All practice questions

A telemetry nurse is caring for an older adult client receiving a continuous intravenous infusion of furosemide for severe decompensated heart failure. Over the past $48$ hours, the client has experienced a net fluid loss of $4.5\ \text{L}$. The nurse notes the client is now exhibiting generalized muscle weakness, shallow respirations at $10\ \text{breaths/min}$, and frequent premature ventricular contractions on the cardiac monitor.

Which physiological mechanism best explains the client's current clinical presentation and laboratory results?

A critical care nurse evaluates a client with severe sepsis who is receiving a continuous intravenous infusion of norepinephrine. The client has become increasingly restless and confused over the past hour, with new-onset mottling of the lower extremities. Current assessment data include:

- Blood pressure: $102/82$ mm Hg
- Heart rate: $128$ beats/min
- Respiratory rate: $32$ breaths/min
- Arterial blood gas (ABG): pH $7.28$, PaCO $_2$ $30$ mm Hg, HCO $_3^-$ $14$ mEq/L, PaO $_2$ $85$ mm Hg
- Central venous oxygen saturation (ScvO $_2$): $48\%$
- Serum lactate: $6.8$ mmol/L

Based on these findings, which action should the nurse prioritize?

A nurse is evaluating a client who sustained a high-grade splenic laceration following blunt torso trauma. The client is currently being managed with non-operative, conservative therapy. Which clinical finding provides the most definitive evidence that the client's physiological status has transitioned from a compensatory state into a progressive state of hypovolemic shock?

A nurse in the neuro-intensive care unit is assessing a client who sustained a complete spinal cord injury at the T3 level $24$ hours ago. The nurse is evaluating the client for potential complications. Which of the following clinical findings specifically indicate that the client is experiencing neurogenic shock rather than spinal shock or hypovolemic shock? Select all that apply.

A client with severe emphysema requires mechanical ventilation via an endotracheal tube following acute respiratory failure. During continuous monitoring, the expiratory flow waveform fails to reach the zero baseline prior to the initiation of the next breath. Over the past fifteen minutes, the client's systolic blood pressure has trended down to 78 mmHg, and the heart rate is steady at 132 beats per minute with weak peripheral pulses. What is the immediate priority action for this client?

A nurse is evaluating a client who was admitted with a mechanical small bowel obstruction. For the past 48 hours, the client has been treated with a nasogastric (NG) tube set to continuous low wall suction, yielding high outputs of gastric drainage. The nurse notes the client is becoming lethargic with a respiratory rate of 10 breaths/min and shallow chest excursion. Based on these clinical findings, which of the following arterial blood gas (ABG) results should the nurse anticipate?

A triage nurse in the emergency department receives a client with acute kidney injury secondary to severe rhabdomyolysis. The client reports profound muscle weakness. A STAT 12-lead electrocardiogram reveals absent P waves, a heart rate of $42\text{ bpm}$, and markedly widened QRS complexes. Arrange the following nursing actions in the most appropriate priority order from first to last.

A nurse is evaluating a client who is $3$ days post-operative following an exploratory laparotomy for a perforated appendix. The client appears restless and has warm, flushed skin.

Based on these findings, which intervention should the nurse perform first?

During bedside rounds in the intensive care unit, the nurse assesses a client admitted $24$ hours ago with acute necrotizing pancreatitis. The client is now profoundly lethargic. Current vital signs reveal a blood pressure of $82/48$ mm Hg, a heart rate of $136$ beats/minute, and a respiratory rate of $36$ breaths/minute. Auscultation identifies diffuse coarse crackles bilaterally. Arterial blood gas (ABG) results while receiving $100\%$ oxygen via a non-rebreather mask are: pH $7.28$, PaCO $_2$ $54$ mm Hg, PaO $_2$ $48$ mm Hg, and HCO $_3^-$ $20$ mEq/L. Based on this client's physiological decompensation, which of the following actions should the nurse anticipate? Select all that apply.

A client is receiving care in the neuroscience unit on the second day following surgical clipping of a ruptured cerebral aneurysm. Assessment reveals increasing lethargy, a heart rate of 118 beats/min, a blood pressure of 88/54 mm Hg, and a central venous pressure (CVP) of 2 mm Hg. Laboratory results show a serum sodium of 122 mEq/L, serum osmolality of 258 mOsm/kg, and a urine sodium of 150 mEq/L. Which of the following is the priority nursing action?

A client is 6 hours post-coronary artery bypass graft (CABG) surgery and is receiving mechanical ventilation. The intensive care nurse notes that the mediastinal chest tube drainage, which had been steadily draining $100\text{ mL/hr}$, has abruptly ceased over the past 45 minutes. The client's blood pressure drops from $115/75\text{ mmHg}$ to $82/64\text{ mmHg}$, heart rate increases from $85\text{ bpm}$ to $128\text{ bpm}$, and central venous pressure (CVP) rapidly rises from $8\text{ mmHg}$ to $19\text{ mmHg}$. Jugular venous distension is visible. The nurse suspects acute cardiac tamponade. Place the following collaborative and nursing actions in the correct priority sequence.

