Physiological Integrity

A healthcare provider prescribes moving a client with left-sided lower extremity weakness out of bed for the first time. In what sequence should the nurse perform the following actions to safely transfer the client from the bed to a wheelchair? (Arrange the items in the correct chronological order, from first to last.)

A 52-year-old client is recovering in the intensive care unit four hours after a right supratentorial craniotomy. The client is lethargic but responds appropriately to verbal commands. Recent assessment reveals a blood pressure of 138/82 mm Hg, an apical pulse of 84 bpm, and a respiratory rate of 14 breaths per minute. Which intervention should the nurse implement to minimize the risk of increased intracranial pressure?

A registered nurse and a nursing assistant are preparing to provide morning hygiene care and reposition an 82-year-old client who underwent a right posterior total hip arthroplasty the previous day. Which directive from the nurse is appropriate for safely managing this client's comfort and mobility during the bath?

A nurse is caring for a 75-year-old client who underwent a lumbar puncture two hours ago. The client is frail, has a history of osteoarthritis, and is experiencing episodes of urinary incontinence. Which nursing actions are appropriate to promote basic care and comfort while ensuring client safety? Select all that apply.

A hospitalized adult weighing $176\text{ lb}$ experiences a prolonged seizure. The healthcare provider orders an intravenous loading dose of phenytoin at $15\text{ mg/kg}$. The client currently has a single peripheral intravenous line continuously infusing $5\%$ dextrose in half-normal saline at $75\text{ mL/hr}$. Given that the maximum safe administration rate for intravenous phenytoin is $50\text{ mg/min}$, which of the following describes the most appropriate method to administer this medication?

A nurse is changing the needleless connector caps on a client's central venous catheter. The client suddenly gasps, becomes extremely tachycardic, and reports a feeling of impending doom. The client's blood pressure drops to 82/48 mm Hg. Suspecting a central line-associated air embolism, arrange the following nursing actions in the sequence they should be performed. All options must be used.

A nurse is evaluating a client admitted with a severe exacerbation of chronic obstructive pulmonary disease (COPD). The client has become increasingly lethargic over the last hour, is difficult to arouse, and exhibits a shallow respiratory rate of 10 breaths/min. Which of the following arterial blood gas (ABG) results is most consistent with this client's current clinical presentation?

An adult client is admitted with a severe systemic fungal infection and has a single peripheral intravenous (IV) catheter. The client is currently receiving a continuous hydration infusion of 0.9% sodium chloride at 100 mL/hr. The healthcare provider prescribes a scheduled intravenous dose of amphotericin B. Which action must the nurse take to administer this medication safely?

A nurse is assessing a client with a history of heart failure who suddenly develops severe dyspnea, a respiratory rate of 34 breaths/min, and pink, frothy sputum. Arrange the following nursing actions in the correct sequence of priority.

A young adult is admitted to the neurocritical care unit following a motor vehicle collision that caused a severe traumatic brain injury. The client's current intracranial pressure reading is elevated. Which physical arrangement of the client's body is most appropriate to promote cerebral venous drainage and prevent further neurological decline?

A nurse is admitting a client who has just returned to the unit following a percutaneous liver biopsy. The client is currently alert and oriented, with stable vital signs. To reduce the risk of post-procedure complications, which of the following actions should the nurse prioritize?

A client is brought to the emergency department after intentionally ingesting a toxic amount of acetylsalicylic acid. The client exhibits tachypnea and diaphoresis. The initial arterial blood gas (ABG) results are: $pH = 7.53$, $PaCO_2 = 26 \text{ mm Hg}$, and $HCO_3^- = 22 \text{ mEq/L}$. Based on these findings, which pathophysiological mechanism is the primary cause of this specific acid-base disturbance?

A client with a newly diagnosed pulmonary embolism requires a continuous intravenous (IV) infusion of heparin. The primary healthcare provider prescribes an initial infusion rate of $14 \text{ units/kg/hr}$. The client's current weight is documented as $187 \text{ lb}$. The pharmacy supplies a sterile IV bag containing $25{}000 \text{ units}$ of heparin mixed in $500 \text{ mL}$ of $0.9\% \text{ sodium chloride}$. Based on this information, at what rate (in $\text{mL/hr}$) should the infusion pump be set? (Round the final answer to the nearest tenth).

A nurse is preparing a client with cirrhosis for a bedside paracentesis to relieve severe ascites. To reduce the risk of procedural complications and establish an accurate baseline for post-procedure evaluation, in what order should the nurse complete the following actions? Arrange the steps from first to last.

A nurse is caring for a client admitted with a severe acute asthma exacerbation. Upon admission, the client was agitated with a respiratory rate of 34 breaths/min. Initial arterial blood gas (ABG) results demonstrated a pH of 7.52, a PaCO2 of 26 mm Hg, and a PaO2 of 72 mm Hg. Two hours later, the client appears lethargic, the respiratory rate has decreased to 14 breaths/min, and breath sounds are significantly diminished with absent wheezing. A repeat ABG reveals a pH of 7.37, a PaCO2 of 42 mm Hg, and a PaO2 of 64 mm Hg. Which of the following is the priority nursing action?

A nurse in the emergency department is caring for a client who presents with lethargy, deep and rapid respirations, and a blood glucose level of $580\text{ mg/dL}$. The healthcare provider diagnoses diabetic ketoacidosis (DKA). Arrange the following nursing actions in the correct priority order from first to last.

A triage nurse is evaluating a client who presents to the emergency department after $3$ days of severe, continuous vomiting. The client reports an inability to keep any oral fluids down. Based on the client's presentation, which of the following clinical findings and laboratory results should the nurse anticipate? Select all that apply.

An adult client who missed three consecutive hemodialysis treatments is admitted to the medical unit with profound fatigue and deep, rapid breathing. An arterial blood gas (ABG) analysis yields the following results: pH $7.25$, PaCO $_2$ $29$ mm Hg, HCO $_3^-$ $14$ mEq/L, and PaO $_2$ $92$ mm Hg. Which of the following physiological mechanisms best explains this client's respiratory pattern?

A nurse is caring for a client who is receiving a continuous intravenous heparin infusion for the treatment of a pulmonary embolism. The client suddenly reports the onset of a new, severe headache. The nurse reviews the most recent laboratory results:

Which of the following is the priority nursing action to reduce the client's risk for life-threatening complications?

A nurse is providing care for a client with a T4 spinal cord injury. The client suddenly reports a severe, throbbing headache and blurred vision. Assessment reveals profuse diaphoresis above the level of the injury, a heart rate of $48 \text{ beats/min}$, and a blood pressure of $218/114 \text{ mm Hg}$. Arrange the following nursing interventions in the order they should be prioritized from first to last.