Physiological Integrity

An adult client who is $24\text{ hours}$ postoperative following a small bowel resection remains NPO (nothing by mouth). The primary healthcare provider prescribes a continuous intravenous (IV) infusion of $1000\text{ mL}$ of lactated Ringer's solution to be administered over an $8\text{-hour}$ period.

At what rate in milliliters per hour (mL/hr) should the nurse set the electronic IV infusion pump? Record your answer as a whole number.

A client weighing $154\text{ lbs}$ is experiencing continuous generalized tonic-clonic seizures. The healthcare provider orders a loading dose of intravenous phenytoin $18\text{ mg/kg}$ to be administered at the maximum safe rate. The client currently has a single 20-gauge peripheral IV in the right forearm with a continuous infusion of $5\%$ dextrose in $0.45\%$ sodium chloride (D5 1/2 NS) running at $100\text{ mL/hr}$. Phenytoin is supplied in $50\text{ mg/mL}$ vials.

Which action by the nurse represents the safest and most appropriate administration technique?

A nurse is preparing to mix and administer a prescribed dose of Regular insulin and NPH insulin in a single syringe. Arrange the steps of this procedure in the correct sequence from first to last.

A nurse is providing morning care for a client who is in balanced suspension skeletal traction for a fractured right femur. Which action by the nurse demonstrates the correct application of basic care and comfort principles?

A nurse is caring for a client who underwent a right transfemoral (above-the-knee) amputation 24 hours ago. Which positioning strategy should be incorporated into the daily routine to ensure optimal joint mobility for future prosthesis use?

A client with stage 5 chronic kidney disease (CKD) arrives at the emergency department after missing three consecutive hemodialysis sessions. The client is lethargic and exhibits deep, rapid respirations at a rate of $34 \text{ breaths/min}$. An electrocardiogram (ECG) reveals tall, peaked T waves. The most recent arterial blood gas (ABG) shows a pH of $7.22$, PaCO2 of $28 \text{ mm Hg}$, PaO2 of $96 \text{ mm Hg}$, and HCO3- of $12 \text{ mEq/L}$. To reduce the risk of imminent physiological collapse, which prescribed action should the nurse implement FIRST?

A registered nurse is reviewing unit protocols for safe intravenous (IV) medication administration. Which of the following practices demonstrate adherence to standard parenteral therapy safety principles? Select all that apply.

A nurse is preparing to perform a routine central venous catheter (CVC) dressing change for a client receiving long-term parenteral nutrition. In what chronological order should the nurse perform the following steps to ensure strict aseptic technique and prevent catheter dislodgement?

The nurse is caring for a client who was recently admitted with a massive pulmonary embolism. The client is currently receiving a continuous intravenous infusion of unfractionated heparin through a single-lumen peripheral catheter. A new prescription is received for an urgent dose of intravenous vancomycin to treat a suspected bloodstream infection. After consulting a drug reference and discovering that the two medications are physically incompatible, which action should the nurse take?

While rounding on the medical unit, a nurse prepares to administer a scheduled intravenous (IV) push medication to a patient. The patient currently has a continuous IV infusion of 0.9% sodium chloride running through a peripheral line. What is the most critical initial action the nurse should take to ensure safe medication administration?

Following a right total hip arthroplasty, a nurse is establishing a plan of care to minimize potential postoperative complications. Which of the following interventions should be included? (Select all that apply.)

A medical-surgical nurse is preparing to administer a scheduled dose of intravenous ceftriaxone $1\text{ g}$ to an adult client diagnosed with bacterial pneumonia. The client currently has a single-lumen peripheral venous catheter that is continuously infusing Lactated Ringer's solution at $125\text{ mL/hr}$. What is the most appropriate nursing intervention for safely delivering the prescribed antibiotic?

A nurse in the intensive care unit is caring for a client with acute respiratory distress syndrome (ARDS) who is mechanically ventilated. The most recent assessment reveals a mean arterial pressure (MAP) of $54 \text{ mm Hg}$ and arterial blood gas (ABG) values showing: $pH = 7.25$, $PaCO_2 = 62 \text{ mm Hg}$, $HCO_3^- = 25 \text{ mEq/L}$, and $PaO_2 = 54 \text{ mm Hg}$ on an $FiO_2$ of $0.80$. To reduce the risk of further physiological deterioration, which of the following interventions should the nurse implement? Select all that apply.

A critical care nurse is tasked with obtaining a blood specimen for a complete blood count (CBC) from a client's multi-lumen central venous catheter (CVC). A continuous infusion of total parenteral nutrition (TPN) is currently infusing through the medial lumen. Place the following steps for obtaining the blood sample in the correct sequential order. (Arrange the steps from first to last).

A primary health care provider prescribes a continuous intravenous heparin infusion for a client diagnosed with a deep vein thrombosis. The client's admission weight is $198\text{ lb}$. The prescribed infusion rate is $15\text{ units/kg/hr}$, and the medication arrives from the pharmacy as a premixed $500\text{ mL}$ bag containing $25,000\text{ units}$ of heparin. At what rate should the nurse set the infusion pump in $\text{mL/hr}$? (Record the answer as a whole number)

A 54-year-old client is being monitored on the acute care unit 90 minutes after an ultrasound-guided percutaneous liver biopsy. The client's baseline vital signs upon arrival to the unit were a blood pressure of 136/74 mm Hg and a heart rate of 72 beats per minute. Upon reassessment, the nurse notes the client is increasingly restless, with a blood pressure of 114/92 mm Hg, a heart rate of 108 beats per minute, and a respiratory rate of 22 breaths per minute. The client also mentions a newly developed dull ache in the right shoulder. To minimize the risk of a severe physiological complication, which of the following actions must the nurse implement?

A 78-year-old client with moderate cognitive impairment is receiving intravenous therapy for a respiratory infection. The client is agitated, repeatedly picks at the venous access site, and exhibits new-onset urinary incontinence. Which basic care and comfort interventions should the nurse include in the plan of care? Select all that apply.

A nurse is developing a comprehensive care plan for an elderly client with end-stage heart failure who is experiencing profound dyspnea at rest, severe fatigue, and anorexia. Which of the following basic care and comfort interventions should the nurse include in the client's plan of care? (Select all that apply.)

A client is transferred to the medical-surgical unit after undergoing an esophagogastroduodenoscopy (EGD) with a gastric biopsy under conscious sedation. Which of the following nursing actions and assessments should the nurse implement to reduce the risk of postoperative complications? Select all that apply.

While monitoring a client receiving an infusion of packed red blood cells, the nurse notes the client suddenly develops chills, dyspnea, and flank pain. Arrange the following nursing actions in the correct priority sequence to mitigate further physiological risk.