Physiological Integrity

A geriatric client with right-sided heart failure and marked dependent edema is receiving inpatient care. The client also has right-sided hemiplegia secondary to a past cerebrovascular event. Over the last few hours, the client has become highly restless and is experiencing new-onset urinary incontinence. Which intervention regarding the client's comfort and care is the most appropriate?

A nurse is preparing to administer an intravenous (IV) push medication that is incompatible with the client's continuous IV fluid infusion. The client has a single peripheral IV access. Arrange the following actions in the correct sequence to safely administer this medication. (Place the first action at the top and the last action at the bottom.)

A nurse is providing care for a client who is 1 day postoperative following a right total hip arthroplasty with a posterior approach. Which nursing action is most appropriate when assisting the client with basic care and mobility?

A nurse is caring for a client admitted with an acute severe asthma exacerbation. Upon admission, the client was anxious and tachypneic with a respiratory rate of 34/min, and auscultation revealed loud, diffuse bilateral wheezing. Two hours later, the nurse notes that the client is now lethargic, the respiratory rate has decreased to 14/min, and breath sounds are markedly diminished. Which of the following arterial blood gas (ABG) results should the nurse anticipate based on the client's current clinical status?

A nurse is caring for a client who is receiving continuous total parenteral nutrition (TPN) via a peripherally inserted central catheter (PICC). Which of the following nursing actions are appropriate for managing this client's parenteral therapy? Select all that apply.

A critically ill adult client is admitted to the intensive care unit with severe diabetic ketoacidosis (DKA). The initial laboratory results indicate a blood glucose level of $715\text{ mg/dL}$, an arterial pH of $7.12$, and a serum potassium level of $3.1\text{ mEq/L}$. To reduce the risk of fatal complications during treatment, arrange the following collaborative interventions in the safest chronological order from first to last.

A nurse is caring for a 68-year-old client admitted 12 hours ago with acute pyelonephritis. The client is currently restless, and the nurse notes their skin is abnormally warm and flushed. Assessment reveals a urine output of 15 mL/hr over the past two hours. Vital signs are:

* Blood pressure: 86/42 mmHg
* Heart rate: 124 bpm
* Respiratory rate: 28 breaths/min
* Temperature: 39.1°C (102.4°F)

An arterial blood gas (ABG) analysis on room air shows: pH 7.31, PaCO2 29 mmHg, HCO3- 14 mEq/L, and PaO2 86 mmHg. Which of the following actions should the nurse perform FIRST?

A nurse is caring for a client who is mechanically ventilated in the intensive care unit following abdominal surgery. The ventilator's high-pressure alarm has been sounding frequently. The client's latest arterial blood gas (ABG) results are provided in the table below:

Which intervention should the nurse implement first to reduce the risk of further physiological decompensation?

A charge nurse is evaluating a newly licensed nurse who is managing a client 12 hours postoperative following a right total pneumonectomy. No chest tube is present. The client's vital signs are: blood pressure 110/70 mmHg, heart rate 98 bpm, respiratory rate 20/min, and oxygen saturation 94% on 2 L/min via nasal cannula. Which action by the newly licensed nurse requires immediate intervention by the charge nurse to prevent a life-threatening complication?

A registered nurse is preparing to administer a mixed dose of NPH and regular insulin to a client with diabetes mellitus. In what order should the nurse perform the following actions to safely prepare the injection? Arrange the steps in the correct sequence.

A client admitted with a hypertensive emergency is receiving a continuous intravenous infusion of sodium nitroprusside at $3 \text{ mcg/kg/min}$. The client weighs $220 \text{ lbs}$. The medication is supplied as $50 \text{ mg}$ of sodium nitroprusside in $250 \text{ mL}$ of $5\%$ dextrose in water (D5W). Upon assessment, the nurse notes the client's blood pressure has decreased to $86/52 \text{ mmHg}$. The healthcare provider prescribes titrating the infusion rate down to $1 \text{ mcg/kg/min}$. Which action is most appropriate for the nurse to take?

A 58-year-old client is being managed in the high-dependency unit for acute necrotizing pancreatitis. Over the past three hours, the nurse notes the client's heart rate has increased from $86$ to $116$ beats/min, and the blood pressure has trended from $134/78$ mm Hg to $112/86$ mm Hg. The client's urine output for the last hour is $15$ mL. The most recent arterial blood gas analysis reveals a pH of $7.31$, PaCO2 of $35$ mm Hg, and HCO3- of $16$ mEq/L. Based on these findings, which immediate risk mitigation action should the nurse prioritize?

An older adult client is prescribed a large-volume cleansing enema to treat severe constipation. Which of the following actions should the nurse take when preparing and administering this intervention?

An emergency department team is treating a client for a hypertensive emergency. The provider prescribes a continuous sodium nitroprusside infusion with instructions to begin at $0.3 \text{ mcg/kg/min}$ and titrate upward by $0.3 \text{ mcg/kg/min}$ every $5 \text{ minutes}$ until the mean arterial pressure (MAP) falls below $100 \text{ mm Hg}$.

The client's admission weight is $231 \text{ lbs}$.
The pharmacy supplies a premixed IV bag containing $50 \text{ mg}$ of sodium nitroprusside in $250 \text{ mL}$ of $5\%$ dextrose in water ($D_5W$).

The nurse initiates the infusion. Because the client's MAP remains consistently above $100 \text{ mm Hg}$ during the initial monitoring period, the nurse performs exactly three protocol-directed upward titrations.

Determine the new IV pump rate in $\text{mL/hr}$ immediately following the third titration. Round your final answer to the nearest whole number.

A nurse is initiating the post-procedure care plan for a client who returned to the medical-surgical unit following a percutaneous liver biopsy. To actively reduce the client's risk for a life-threatening complication, which intervention should the nurse implement?

An emergency department triage nurse evaluates a client who sustained blunt force abdominal trauma in a motor vehicle collision. The nurse suspects the client is entering the compensatory stage of shock. Which of the following assessment findings support this physiological adaptation? Select all that apply.

A nurse is assessing a client who underwent a percutaneous coronary intervention (PCI) via the right femoral artery 2 hours ago. The client suddenly reports a warm, wet sensation in their right groin. The nurse immediately dons clean gloves and observes active arterial bleeding and a rapidly expanding hematoma. Place the following nursing interventions in the correct priority sequence to manage this complication.

A nurse is preparing to remove a client's non-tunneled central venous catheter (CVC). After performing hand hygiene, donning appropriate personal protective equipment (PPE), and removing the old dressing, in what order should the nurse perform the following actions? Arrange the steps from first to last.

A client with severe acute respiratory distress syndrome (ARDS) is mechanically ventilated and requires continuous sedation. The healthcare provider prescribes a propofol infusion at $30 \text{ mcg/kg/min}$. The client weighs $209 \text{ lb}$. The pharmacy dispenses propofol $1,000 \text{ mg}$ in a $100 \text{ mL}$ lipid emulsion. What should the nurse set the infusion pump rate to in $\text{mL/hr}$? Record your answer to the nearest whole number.

A nurse is assessing a client who experienced significant blood loss from a severe laceration. Which assessment findings should the nurse identify as early compensatory signs of hypovolemic shock? Select all that apply.