A nurse is monitoring a client who sustained a closed femur fracture and pelvic contusions following a motor vehicle collision. Serial assessments over a three-hour period reveal the following trends:

Based on the physiological mechanisms underlying these assessment trends, which action should the nurse prioritize?

A triage nurse in the emergency department receives a $45$-year-old client who was rescued from an enclosed structural fire. The client sustained deep partial-thickness and full-thickness burns to the face, anterior chest, and bilateral entire upper extremities.

The nurse assesses the following initial clinical data:

Physical assessment reveals a hoarse voice, singed nasal hairs, and carbonaceous sputum.

Which interventions should the nurse anticipate incorporating into the immediate plan of care? (Select all that apply)

An intensive care nurse evaluates a mechanically ventilated client $24$ hours post-splenectomy who received a massive transfusion protocol for hemorrhagic shock. Over the last two hours, the client's urine output decreased to $10\text{ mL/hr}$, peak inspiratory pressure (PIP) increased from $24\text{ cm H}_2\text{O}$ to $52\text{ cm H}_2\text{O}$, and blood pressure dropped from $118/72\text{ mm Hg}$ to $82/46\text{ mm Hg}$. The current central venous pressure (CVP) is $21\text{ mm Hg}$. Which action should the nurse take first?

A $34$-year-old client with a known history of Graves' disease is admitted to the progressive care unit exhibiting extreme restlessness, profound diaphoresis, and delirium. Current vital signs reveal a heart rate of $188\text{ beats/min}$, blood pressure of $182/104\text{ mmHg}$, and a core temperature of $40.6^\circ\text{C}$ ($105.1^\circ\text{F}$). The client is diagnosed with a thyrotoxic crisis (thyroid storm). The healthcare provider prescribes several emergent interventions. Arrange the following actions in the correct physiological priority order.

An emergency department nurse is caring for a trauma client undergoing aggressive resuscitation for severe hemorrhagic shock. Over the last $120$ minutes, the client has received $10$ units of packed red blood cells (PRBCs) and $6$ units of fresh frozen plasma (FFP). During the ongoing assessment, the nurse notes a core body temperature of $34.2^\circ\text{C}$ ($93.5^\circ\text{F}$) and new-onset facial muscle twitching. The telemetry monitor displays peaked T waves, a widening QRS complex, and a prolonged QT interval. Which of the following physiological adaptations and underlying mechanisms correlate with this client's current presentation? (Select all that apply.)

A rapid response team is called for a client admitted with community-acquired pneumonia who began receiving an initial infusion of intravenous ampicillin-sulbactam $15$ minutes ago. The client presents with acute respiratory distress, audible stridor, and diffuse urticaria. Vital signs are: blood pressure $68/38$ mm Hg, heart rate $52$ bpm, respiratory rate $32$ breaths/min, and SpO2 $86\%$ on room air. The client's medication history includes daily lisinopril, metoprolol succinate, timolol ophthalmic drops, and atorvastatin. The nurse immediately stops the antibiotic infusion and administers $0.5$ mg of intramuscular epinephrine. Five minutes later, the client's blood pressure is $70/40$ mm Hg, heart rate is $54$ bpm, and severe wheezing persists. Which of the following is the most appropriate priority intervention?

A nurse is caring for a client with a complete $T4$ spinal cord injury. The client suddenly reports a severe, pounding headache and blurred vision. The nurse observes profuse diaphoresis and flushing above the level of the spinal lesion, accompanied by marked pallor and piloerection below the lesion. The client's blood pressure is $220/115$ mmHg and heart rate is $48$ bpm. Place the following nursing interventions in the correct sequence of priority to manage this acute complication.

A nurse is caring for a client admitted with severe diabetic ketoacidosis (DKA). The client is receiving a continuous intravenous regular insulin infusion and 0.9% sodium chloride. The nurse observes that the client's deep, rapid breathing has transitioned to shallow, weak respirations over the last $30$ minutes, and the client is now profoundly lethargic and difficult to arouse.

Recent laboratory results:
- Blood glucose: $230$ mg/dL ($12.8$ mmol/L)
- Serum potassium: $2.7$ mEq/L ($2.7$ mmol/L)
- Arterial Blood Gas (room air): pH $7.20$, PaCO $_2$ $49$ mm Hg, HCO $_3^-$ $11$ mEq/L, PaO $_2$ $82$ mm Hg

Which of the following is the priority nursing action?

An older adult client is admitted with a severe urinary tract infection. Over the past hour, the client has become restless and confused. Current vital signs are: blood pressure $84/52\text{ mm Hg}$, heart rate $128\text{ bpm}$, respiratory rate $30\text{ breaths/min}$, and temperature $101.8^\circ\text{F}$ ($38.8^\circ\text{C}$). Oxygen saturation is $93\%$ on room air. An arterial blood gas (ABG) and serum lactate analysis reveal the following:

Which of the following prescribed interventions should the nurse prioritize?