Physiological Integrity

A nurse is assessing a client who underwent a bedside thoracentesis 1 hour ago to drain a large pleural effusion. To reduce the risk of a life-threatening complication, which assessment finding requires the most immediate intervention by the nurse?

A client receiving a continuous intravenous infusion of unfractionated heparin at $1,500\text{ units/hr}$ through a dedicated 20-gauge peripheral catheter suddenly reports a severe "thunderclap" headache and exhibits unequal pupils. The nurse immediately stops the infusion pump due to suspected intracranial hemorrhage. The healthcare provider prescribes stat intravenous protamine sulfate. What is the most critical action the nurse must take to safely utilize the existing vascular access for the antidote administration?

While managing the care of a client recovering from a recent left total hip replacement (posterior approach), the nurse must implement specific positioning and safety measures. Which action by the nurse is correct?

During bedside rounds on an orthopedic unit, the charge nurse observes a newly hired nurse preparing to assist a client onto a bedpan. The client had a left total hip arthroplasty (posterior surgical approach) two days ago. Which action by the newly hired nurse demonstrates the safest technique for this procedure?

To promote hemostasis and prevent bleeding complications after a percutaneous liver biopsy, the healthcare team must ensure the client maintains a specific resting posture. Which positioning strategy is correct for this client during the immediate post-procedure period?

A clinical team is providing hygiene and mobility support for a bedfast client who exhibits new-onset urinary incontinence and a localized, non-blanchable redness over the sacral area. Which interventions are appropriate for this client? Select all that apply.

A nurse is caring for a 62-year-old client who underwent a cardiac catheterization via the right femoral artery 2 hours ago for the evaluation of ischemic heart disease. Which of the following nursing actions will reduce the client's risk for post-procedure complications? Select all that apply.

An adult client is admitted to the gastroenterology unit and requires continuous total parenteral nutrition (TPN). The TPN is infusing through a single-lumen peripherally inserted central catheter (PICC). The client has a new prescription for a scheduled intravenous (IV) dose of pantoprazole. Which action should the nurse take to safely administer the medication?

A nurse is preparing to administer a scheduled dose of intravenous (IV) piggyback ceftriaxone to a client admitted with pneumonia. The client currently has a continuous IV infusion of parenteral nutrition (PN) running at $75\text{ mL/hr}$ through a central venous catheter. Which action must the nurse prioritize first?

A client hospitalized with severe cellulitis requires scheduled doses of intravenous vancomycin. The client has an active, continuous heparin drip running via a dedicated single-lumen peripheral catheter. Which of the following nursing actions are necessary for safe administration and monitoring? Select all that apply.

A nurse is caring for a client with decompensated liver cirrhosis who has just undergone a therapeutic paracentesis with the removal of $6.5$ liters of ascitic fluid. Thirty minutes after the procedure, the client reports feeling lightheaded. The puncture site dressing is dry and intact.

Current arterial blood gas (ABG) on room air:
pH: $7.49$
PaCO $_2$: $30$ mmHg
PaO $_2$: $88$ mmHg
HCO $_3^-$: $23$ mEq/L

Which of the following is the priority nursing action to reduce the client's risk of a severe physiological complication?

A rapid response nurse is managing a client who experienced a severe extravasation of a continuous norepinephrine infusion from a peripheral intravenous catheter. Following the facility's extravasation management protocol, the primary health care provider prescribes phentolamine mesylate $0.15\text{ mg/kg}$ to be infiltrated subcutaneously around the ischemic site.

The client weighs $191.4\text{ lbs}$.

The pharmacy dispenses phentolamine in lyophilized vials, which the nurse reconstitutes to yield a concentration of $5\text{ mg/mL}$.

The protocol mandates that the exact calculated phentolamine dose must be further diluted with $0.9\%$ sodium chloride to achieve a final total syringe volume of $12\text{ mL}$ prior to administration.

How many milliliters ($\text{mL}$) of $0.9\%$ sodium chloride must the nurse draw up to mix with the phentolamine? Record your answer to the nearest tenth.

A client with severe sepsis is receiving a continuous intravenous (IV) infusion of norepinephrine at $0.05\text{ mcg/kg/min}$ through the proximal lumen of a double-lumen central venous catheter (CVC). The healthcare provider orders an intermittent IV infusion of piperacillin/tazobactam $3.375\text{ g}$ diluted in $100\text{ mL}$ of normal saline to be administered over $30\text{ minutes}$. A drug reference indicates that piperacillin/tazobactam is physically incompatible with norepinephrine. Which of the following is the most appropriate action by the nurse?

A nurse is preparing to administer a large-volume cleansing enema to an adult client experiencing severe constipation. Arrange the following nursing actions in the correct chronological sequence of execution.

A nurse is caring for a client who is receiving continuous enteral tube feedings via a nasogastric (NG) tube. Which actions should the nurse take to reduce the client's risk of aspiration? Select all that apply.

A client with severe gastroenteritis requires intravenous rehydration. The treatment plan includes $1,000\text{ mL}$ of $0.9\%$ sodium chloride to run over a $4\text{-hour}$ period. At what rate in $\text{mL/hr}$ should the nurse program the infusion pump? (Record your answer using a whole number.)

A nurse is preparing to obtain a blood specimen for a comprehensive metabolic panel from a client's multi-lumen central venous catheter (CVC). A continuous infusion of parenteral nutrition is currently running through an adjacent lumen. To reduce the risk of pre-analytical laboratory errors and maintain line patency, in what order should the nurse perform the following actions? (Arrange the items in the correct chronological sequence.)

A nurse discovers that a client's central venous catheter (CVC) tubing has accidentally disconnected from the injection cap. The client suddenly appears extremely restless, is gasping for air, and exhibits circumoral cyanosis. Which of the following is the priority nursing action?

An older adult client is admitted with a severe exacerbation of chronic obstructive pulmonary disease (COPD). During evening rounds, the client reports extreme fatigue but states, "I cannot fall asleep because I feel like I am suffocating when I lie down." Which nursing action is most appropriate to promote comfort and facilitate rest for this client?

A client is admitted to the cardiac intensive care unit with acute decompensated heart failure and a severely elevated blood pressure. The client is receiving a continuous intravenous (IV) infusion of nitroglycerin currently running at $15\text{ mcg/min}$. The provider's prescription states: "Titrate nitroglycerin infusion upward by $5\text{ mcg/min}$ every 5 minutes until systolic blood pressure is less than $140\text{ mm Hg}$." The pharmacy provides a premixed nitroglycerin solution of $50\text{ mg}$ in $250\text{ mL}$ of $5\%$ dextrose in water (D5W). The client's blood pressure remains elevated, requiring exactly two dosage titrations over the next 10 minutes. What will the nurse set the IV infusion pump rate to in $\text{mL/hr}$ following the second titration? Record your answer as a number with one decimal place.