Physiological Integrity

A nurse is developing a plan of care for an older adult client who is largely immobile and has a newly identified Stage 3 sacral pressure injury. Which of the following basic care and comfort interventions should the nurse include? Select all that apply.

A nurse is assessing a client who is 12 hours postoperative following an open laparotomy for a ruptured spleen. Which of the following assessment findings are indicative of early compensatory hypovolemic shock? Select all that apply.

An intensive care nurse assumes care for a client admitted with acute decompensated heart failure. The client, who weighs 176 lb, has a continuous intravenous line infusing dopamine. The medication bag is labeled: dopamine 400 mg in 250 mL of 5% dextrose in water. The smart pump displays a current infusion rate of 15 mL/hr. Based on this data, what dosage of dopamine is the client receiving in mcg/kg/min? Record your answer as a whole number.

A client weighing $198$ lb is admitted with a new diagnosis of deep vein thrombosis. The healthcare provider prescribes a continuous intravenous (IV) heparin infusion. The hospital's weight-based protocol orders an initial IV bolus of $80$ units/kg, followed by a continuous infusion at $18$ units/kg/hr. The pharmacy dispenses a premixed IV bag containing $25,000$ units of heparin in $250$ mL of $5\%$ Dextrose in Water (D5W).

Based on the protocol, which of the following is the correct continuous infusion rate in mL/hr to program into the IV pump? (Round the final answer to the nearest tenth.)

A nurse is evaluating a client who is receiving treatment for severe acute pancreatitis. The client's vital sign trends over the last hour show a blood pressure decrease from 110/70 mm Hg to 92/58 mm Hg, and a heart rate increase from 98 bpm to 122 bpm. The client is breathing at 28 breaths/min. Assessment reveals cool, pale extremities. The arterial blood gas (ABG) results are: pH 7.29, $\text{PaCO}_2$ 30 mm Hg, $\text{HCO}_3^-$ 14 mEq/L. Based on the clinical assessment and ABG results, which of the following is the most accurate interpretation of the client's current physiological state?

A nurse is caring for an adult client who is receiving mechanical ventilation for acute respiratory failure. The client is currently positioned flat and supine in bed. The most recent arterial blood gas (ABG) results reveal a $\text{pH}$ of $7.28$, $\text{PaCO}_2$ of $58 \text{ mm Hg}$, $\text{PaO}_2$ of $62 \text{ mm Hg}$, and $\text{HCO}_3^-$ of $24 \text{ mEq/L}$. Which of the following nursing actions should be prioritized to reduce the client's risk for physiological decompensation?

A 65-year-old client with severe heart failure has a single peripheral venous catheter in the left forearm. A milrinone drip is currently infusing through this line to maintain cardiac output. Due to increasing respiratory distress from pulmonary edema, the healthcare provider orders a stat dose of furosemide 40 mg to be given by IV push. The drug reference manual indicates that furosemide and milrinone will form a precipitate if mixed. Which action represents the safest method to deliver the prescribed diuretic?

A nurse is caring for a client with suspected *Neisseria meningitidis* who has just returned to the unit following a bedside lumbar puncture. Which of the following nursing actions is most appropriate to minimize the client's risk for post-procedure complications and maintain a safe environment?

A nurse is providing morning care for an older adult client who is 2 days post-operative following a right total hip arthroplasty (posterior approach). Which nursing action is most appropriate?

An adult client with suspected cirrhosis is scheduled for a bedside percutaneous liver biopsy. To minimize the risk of procedural and post-procedural complications, arrange the following nursing actions in the correct chronological sequence. (Place the first action at the top and the final action at the bottom.)

While performing a routine surgical incision check on a postoperative laparotomy client, the client experiences a forceful coughing episode and reports a sudden tearing sensation. Upon inspection, the nurse observes complete separation of the surgical wound layers with visible protrusion of intestinal loops. Arrange the following emergency nursing actions in the correct priority sequence to mitigate the risk of severe physiological decompensation.

The nursing unit receives a client who is being treated for a pulmonary embolism with a continuous intravenous (IV) heparin infusion. The attending provider adds a prescription for intermittent IV vancomycin due to a newly suspected wound infection. During the medication preparation phase, the nurse checks a compatibility chart and identifies that heparin and vancomycin form a precipitate when mixed at the Y-site. The client has only one functioning peripheral venous access catheter.

Which action represents the safest nursing intervention?

A nurse is developing a plan of care for a client who is 48 hours postoperative following a right below-the-knee amputation (BKA). Which of the following nursing interventions should the nurse include to promote comfort, mobility, and healing? Select all that apply.

An older adult client with a history of moderate dementia is admitted to the medical-surgical unit with dehydration and generalized weakness. The healthcare provider prescribes oral rehydration and the insertion of a peripheral intravenous (IV) catheter for fluid replacement. Which nursing intervention is most appropriate to include in the client's plan of care?

A nurse is caring for a client who is receiving an intravenous transfusion of packed red blood cells (PRBCs). Fifteen minutes after the infusion begins, the client becomes restless and reports sudden chills and severe lower back pain. In what order should the nurse perform the following interventions? Arrange the actions from first to last.

A client at $34$ weeks of gestation is receiving a continuous intravenous (IV) infusion of magnesium sulfate for the management of severe preeclampsia. During an hourly assessment, the nurse notes the client is difficult to arouse, the respiratory rate is $10\text{ breaths/minute}$, deep tendon reflexes are absent, and urine output was $20\text{ mL}$ over the past hour. The nurse immediately stops the magnesium sulfate infusion. Which of the following actions is the highest priority?

During the morning assessment of a $12$-day-old neonate, the nurse notes that a continuous intravenous (IV) infusion of Lactated Ringer's solution is actively running. The healthcare provider has just entered a new prescription for an intermittent IV infusion of ceftriaxone. Based on principles of pharmacological safety, which intervention is most appropriate?

A nurse is preparing to draw a blood specimen for laboratory analysis from a client's multi-lumen central venous catheter. Continuous intravenous fluids are currently infusing through the other lumens. Arrange the following actions in the correct chronological sequence to safely obtain the blood sample.

A 64-year-old client is admitted to the surgical unit 3 hours after undergoing a right-sided pneumonectomy for lung cancer. The client is awake, receiving oxygen at 2 L/min via nasal cannula, and reports moderate incisional pain. Which nursing intervention is essential to reduce the client's risk of physiological decompensation?

A client with an unresolved high small bowel obstruction has experienced severe, recurrent emesis for the past 72 hours. During the morning assessment, the nurse observes a respiratory rate of 10 breaths per minute, generalized muscle weakness, and new-onset prominent U waves on the telemetry monitor. Based on these physiological changes, which arterial blood gas (ABG) profile should the nurse identify as most consistent with this client's condition?