Physiological Integrity

A $72$-year-old client with a history of heart failure is being monitored $30\text{ minutes}$ after a bedside therapeutic thoracentesis, during which $1,600\text{ mL}$ of pleural fluid was rapidly removed. Which assessment findings indicate a developing physiological complication that requires immediate rapid response? Select all that apply.

An adult client is admitted to the medical-surgical unit and requires continuous enteral feedings through a newly placed percutaneous endoscopic gastrostomy (PEG) tube. The nursing team is establishing a daily care routine to maintain skin integrity, prevent complications, and ensure physiological stability. Which of the following actions are appropriate for the nurse to implement? (Select all that apply)

A nurse enters a client's room and discovers that the intravenous tubing has disconnected from the client's central venous catheter. The client is suddenly experiencing severe dyspnea, tachycardia, and a feeling of impending doom. Suspecting an air embolism, arrange the following nursing actions in the correct priority order to minimize further physiological risk.

A client with a complete T4 spinal cord injury reports a sudden, severe, throbbing headache and blurred vision. The nurse observes profuse diaphoresis above the level of the injury and obtains a blood pressure reading of 218/114 mm Hg. Arrange the following nursing interventions in the priority order of execution.

A client with severe acute pancreatitis is receiving continuous total parenteral nutrition (TPN) through a single-lumen peripherally inserted central catheter (PICC). During the shift, the client develops a temperature of 101.4°F (38.6°C) and a white blood cell count of 16,000/mm³. The healthcare provider prescribes intermittent intravenous (IV) ciprofloxacin every 12 hours. Which nursing action ensures the safe administration of the prescribed antibiotic?

A nurse is preparing to administer an intermittent intravenous (IV) infusion of phenytoin to a client who has a single peripheral IV catheter. The client is currently receiving a continuous IV infusion of 5% dextrose in water (D5W). Which of the following is the most appropriate action by the nurse?

A surgical client is transferred to the acute care unit after undergoing a left eye cataract removal. To ensure safety and promote optimal healing, which intervention should the nurse implement?

A nurse is preparing to perform open-system tracheostomy tube suctioning for an adult client who is experiencing audible coarse crackles and a sudden decrease in oxygen saturation. To minimize the risk of mucosal trauma and hypoxemia, arrange the following procedural steps in the correct chronological sequence. All options must be used.

A nurse is evaluating an adult client with a history of severe left ventricular failure who suddenly exhibits extreme dyspnea, copious pink-tinged frothy sputum, and profound diaphoresis. Assessment reveals cold, mottled extremities. Current vital signs are a heart rate of 134 beats/minute, respiratory rate of 36 breaths/minute, and blood pressure of 78/50 mm Hg. Arterial blood gas (ABG) analysis on room air indicates a pH of 7.15, PaCO2 of 62 mm Hg, PaO2 of 48 mm Hg, and HCO3 of 18 mEq/L. Which action should the nurse take first?

A client who is hemodynamically unstable is admitted to the critical care unit. The client's body weight is recorded as $187\text{ lbs}$. The healthcare provider prescribes a continuous intravenous infusion of norepinephrine at $0.05\text{ mcg/kg/min}$. The pharmacy dispenses an intravenous solution containing norepinephrine $4\text{ mg}$ in $250\text{ mL}$ of $0.9\%\text{ Sodium Chloride}$. At what rate should the nurse program the infusion pump? Record your answer in $\text{mL/hr}$ and round to the nearest tenth.

An adult client requires a large-volume cleansing enema for the treatment of severe constipation. The nurse has gathered all necessary supplies and warmed the solution. In what order must the nurse execute the following procedural steps to safely administer the enema? (Arrange the steps in the correct chronological sequence.)

A nurse is caring for a client in the intensive care unit who is experiencing severe hypotension and weighs $87\text{ kg}$. The healthcare provider prescribes a continuous intravenous (IV) infusion of norepinephrine at $0.05\text{ mcg/kg/min}$. The pharmacy dispenses norepinephrine $4\text{ mg}$ in $250\text{ mL}$ of $5\%$ dextrose in water ($\text{D}_5\text{W}$). At what rate should the nurse set the IV infusion pump in $\text{mL/hr}$? (Round the answer to the nearest tenth. Do not use a trailing zero.)

A nurse is caring for a client who is receiving continuous enteral nutrition via a nasogastric tube. Upon entering the room, the nurse observes the client coughing forcefully, expectorating formula, and displaying circumoral cyanosis. Arrange the following nursing actions in the priority order they should be performed. (Place the first action at the top and the last action at the bottom.)

A client with severe chronic obstructive pulmonary disease reports acute shortness of breath and exhaustion while trying to rest. The individual is currently in a semi-Fowler's position but continues to use accessory muscles to breathe. Which action should the nurse take to improve respiratory comfort?

A client with suspected hepatic cirrhosis is transferred to the clinical unit immediately following a percutaneous liver biopsy. Which of the following nursing actions is the priority to reduce the risk of the most significant complication associated with this procedure?

A nurse is caring for a $45$-year-old client who is $2$ hours post-operative following an abdominal hysterectomy. Initial vital signs upon arrival to the unit were: blood pressure $118/76$ mm Hg, heart rate $88$ beats/min, and respiratory rate $16$ breaths/min. One hour later, the client's vital signs are: blood pressure $110/84$ mm Hg, heart rate $112$ beats/min, and respiratory rate $22$ breaths/min. The client reports feeling increasingly anxious and thirsty. Which of the following is the priority nursing action?

A nurse is caring for a client receiving intravenous fluids via a central venous catheter. The nurse enters the room and observes that the IV tubing has disconnected from the catheter hub. The client is suddenly exhibiting severe dyspnea, tachycardia, and expresses a feeling of impending doom. Arrange the following nursing actions in the correct order of priority.

A 68-year-old client is transferred to the progressive care unit following a percutaneous coronary intervention (PCI) utilizing a right femoral artery approach. The client has a history of hypertension and osteoarthritis. Three hours post-procedure, the nurse performs a scheduled assessment and notes the following:
- Blood pressure is 104/62 mm Hg, down from a pre-procedure baseline of 142/86 mm Hg.
- Heart rate has increased to 112 bpm from 74 bpm.
- The right groin dressing remains dry and intact without visible hematoma.
- Bilateral pedal pulses are equal and easily palpable.
- The client reports, "My lower back is aching severely, but it is probably just my arthritis acting up from this firm mattress."

Which action should the nurse take first to reduce the client's risk for physiological decompensation?

An 82-year-old individual is receiving inpatient treatment for pneumonia. Due to profound fatigue, the healthcare provider has prescribed strict bed rest. The client requires total assistance with personal hygiene and mobility. Which nursing action is most appropriate to promote comfort and prevent complications of immobility?

During a shift in the cardiac care unit, a nurse evaluates a client experiencing severe pulmonary edema secondary to cardiogenic shock. The client is currently receiving a continuous dobutamine infusion via their only patent peripheral intravenous (IV) catheter. A new stat prescription for intravenous furosemide is received. Which of the following actions must the nurse perform to safely administer the medication?