Physiological Integrity

A mechanically ventilated client in the intensive care unit requires continuous sedation. The healthcare provider's order reads: dexmedetomidine $0.8\text{ mcg/kg/hr}$ continuous IV infusion. The client weighs $154\text{ lb}$. The pharmacy dispenses a pre-mixed solution containing $200\text{ mcg}$ of dexmedetomidine in $50\text{ mL}$ of $0.9\%$ sodium chloride.

At what rate, in $\text{mL/hr}$, should the infusion pump be programmed? Record your answer using a whole number.

A nurse is planning positioning and mobility interventions for a client who is recovering from a right total hip arthroplasty with a posterior approach. Which of the following actions should the nurse include in the client's plan of care?

The nurse is receiving the shift report for four clients on a progressive care step-down unit. Which client should the nurse assess FIRST?

A nurse is caring for a client who sustained a complete cervical spinal cord injury at the C6 level two months ago. The client suddenly reports an intense, pounding headache and blurred vision. The nurse notes profound diaphoresis on the client's face and neck, nasal congestion, and a blood pressure reading of 214/112 mm Hg. Arrange the following nursing interventions in the correct priority order from first to last to mitigate the risk of severe complications.

During the second hour of admission to the intensive care unit, a 24-year-old client being treated for status asthmaticus exhibits a significant change in clinical status. Initially, the client presented with severe agitation, accessory muscle use, a respiratory rate of $34 \text{ breaths/minute}$, and loud bilateral expiratory wheezes. The client was placed on $4 \text{ L/min}$ supplemental oxygen via nasal cannula.

Currently, the client appears profoundly lethargic. The respiratory rate has decreased to $14 \text{ breaths/minute}$, and auscultation reveals a "silent chest" with absent wheezing. The nurse compares the initial arterial blood gas (ABG) results with the most recent draw (both drawn on the same oxygen settings):

Which of the following is the priority nursing action?

A client diagnosed with symptomatic anemia is currently receiving a transfusion of packed red blood cells via a 20-gauge peripheral intravenous catheter. Following a sudden drop in blood pressure to 85/50 mmHg, the healthcare provider prescribes a rapid bolus of Lactated Ringer's solution. Which action is most appropriate for the nurse to take?

A nurse is monitoring a client who is receiving a transfusion of packed red blood cells (PRBCs) for severe anemia. Ten minutes after the infusion begins, the client reports sudden, intense lower back pain and a feeling of impending doom. The nurse notes that the client is tachycardic, tachypneic, and hypotensive. To safely manage this suspected acute hemolytic transfusion reaction and reduce the risk of further physiological compromise, arrange the following nursing actions in the correct priority sequence.

A nurse is assessing a client who has experienced severe vomiting and diarrhea for the past 48 hours. Which of the following assessment findings should the nurse identify as indicating fluid volume deficit? Select all that apply.

During a routine safety and assessment round on a medical-surgical unit, a nurse evaluates four clients. Which of the following observations indicates a severe physiological risk that requires immediate intervention by the nurse?

A client is recovering in the surgical unit after an open abdominal procedure. Which assessment finding provides the earliest physiological indication that the client is developing hypovolemic shock?

A critically ill client with septic shock has a triple-lumen central venous catheter (CVC) inserted in the right internal jugular vein. The client is receiving a continuous intravenous infusion of norepinephrine through the proximal lumen and a continuous intravenous infusion of propofol through the distal lumen. The medial lumen is currently saline-locked. The healthcare provider prescribes an intermittent intravenous piggyback (IVPB) dose of pantoprazole. The nurse verifies in an intravenous drug reference guide that pantoprazole is physically incompatible at the Y-site with both norepinephrine and propofol. What is the most appropriate nursing action?

A young adult client is being monitored on the trauma step-down unit $18$ hours after surgical stabilization of multiple long-bone fractures. The client suddenly exhibits profound agitation and disorientation. The nurse collects the following clinical data:

• Vital Signs: Heart rate $124\text{/min}$, respiratory rate $30\text{/min}$, blood pressure $108/68\text{ mm Hg}$, temperature $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$)
• Arterial Blood Gas (Room Air): pH $7.51$, $\text{PaCO}_2$ $28\text{ mm Hg}$, $\text{PaO}_2$ $52\text{ mm Hg}$, $\text{HCO}_3^-$ $23\text{ mEq/L}$
• Focused Assessment: Capillary refill is $2$ seconds. Small, non-blanching red macules are newly present across the axillae and conjunctivae.

Based on these findings, which intervention must the nurse execute immediately to mitigate the client's risk of physiological collapse?

A nurse is creating a plan of basic care and comfort for a 78-year-old client who is 24 hours postoperative following a right total knee arthroplasty (TKA). Which of the following interventions should the nurse include in the client's care plan? Select all that apply.

A nurse is caring for a client who returned to the telemetry unit thirty minutes ago following a percutaneous coronary intervention (PCI) via the right femoral artery. Which of the following nursing interventions are necessary to reduce the risk of physiological complications? (Select all that apply.)

A nurse is evaluating a client admitted with a severe urinary tract infection who is now increasingly confused. Current vital signs include a blood pressure of 90/72 mm Hg, a heart rate of 128/min, a respiratory rate of 28/min, and a temperature of 39.2°C (102.6°F). Arterial blood gas (ABG) analysis on room air reveals a pH of 7.28, a PaCO2 of 28 mm Hg, a HCO3- of 14 mEq/L, and a PaO2 of 88 mm Hg. Based on these findings, which of the following is the most appropriate interpretation and priority nursing action?

A conscious client with diabetes mellitus reports feeling shaky, diaphoretic, and weak. Arrange the following nursing actions in the correct chronological sequence according to the standard management of hypoglycemia.

A client is receiving care in the critical care unit following a closed head injury. The nurse is continuously monitoring the client's neurological status and physiological adaptation. Which of the following assessment findings strongly indicate that the client is losing compensatory auto-regulation and developing critically elevated intracranial pressure? Select all that apply.

A 45-year-old client is admitted to the burn unit after sustaining full-thickness thermal burns to 40% of their total body surface area. Eight hours into the emergent resuscitation phase, the nurse assesses the following: blood pressure 84/52 mm Hg, heart rate 136 beats/minute, and a cumulative urine output of 25 mL over the past two hours. Arterial blood gas results indicate a pH of 7.28, PaCO2 of 29 mm Hg, and HCO3- of 15 mEq/L. Based on these clinical indicators, what is the most accurate interpretation of the client's condition and the priority nursing intervention?

A nurse is caring for a client who is receiving a transfusion of packed red blood cells. The client suddenly reports severe lower back pain and chills. Arrange the following nursing actions in the correct order of priority to minimize physiological risk to the client.

A client is admitted to the intensive care unit with urosepsis. During the initial assessment, the client is restless with a temperature of 38.9°C (102°F), a heart rate of 115/min, a respiratory rate of 30/min, and a blood pressure of 118/68 mm Hg. Which arterial blood gas (ABG) result should the nurse anticipate as the most likely early physiological adaptation in this client?