider's prescription is for $50\text{ mg/kg/day}$ administered in $4$ equally divided doses. How many milligrams (mg) should the nurse administer for one single dose?

A nurse is caring for a client with a history of severe chronic obstructive pulmonary disease (COPD) who was admitted for community-acquired pneumonia. The client is currently receiving oxygen at $2 \text{ L/min}$ via nasal cannula. The most recent arterial blood gas (ABG) results reveal a $pH$ of $7.28$, $PaCO_2$ of $64 \text{ mm Hg}$, $HCO_3^-$ of $30 \text{ mEq/L}$, and $PaO_2$ of $56 \text{ mm Hg}$. The client's vital signs are blood pressure $86/54 \text{ mm Hg}$, heart rate $118 \text{ bpm}$, and respiratory rate $28 \text{ breaths/min}$. Which of the following actions should the nurse prioritize to reduce the risk of further physiological decompensation? Select all that apply.

A nurse is preparing to withdraw a prescribed intravenous medication from a glass ampule. Place the steps for this procedure in the correct chronological order.

A client diagnosed with a massive pulmonary embolism is receiving a continuous intravenous (IV) infusion of unfractionated heparin. The healthcare provider prescribes an intermittent IV antibiotic to be infused over 90 minutes. Upon checking the facility's drug reference guide, the nurse notes that the antibiotic is chemically incompatible with heparin. The client currently has only one patent 20-gauge peripheral IV catheter. Which action is most appropriate for the nurse to take?

A critically ill adult client in the intensive care unit has a triple-lumen central venous catheter. The client is receiving continuous intravenous infusions of total parenteral nutrition (TPN) via the distal lumen, propofol via the medial lumen, and norepinephrine via the proximal lumen. The client's mean arterial pressure acutely drops to $45\text{ mm Hg}$. The healthcare provider prescribes a stat $500\text{ mL}$ bolus of $0.9\%$ sodium chloride and the initiation of a continuous vasopressin infusion. Which of the following is the most appropriate nursing action?

A nurse is developing a plan of care for a 72-year-old client who recently suffered an ischemic stroke and is now receiving continuous enteral nutrition via a nasogastric (NG) tube. Which of the following actions should the nurse include to minimize the risk of complications? Select all that apply.

A nurse is preparing to administer a prescribed intravenous (IV) push medication through a client's continuous IV infusion line. Which action is essential for the nurse to perform prior to injecting the medication?

A client experiencing an acute exacerbation of chronic obstructive pulmonary disease (COPD) becomes increasingly lethargic. Recent arterial blood gas (ABG) analysis reveals a pH of 7.25, PaCO2 of 72 mm Hg, HCO3 of 28 mEq/L, and PaO2 of 58 mm Hg. To reduce the risk of impending respiratory failure, which intervention should the nurse implement first?

During the overnight shift in the neurosurgical intensive care unit, the nurse assumes care of a client who underwent a supratentorial tumor resection earlier in the day. Upon the hourly evaluation, the client demonstrates lethargy but withdraws purposefully from noxious stimuli. The physiological monitor displays a blood pressure of $172/64$ mmHg, an apical pulse of $52$ beats per minute, and an irregular respiratory pattern of $10$ breaths per minute. The indwelling catheter drainage system has collected $550$ mL of pale urine over the last $60$ minutes with a specific gravity of $1.003$. An arterial blood gas panel drawn on $40\%$ supplemental $O_2$ reveals a $pH$ of $7.28$, $PaCO_2$ of $54$ mmHg, $HCO_3^-$ of $24$ mEq/L, and $PaO_2$ of $88$ mmHg. Based on this diagnostic data, which action must the nurse prioritize to prevent lethal decompensation?

A client is scheduled to receive a bolus enteral formula via an established nasogastric (NG) tube. Which sequence of actions must the nurse execute to safely deliver this nutritional support? Arrange the clinical steps in the correct chronological order from first to last.

A nurse is caring for a client in the intensive care unit who is experiencing a hypertensive emergency. The client weighs $209\text{ lbs}$. The healthcare provider prescribes a continuous intravenous infusion of sodium nitroprusside at $3\text{ mcg/kg/min}$. The pharmacy dispenses a premixed IV bag containing $50\text{ mg}$ of sodium nitroprusside in $250\text{ mL}$ of $5\%$ dextrose in water (D5W).

At what rate, in $\text{mL/hr}$, should the nurse set the infusion pump? (Record your answer using one decimal place.)

A registered nurse (RN) is preparing to administer intravenous (IV) medications and fluids to a critically ill client. Which of the following actions by the RN demonstrate safe pharmacological and parenteral therapy practices? Select all that apply.

Following a percutaneous liver biopsy, the client is transferred back to the medical-surgical unit. To decrease the risk of internal hemorrhage, what is the most appropriate position for this client?

A client with severe acute pancreatitis is receiving total parenteral nutrition (TPN) and a separate intravenous lipid emulsion via a multi-lumen peripherally inserted central catheter (PICC). Which nursing actions are required for the safe administration and monitoring of these parenteral therapies? (Select all that apply.)

A 28-year-old client is mechanically ventilated in the intensive care unit following a severe traumatic brain injury. The client is sedated and receiving continuous intracranial pressure (ICP) monitoring. Current assessment findings include:

- Vital signs: Blood pressure 155/85 mm Hg, Heart rate 62 bpm, SpO2 98%.
- Current ICP: 24 mm Hg (Baseline for this client: 12 mm Hg).
- Arterial Blood Gas (ABG) results: pH 7.31, PaCO2 54 mm Hg, PaO2 95 mm Hg, HCO3 26 mEq/L.

Which action should the nurse prioritize to reduce the client's risk for neurological deterioration?

A nurse is coordinating care for an older adult client who is recovering from a right middle cerebral artery (MCA) infarction. The client exhibits left-sided hemiplegia, moderate dysphagia, and episodes of evening agitation. Which intervention demonstrates the correct application of basic care and comfort principles?

The nurse is preparing a client for a bedside abdominal paracentesis. In what order should the nurse perform the following actions to ensure client safety and reduce the risk of complications? Arrange the actions in the correct chronological sequence.

An adult client being treated for severe sepsis has a double-lumen central venous catheter in place. One lumen is dedicated to a continuous infusion of total parenteral nutrition, and the other lumen is delivering a continuous infusion of norepinephrine. The provider prescribes an immediate intravenous dose of vancomycin. What is the safest action by the nurse?

A nurse is evaluating a client who is $2\text{ hours}$ post-procedure following a right-sided cardiac catheterization via the femoral artery. Which of the following clinical findings indicate a developing complication and require immediate intervention? Select all that apply.