Physiological Integrity

During the morning rounds, a client who experienced a massive anterior myocardial infarction 12 hours prior is evaluated by the nursing team. Which of the following assessment findings should immediately alert the team to the early development of cardiogenic shock? Select all that apply.

To ensure medication safety, a nurse is performing an independent double-check of a milrinone infusion for a client with acute decompensated heart failure. The client weighs $80 \text{ kg}$. The infusion pump is currently delivering the medication at a rate of $15 \text{ mL/hr}$. The available medication is a premixed bag containing $20 \text{ mg}$ of milrinone in $100 \text{ mL}$ of 0.9% sodium chloride.

Calculate the dose the client is receiving in $\text{mcg/kg/min}$. Record your answer to the nearest hundredth.

A nurse is caring for a client with a history of heart failure who suddenly develops severe dyspnea, becomes extremely restless, and expectorates pink, frothy sputum. Arrange the following nursing actions in the correct sequence of priority from first to last.

An adult client in the intensive care unit is undergoing a spontaneous breathing trial (SBT) via continuous positive airway pressure (CPAP) to evaluate readiness for extubation. After 30 minutes, the client becomes severely restless, diaphoretic, and exhibits increased accessory muscle use. Arterial blood gas (ABG) analysis reveals a pH of $7.29$, a PaCO $_2$ of $56$ mm Hg, a PaO $_2$ of $64$ mm Hg, and an HCO $_3^-$ of $25$ mEq/L. Which action is the priority for the nurse to take?

A clinical nurse is preparing to obtain a blood specimen from an adult client's central venous access device (CVAD). To reduce the risk of central line-associated bloodstream infection (CLABSI), inaccurate laboratory results, and catheter occlusion, place the following actions in the correct chronological order.

A nurse is assuming care for a client who just arrived on the medical-surgical unit following a percutaneous liver biopsy. To mitigate the risk of the most significant post-procedural complication, which specific intervention must the nurse execute?

A client is transferred to the medical-surgical unit following a diagnostic lumbar puncture to evaluate a sudden onset of severe headaches and nuchal rigidity. Which nursing interventions are essential to incorporate into the client's immediate care plan to mitigate the risk of post-procedure complications? Select all that apply.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via a multi-lumen central venous catheter. Which of the following interventions should the nurse implement? (Select all that apply.)

An adult client arrives at the emergency department presenting with profound lethargy, deep and rapid Kussmaul respirations, and a fruity breath odor. Laboratory results reveal a blood glucose of 680 mg/dL (37.7 mmol/L), a serum pH of 7.15, and positive serum ketones. Arrange the following collaborative interventions in the correct sequence of priority.

A nurse is assessing a client who is 4 days postoperative following an exploratory laparotomy. The client reports feeling a sudden "tearing" sensation in the abdomen after coughing forcefully. Upon inspection, the nurse observes that the surgical incision has separated and loops of bowel are protruding. Place the following nursing interventions in the correct order of priority.

A 68-year-old client with a history of severe chronic obstructive pulmonary disease (COPD) and a recent tracheostomy requires open airway suctioning. The client exhibits audible coarse crackles, restlessness, and an oxygen saturation drop to 88%. To mitigate the risk of physiological decompensation during the procedure, arrange the following nursing actions in the correct chronological sequence from first to last.

An older adult patient is recovering in the surgical unit one day after receiving a left total hip arthroplasty via a posterior approach. When providing basic care and comfort measures, which action by the registered nurse demonstrates safe practice?

A nurse is caring for a hemodynamically unstable client with septic shock. The client is receiving a continuous intravenous (IV) infusion of norepinephrine through a single 20-gauge peripheral IV line to maintain a mean arterial pressure (MAP) greater than 65 mm Hg. The healthcare provider prescribes a stat dose of intravenous piperacillin-tazobactam. Which action by the nurse is the most appropriate?

During the immediate postoperative period following a subtotal thyroidectomy, a client reports a sudden sensation of tightness in the anterior neck region and exhibits frequent, forced swallowing. The respiratory rate is currently 26 breaths/minute with faint inspiratory stridor. To mitigate the highest immediate risk to the client, which action must the nurse execute first?

A nurse is reviewing the plan of care for a client diagnosed with myxedema coma. The client presents with a core body temperature of $34.2^\circ\text{C}$ ($93.6^\circ\text{F}$), a blood pressure of $86/52\text{ mm Hg}$, and a serum sodium level of $122\text{ mEq/L}$. Arterial blood gas results indicate uncompensated respiratory acidosis. Which of the following prescribed interventions should the nurse question?

While caring for a client with a history of hepatic cirrhosis on the hepatology unit, the nurse observes the client suddenly vomit a copious amount of bright red blood. The client is lethargic, with a heart rate of 142 beats per minute and a blood pressure of 76/42 mm Hg. In what order should the nurse implement the following interventions? Place the actions in sequence from first to last.

A nurse is preparing to administer a prescribed dose of intravenous phenytoin by direct injection (IV push). The client has a single peripheral intravenous catheter currently infusing 5% dextrose in water (D5W) continuously. Knowing that phenytoin is incompatible with dextrose solutions, arrange the following nursing actions in the correct sequence to safely administer the medication.

A client admitted with acute decompensated heart failure is receiving a continuous intravenous infusion of dobutamine for inotropic support. During the shift, the client suddenly exhibits severe dyspnea, a respiratory rate of 34 breaths per minute, and bilateral coarse crackles on auscultation. The provider verbally orders 40 mg of furosemide to be administered via direct intravenous injection immediately. The client currently has only one functioning 20-gauge peripheral venous catheter. Which action is the priority for the registered nurse to safely administer this medication?

A home health nurse is developing a plan of care for an older adult client with severe rheumatoid arthritis who experiences chronic joint pain and morning stiffness. Which of the following interventions should the nurse include in the plan of care to promote basic care and comfort? Select all that apply.

A nurse in the intensive care unit is caring for a client with a hypertensive emergency. The client weighs $198\text{ lb}$. The client is currently receiving a continuous intravenous (IV) infusion of nitroprusside at $14\text{ mL/hr}$. The IV solution contains $50\text{ mg}$ of nitroprusside in $250\text{ mL}$ of $5\%$ dextrose in water ($D_5W$). Based on the client's current blood pressure of $185/110\text{ mm Hg}$, the healthcare provider prescribes an increase in the nitroprusside infusion rate by $0.5\text{ mcg/kg/min}$. What is the new infusion rate in $\text{mL/hr}$ that the nurse should set on the IV pump? Record your answer using one decimal place.