Physiological Integrity

A nurse is assessing a client who is $4$ hours postoperative following an open abdominal procedure. The surgical dressing is dry and intact, and a closed-suction drain has collected $15\text{ mL}$ of serosanguineous fluid. The client has become increasingly restless over the past hour. Current vital signs are: blood pressure $104/86\text{ mmHg}$, heart rate $118\text{ beats/min}$, and respiratory rate $24\text{ breaths/min}$. An arterial blood gas (ABG) analysis reveals a pH of $7.33$, PaCO $_2$ of $32\text{ mmHg}$, and HCO $_3^-$ of $16\text{ mEq/L}$. Based on this physiological presentation, which is the priority nursing intervention?

A client with a right tibial fracture is non-weight-bearing on the affected extremity. The nurse is instructing the client on how to safely ascend a flight of stairs using axillary crutches. Arrange the following actions in the correct sequence from first to last.

A nurse is preparing to administer an intravenous (IV) push medication through the lowest injection port of a primary IV line. The client has a single-lumen central venous catheter with a continuous infusion of a medication that is physically incompatible with the prescribed IV push drug. Arrange the following steps in the correct chronological order to safely administer this medication.

A client is 3 days post-operative following an abdominal laparotomy. While coughing forcefully, the client reports a 'giving way' sensation in the abdomen. The nurse inspects the surgical site and observes that the incision has separated with a loop of bowel protruding. Arrange the following nursing actions in the correct priority sequence to mitigate further physiological risk.

A nurse is preparing to administer a mixed dose of 5 units of regular insulin and 15 units of NPH insulin to a client with type 2 diabetes mellitus before breakfast. Place the following steps for preparing this medication in a single syringe in the correct chronological order.

An older adult is recovering in the orthopedic unit after undergoing a right posterior total hip arthroplasty. The individual requires assistance with bowel elimination and requests a bedpan. To safely facilitate this without compromising the surgical site, which action is the most appropriate?

A nurse is planning care for an older adult client who is 48 hours post-operative following a right total hip arthroplasty (posterior approach). The client requires assistance with daily activities, and the nurse is coordinating care with an unlicensed assistive personnel (UAP). Which of the following interventions should the nurse include in the client's plan of care to promote comfort and safety? (Select all that apply)

A nurse is caring for a client with acute decompensated heart failure who has a prescription for a continuous IV infusion of milrinone at $0.375 \text{ mcg/kg/min}$. The client weighs $209 \text{ lbs}$. The pharmacy provides milrinone $20 \text{ mg}$ in $100 \text{ mL}$ of $0.9\% \text{ NaCl}$. The nurse should set the IV infusion pump to deliver how many $\text{mL/hr}$? (Round the final answer to the nearest tenth.)

A 26-year-old client with a history of poorly controlled asthma presents to the emergency department with severe dyspnea, use of accessory muscles, and a respiratory rate of $38$ breaths per minute. Initial arterial blood gas (ABG) analysis reveals a $pH$ of $7.50$, $PaCO_2$ of $27$ mm Hg, and $PaO_2$ of $74$ mm Hg. The client is treated with high-dose nebulized albuterol and intravenous methylprednisolone. During reassessment $45$ minutes later, the nurse notes that the client's breath sounds are now severely diminished with minimal wheezing, the respiratory rate has decreased to $16$ breaths per minute, and the client is difficult to arouse. A repeat ABG shows a $pH$ of $7.36$, $PaCO_2$ of $44$ mm Hg, and $PaO_2$ of $60$ mm Hg. Which of the following is the priority nursing action?

A nurse is caring for a 65-year-old client who underwent a left above-the-knee amputation two days ago. The client reports intermittent phantom limb pain and is preparing for future physical rehabilitation. Which of the following nursing interventions is most appropriate to promote optimal mobility and comfort?

A nurse is planning care for a client who is 12 hours post-operative following an exploratory laparotomy and small bowel resection. The client has a nasogastric (NG) tube set to low continuous suction and a surgical drain in place. To reduce the risk of potential complications, which of the following nursing interventions should the nurse include in the plan of care? (Select all that apply.)

A nurse is evaluating a client who sustained a complete spinal cord injury at the T4 level several weeks ago. The client suddenly reports a severe, throbbing headache. The nurse observes profuse diaphoresis on the client's face and neck, and obtains a blood pressure reading of 198/104 mm Hg. Which action must the nurse implement first to reduce the risk of a life-threatening complication?

A healthcare provider orders a stat intravenous bolus of phenytoin 400 mg for a hospitalized client experiencing seizure activity. The client's only current venous access is a 20-gauge peripheral catheter through which 5% dextrose in water (D5W) is actively infusing at 100 mL/hr. Which of the following actions represents the safest method for the nurse to administer this medication?

A client is admitted to the intensive care unit with severe diabetic ketoacidosis (DKA). The client is lethargic and exhibiting deep, rapid Kussmaul respirations. The initial capillary blood glucose is $650$ mg/dL ($36.1$ mmol/L). The healthcare provider has entered multiple collaborative prescriptions.

Arrange the following collaborative and nursing interventions in the correct chronological order of implementation for this client. (Place the first priority action at the top and the final action at the bottom.)

An intensive care nurse is managing a male patient diagnosed with cardiogenic shock. The patient's body weight is recorded as $198 \text{ lb}$. The medical team orders an intravenous infusion of dopamine at a rate of $5 \text{ mcg/kg/min}$ to support cardiac output. The available medication from the pharmacy is a premixed bag containing $400 \text{ mg}$ of dopamine dissolved in $250 \text{ mL}$ of $5\%$ dextrose in water (D5W).

Determine the appropriate infusion pump setting in $\text{mL/hr}$ to deliver the prescribed dose. Round the final answer to the nearest tenth.

A nurse enters a client's room and observes that the client's central venous catheter tubing has disconnected from the hub. The client is gasping for air, appears cyanotic, and reports severe, sudden-onset chest pain. Arrange the following nursing actions in the priority order they should be performed to reduce the risk of cardiopulmonary collapse.

A nurse is closely monitoring a client who sustained a severe traumatic brain injury. The nurse observes neurological deterioration and suspects the onset of Cushing's triad as a result of elevated intracranial pressure. Which of the following physiological assessment findings represent this critical syndrome? Select all that apply.

A client is receiving continuous nasogastric suctioning for a mechanical bowel obstruction. On the third day of treatment, the client reports numbness around the mouth and tingling in the extremities. Upon further assessment, the nurse notes a positive Chvostek sign. Which arterial blood gas (ABG) values correlate most accurately with this clinical presentation?

A nurse is evaluating a 58-year-old client who underwent a percutaneous left renal biopsy $4$ hours ago. The client is increasingly difficult to arouse. Current vital signs reveal a heart rate of $122 \text{ beats/min}$, blood pressure of $88/54 \text{ mm Hg}$, and respiratory rate of $24 \text{ breaths/min}$. The client's abdomen appears taut and distended. Recent arterial blood gas (ABG) results on room air demonstrate a $\text{pH}$ of $7.28$, $\text{PaCO}_2$ of $32 \text{ mm Hg}$, and $\text{HCO}_3^-$ of $15 \text{ mEq/L}$. Which nursing action is the highest priority to reduce the client's risk of further physiological decompensation?

A nurse is caring for a client with hypovolemic shock who is receiving a rapid, continuous intravenous infusion of Lactated Ringer's solution through a single large-bore peripheral catheter. The healthcare provider prescribes a stat unit of packed red blood cells (PRBCs). Which of the following is the safest nursing action for administering the blood product?