Physiological Integrity

A nurse is planning care for an older adult client who is 1 day postoperative following a right total hip arthroplasty (posterior approach). The client has a history of mild cognitive impairment and is currently experiencing intermittent confusion. Which of the following interventions should the nurse include in the client's care plan to promote basic care and comfort? Select all that apply.

A nurse is assessing a postoperative client who is at risk for internal hemorrhage. Which of the following clinical findings should the nurse identify as the earliest indicator of developing hypovolemic shock?

A nurse is caring for a client admitted with pneumonia who has a continuous, compatible 0.9% sodium chloride infusion running at 75 mL/hr. The nurse is preparing to administer a prescribed intravenous (IV) push dose of dexamethasone. In which order should the nurse perform the following actions? Arrange the steps from first to last.

A nurse is caring for a client who is 24 hours post-operative following a right total hip arthroplasty. The client suddenly reports sharp, right-sided chest pain and acute shortness of breath. The client appears highly agitated and diaphoretic. Vital signs are: heart rate 128 bpm, blood pressure 92/64 mm Hg, respiratory rate 30 breaths/min, and oxygen saturation 84% on room air. An arterial blood gas (ABG) is obtained with the following results: pH 7.52, PaCO2 28 mm Hg, PaO2 54 mm Hg, and HCO3 24 mEq/L. Which of the following is the priority nursing action?

An older adult client with advanced dementia and frequent urinary incontinence is confined to bed. The nurse notes new, non-blanchable erythema on the client's sacrum. The client has also been frequently scratching at the perineal area. Which nursing intervention is the most appropriate to promote comfort and protect the client's skin integrity?

An emergency department nurse is caring for an older adult client who was brought from an assisted living facility with a suspected urinary tract infection. The client, who is typically alert and oriented, is currently restless and agitated. Vital signs reveal a temperature of 38.2°C (100.8°F), a heart rate of 118 beats/min, a respiratory rate of 24 breaths/min, and a blood pressure of 106/82 mm Hg. The client's blood pressure upon arrival one hour ago was 128/74 mm Hg. Which of the following actions should the nurse take first?

A nurse is monitoring a client who was admitted with diabetic ketoacidosis (DKA) and is currently receiving a continuous intravenous infusion of regular insulin and 0.9% sodium chloride. Which of the following assessment findings should the nurse identify as a complication of the current treatments? (Select all that apply.)

A nurse is preparing to discontinue a client's non-tunneled central venous catheter (CVC) located in the right subclavian vein. Place the following nursing actions in the correct chronological order to ensure safe removal and prevent complications.

A nurse is evaluating a client 24 hours after an endoscopic retrograde cholangiopancreatography (ERCP) who has developed severe post-procedure acute pancreatitis. The nurse is monitoring the client for subtle indicators of physiological decompensation. Which of the following assessment findings require immediate intervention to reduce the risk of life-threatening complications? Select all that apply.

A client is 48 hours postoperative following a right above-the-knee amputation and is preparing to begin physical therapy. To prevent common postoperative complications associated with this procedure, which of the following actions should the nurse take?

A client is admitted to the emergency department with a diagnosis of severe diabetic ketoacidosis (DKA). The client is lethargic with Kussmaul respirations and a capillary blood glucose of 580 mg/dL (32.2 mmol/L). The nurse is preparing to initiate the prescribed treatment plan. In what order should the nurse implement the following actions? Arrange the interventions from highest priority to lowest priority.

A nursing team is preparing to transfer an immobile client from a bed to a stretcher using a slide board (transfer board) and a draw sheet. Place the following steps in the correct chronological order to ensure a safe transfer.

Following a complicated vaginal delivery, a client develops an acute postpartum hemorrhage. The healthcare provider prescribes an immediate transfusion of packed red blood cells (PRBCs). The client has one functioning 18-gauge intravenous (IV) catheter in the right forearm, which is currently delivering a continuous infusion of lactated Ringer's solution mixed with 30 units of oxytocin. Which of the following actions should the nurse take?

While assessing a client who is being treated for severe hypotension, the nurse examines the peripheral intravenous access site where dopamine is infusing. The area is markedly pale, edematous, and cold to the touch, and the client complains of an intense burning sensation. The nurse immediately halts the infusion pump. Which action is the most appropriate next step for the nurse to take?

A nurse is evaluating a client who returned to the nursing unit $2$ hours ago following a cardiac catheterization via the right radial artery approach. Which of the following assessment findings should the nurse identify as the highest priority to report to the healthcare provider?

A nurse is caring for a client who is receiving a continuous intravenous infusion of alteplase for an acute ischemic stroke. During the infusion, the client suddenly reports a severe, bursting headache, exhibits extreme restlessness, and the blood pressure increases to 198/112 mm Hg. Which action should the nurse take first to reduce the client's risk for life-threatening complications?

A nurse is preparing to administer a continuous intravenous (IV) infusion of heparin for a client diagnosed with a pulmonary embolism. The healthcare provider's prescription is for $18 \text{ units/kg/hr}$. The client's admission weight is $198 \text{ lb}$. The available IV fluid is heparin $25,000 \text{ units}$ in $250 \text{ mL}$ of $0.45\%$ sodium chloride.

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

A clinical nurse is preparing to discontinue a non-tunneled central venous access device (CVAD) located in the right internal jugular vein of an adult client. To minimize the risk of a venous air embolism and promote physiological integrity, in what order should the nurse execute these interventions? Arrange the steps in the correct chronological sequence.

A nurse is caring for a client who is receiving an intravenous infusion of ceftriaxone for a severe infection. Ten minutes into the infusion, the client suddenly reports throat tightness, severe dizziness, and develops visible facial swelling. Arrange the following nursing actions in the correct order of priority.

A nurse is caring for a client who is receiving a continuous infusion of total parenteral nutrition (TPN) through a single-lumen peripherally inserted central catheter (PICC). The client reports severe nausea, and the healthcare provider prescribes ondansetron 4 mg IV push once immediately. Which of the following is the priority nursing action?