Physiological Integrity

A nurse is preparing to administer a scheduled bolus enteral feeding via a percutaneous endoscopic gastrostomy (PEG) tube to a client who is receiving long-term nutritional support. Arrange the following nursing actions in the correct sequence.

An intensive care nurse is managing a client in profound cardiogenic shock complicated by severe metabolic acidosis. The client has a single-lumen central venous catheter currently dedicated to a continuous intravenous infusion of norepinephrine at $0.15 \text{ mcg/kg/min}$ to maintain a mean arterial pressure of $62 \text{ mm Hg}$. The healthcare provider gives a STAT prescription for $50 \text{ mEq}$ of intravenous sodium bicarbonate. Which action represents the safest and most appropriate method for the nurse to administer this medication?

A 62-year-old client has a chest tube connected to a closed water-seal drainage system for the treatment of a right-sided spontaneous pneumothorax. Which assessment findings indicate a developing physiological complication or system malfunction that requires immediate intervention? Select all that apply.

A nurse is instructing a client with right-sided hemiparesis on how to safely ambulate using a single-point cane. Place the following steps of the ambulation sequence in the correct order. (Arrange the items from first to last.)

A nurse on a medical-surgical unit is caring for a client with a serum potassium level of $2.4 \text{ mEq/L}$. The healthcare provider prescribes an intravenous infusion of $40 \text{ mEq}$ of potassium chloride in $100 \text{ mL}$ of $0.9\% \text{ sodium chloride}$ to be administered over $30 \text{ minutes}$. The client has a patent 20-gauge peripheral intravenous catheter. Which of the following is the priority nursing action?

An older adult client is restricted to bed rest on the surgical unit following a lumbar spinal fusion. When addressing the client's basic care, comfort, and mobility needs, which interventions should the nurse implement? Select all that apply.

A nurse is planning skin integrity and comfort measures for an intubated client with severe acute respiratory distress syndrome (ARDS) who is undergoing therapeutic prone positioning. Which action is the most appropriate to include in the plan of care to protect the client's skin and promote safety?

A telemetry nurse is caring for a client who suddenly develops paroxysmal supraventricular tachycardia (SVT). The client's heart rate is 205 beats/min, and blood pressure is 114/72 mm Hg. The client is alert and reports feeling a "racing heart." The client has a double-lumen central venous catheter (CVC) in the right internal jugular vein. The proximal lumen is infusing continuous normal saline, and the distal lumen is capped. No peripheral intravenous access is available. The healthcare provider is at the bedside and verbally orders, "Administer adenosine 6 mg rapid IV push stat."

What is the most appropriate action by the nurse?

A client is receiving an initial intravenous infusion of vancomycin for a severe soft tissue infection. Fifteen minutes after the infusion begins, the nurse observes that the client's face, neck, and upper chest are intensely red. The client reports feeling dizzy and severely itchy. Current vital signs reveal a blood pressure of $88/54 \text{ mmHg}$ and a heart rate of $118 \text{ beats/min}$. What is the priority nursing action?

A nurse is caring for a client with cardiogenic shock who weighs $85 \text{ kg}$. The healthcare provider prescribes a continuous intravenous (IV) infusion of dopamine at $5 \text{ mcg/kg/min}$. The pharmacy provides an IV bag containing $400 \text{ mg}$ of dopamine mixed in $250 \text{ mL}$ of $5\%$ Dextrose in Water (D5W). At what rate should the nurse set the IV infusion pump in $\text{mL/hr}$? (Record your answer to the nearest tenth.)

A 32-year-old client is admitted to the emergency department following a high-speed motor vehicle collision. The client sustained blunt trauma to the anterior chest. The nurse's initial assessment reveals a blood pressure of 88/54 mm Hg, heart rate of 134 bpm, and respiratory rate of 32 breaths/min. The client's trachea is deviated to the left, and jugular venous distention (JVD) is present despite the head of the bed being elevated to 45 degrees. An arterial blood gas (ABG) analysis on room air shows pH 7.28, PaCO2 56 mm Hg, HCO3 24 mEq/L, and PaO2 58 mm Hg. Which action should the nurse take FIRST?

During the first 4 hours of postoperative care following a radical nephrectomy, a client's physiological parameters begin to shift. The initial postoperative assessment revealed a blood pressure of 138/76 mm Hg and a heart rate of 78 beats/min. The current assessment shows a blood pressure of 116/88 mm Hg, a heart rate of 115 beats/min, and a respiratory rate of 22 breaths/min. In response to these changes, which of the following interventions should the nurse prioritize?

A nurse is planning basic care and comfort measures for a geriatric client who is recovering from a right total hip arthroplasty utilizing a posterior surgical approach. The client reports sacral discomfort from prolonged bed rest, and the nurse must reposition them while mitigating the risk of complications. Which action is the most appropriate?

A 72-year-old client with a history of moderate dementia is hospitalized for treatment of aspiration pneumonia. The client is receiving continuous intravenous (IV) fluids, has a poor appetite, and exhibits increased restlessness, repeatedly pulling at the IV tubing. Which of the following nursing actions are appropriate to promote the client's basic care and comfort? Select all that apply.

The nurse is reviewing the health records of several clients to determine their risk for acid-base imbalances. Which of the following conditions place a client at high risk for developing respiratory acidosis? Select all that apply.

An emergency department nurse is evaluating a young adult who presented with a severe acute asthma exacerbation. Upon arrival, the client exhibited audible wheezing, prominent intercostal retractions, and a respiratory rate of 36 breaths/min. The baseline arterial blood gas (ABG) results on room air were:

One hour after the administration of continuous nebulized bronchodilators and intravenous corticosteroids, the nurse reassesses the client. The client is now lethargic, the respiratory rate has decreased to 12 breaths/min, and lung sounds are significantly diminished bilaterally with no audible wheezing. The repeat ABG results are:

Which intervention is the most appropriate priority action based on these clinical changes?

An adult client is recovering on the surgical unit 48 hours after undergoing a right above-the-knee amputation. To prevent complications related to immobility and promote optimal physical comfort, which action should the nurse take?

A client is receiving care in the urgent care clinic after experiencing severe, watery diarrhea for the past three days. Based on the significant loss of lower gastrointestinal fluids, which acid-base imbalance should the nurse anticipate?

A nurse is preparing to administer a prescribed parenteral medication from a glass ampule. Arrange the following actions in the correct chronological order to ensure safe preparation. (Place the first action at the top and the final action at the bottom.)

A nurse is preparing to administer an intermittent bolus enteral feeding via a nasogastric (NG) tube to an adult client. In what order should the nurse perform the following actions? Arrange the steps in the correct chronological sequence from first to last.