Physiological Integrity

A 68-year-old client with a history of severe chronic obstructive pulmonary disease (COPD) and a recent right-sided ischemic stroke is receiving continuous enteral tube feedings. The client suddenly develops severe dyspnea, coarse crackles in the bilateral lung bases, and an oxygen saturation of 84% on room air. To mitigate the risk of further physiological decompensation, which action is the priority for the nurse to perform?

A nurse is performing a tubing change on a client's central venous catheter. The client suddenly gasps, reports severe chest pain, and exhibits acute dyspnea. Suspecting an air embolism, arrange the following nursing actions in the correct priority order from first to last.

An adult client is receiving care in the emergency department for ongoing seizure activity. Current vital signs include a blood pressure of $118/74 \text{ mmHg}$ and a heart rate of $108 \text{ beats/min}$. The client has one peripheral intravenous (IV) catheter currently infusing $5\%$ dextrose in water (D5W) at $100 \text{ mL/hr}$. The provider prescribes an IV loading dose of phenytoin. Which technique is safest for the nurse to use when administering this therapy?

An adult client is recovering on the medical-surgical unit following a percutaneous liver biopsy. During the afternoon assessment, the client reports a new onset of right shoulder pain. The electronic health record displays a gradual heart rate increase from 72 to 112 beats/min and a blood pressure shift from 124/76 mm Hg to 108/84 mm Hg over the last two hours. What is the priority nursing intervention?

A nurse is preparing to administer a scheduled dose of $1 \text{ gram}$ of intravenous (IV) vancomycin to a client with a severe methicillin-resistant Staphylococcus aureus (MRSA) infection. The pharmacy has dispensed the medication in $250 \text{ mL}$ of $0.9\%$ sodium chloride. Which action demonstrates safe administration of this parenteral therapy?

A nurse is preparing to administer a mixture of regular insulin and NPH insulin to a client with type 2 diabetes mellitus. Arrange the following steps for drawing up these insulins in a single syringe in the correct chronological order.

A nurse is monitoring a client admitted with acute pancreatitis who is at risk for hypovolemic shock due to severe fluid shifts. Which assessment finding should the nurse identify as the earliest physiological indicator of this complication?

A nurse is changing the intravenous (IV) tubing for a client receiving continuous total parenteral nutrition (TPN) via a central venous catheter. The catheter hub is accidentally left unclamped during the tubing exchange. The client suddenly gasps, reports sharp chest pain, and becomes severely dyspneic, pale, and tachycardic. Which of the following is the priority nursing action?

A clinical team is monitoring a client who has been undergoing continuous nasogastric decompression for three days due to a severe small bowel obstruction. The nurse should identify which of the following findings as evidence that the client is developing metabolic alkalosis? (Select all that apply)

While a nurse is administering a prescribed medication via direct intravenous injection, the client suddenly reports a pounding headache, a tight sensation in the chest, and facial warmth. The nurse notes that the client's face is flushed and the cardiac monitor displays an irregular heart rate. Based on these immediate clinical manifestations, which intravenous therapy complication is the client most likely experiencing?

A registered nurse is preparing to reconstitute a powdered parenteral medication using a multidose vial of sterile water for injection. Arrange the following procedural steps in the correct chronological order from first to last.

A nurse is assessing a client who was admitted to the medical-surgical unit with severe hematemesis and melena. The nurse suspects the client is entering the early compensatory stage of hypovolemic shock. Which of the following assessment findings support this conclusion? Select all that apply.

During an ongoing transfusion of packed red blood cells (PRBCs) for a client with severe anemia, the client suddenly develops bilateral lung crackles, severe shortness of breath, and jugular venous distention. A rapid response is called, and the attending physician orders a stat dose of intravenous furosemide. The client currently has only one single-lumen peripheral intravenous catheter in place. What is the priority nursing action to safely administer this prescribed therapy?

A nurse is caring for a client who sustained a closed transverse femur fracture 36 hours ago. The client suddenly becomes highly agitated, reports a feeling of impending doom, and is experiencing severe dyspnea. The nurse notes the appearance of a petechial rash over the client's anterior chest and neck. An arterial blood gas (ABG) analysis is obtained while the client is breathing room air, revealing the following results: pH 7.48, $PaCO_2$ 29 mm Hg, $PaO_2$ 54 mm Hg, and $HCO_3^-$ 23 mEq/L. What is the priority nursing action?

Following a severe myocardial infarction, a client requires pharmacological blood pressure support. The client is currently receiving a continuous dopamine infusion at 5 mcg/kg/min through their only patent peripheral venous access site, maintaining a mean arterial pressure (MAP) of 68 mm Hg. The healthcare provider prescribes a scheduled dose of an intermittent intravenous antibiotic. Upon consulting the facility's parenteral drug reference, the nurse confirms the antibiotic is completely incompatible with dopamine. What is the most appropriate intervention for this situation?

A nurse is caring for a client with a spinal cord injury at the T4 level. The client suddenly reports a severe, pounding headache and becomes profusely diaphoretic above the level of injury. The client's blood pressure is 210/110 mmHg and heart rate is 52 bpm. In what order should the nurse perform the following actions? Arrange the actions in chronological sequence from first to last.

A nurse is preparing to administer a prescribed intravenous (IV) push medication through a peripheral IV line. The current continuous IV fluid infusing is incompatible with the prescribed IV push medication. In what order should the nurse perform the following actions to safely administer the medication? Arrange the actions in the correct sequence.

A nurse is evaluating a client who is 4 hours postoperative following a partial nephrectomy. Which assessment finding provides the earliest indication that the client is developing hypovolemic shock?

An adult client is receiving care in the medical-surgical unit for a pulmonary embolism and a newly diagnosed lower respiratory tract infection. The client has a continuous intravenous (IV) infusion of heparin running through a dedicated peripheral IV catheter. The healthcare provider urgently prescribes a dose of IV levofloxacin. Upon reviewing the hospital's parenteral compatibility database, the nurse determines that heparin and levofloxacin are physically incompatible. Which of the following is the most appropriate nursing action?

A nurse is caring for a client who is receiving a unit of packed red blood cells (PRBCs). Fifteen minutes after the transfusion begins, the client reports severe lower back pain, chills, and shortness of breath. Arrange the following nursing actions in the priority order they should be performed.