Physiological Integrity

A client is admitted to the intensive care unit with severe sepsis secondary to a perforated viscus. The nurse has just completed administering a prescribed initial intravenous fluid bolus of 30 mL/kg of 0.9% sodium chloride. A subsequent reassessment reveals a blood pressure of 82/46 mmHg, a heart rate of 126 beats/minute, a respiratory rate of 28 breaths/minute, and a urine output of 15 mL over the past hour. Arterial blood gas results demonstrate a pH of 7.27, $PaCO_2$ of 30 mmHg, $PaO_2$ of 82 mmHg, and $HCO_3^-$ of 14 mEq/L. Based on these findings, which of the following is the priority nursing action?

A critical care nurse is managing a client with symptomatic bradycardia who is unresponsive to standard atropine therapy. The client weighs $187\text{ lbs}$. The healthcare provider prescribes a continuous IV infusion of dopamine at $4\text{ mcg/kg/min}$. The pharmacy supplies a premixed bag containing $250\text{ mg}$ of dopamine in $500\text{ mL}$ of $5\%$ dextrose in water (D5W). What is the correct infusion pump setting in $\text{mL/hr}$? Record your answer using one decimal place.

A client with chronic kidney disease presents to the emergency department reporting profound muscle weakness and palpitations. The continuous cardiac monitor displays tall, peaked T waves and a widened QRS complex. Laboratory results show a serum potassium level of 7.2 mEq/L (7.2 mmol/L). The arterial blood gas (ABG) analysis reveals: pH 7.27, PaCO2 36 mmHg, PaO2 92 mmHg, and HCO3- 16 mEq/L. To immediately reduce the risk of a fatal ventricular dysrhythmia, which prescribed action should the nurse take first?

A nurse is caring for a client who has a central venous catheter. While the nurse is changing the injection caps, the client suddenly becomes extremely restless, gasps for air, and reports severe chest pain. The nurse suspects a venous air embolism. In what order should the nurse perform the following actions? Arrange the items from first to last.

A nurse is monitoring a client who is receiving a transfusion of packed red blood cells. Ten minutes into the transfusion, the client reports sudden lower back pain, chills, and shortness of breath. Arrange the following nursing actions in the correct priority sequence.

During morning rounds, the nurse reviews the electronic health record for a client with a long-standing history of severe chronic obstructive pulmonary disease (COPD). The client is currently resting comfortably while receiving oxygen therapy at 2 L/min via a nasal cannula. The most recent arterial blood gas analysis reveals a pH of 7.36, a PaCO2 of 58 mm Hg, a PaO2 of 62 mm Hg, and a bicarbonate (HCO3-) level of 32 mEq/L. Which of the following actions should the nurse implement based on this data?

A client receiving an intravenous transfusion of packed red blood cells (PRBCs) suddenly reports severe lower back pain, chills, and shortness of breath. To reduce the risk of severe physiological complications from a suspected acute hemolytic transfusion reaction, arrange the following nursing actions in the correct priority sequence.

A client is receiving care in the trauma step-down unit after sustaining a T4 complete spinal cord injury. When evaluating the client for potential hemodynamic complications, which assessment finding specifically indicates that the client is developing neurogenic shock rather than hemorrhagic shock?

A nurse in the neurological intensive care unit is evaluating a client who sustained a complete T3 spinal cord injury two months ago. The client suddenly reports a severe, throbbing headache and blurred vision. The nurse observes pronounced flushing and diaphoresis on the client's face, neck, and upper chest, while the skin on the lower extremities is pale and cool. Vital signs reveal a blood pressure of 210/110 mmHg, a heart rate of 48 beats/min, and respirations of 22 breaths/min. Which immediate nursing actions are appropriate? Select all that apply.

A client with right-sided hemiparesis is receiving continuous enteral nutrition via a nasogastric tube. When organizing the client's daily care and hygiene, which interventions should the nurse include? Select all that apply.

During morning rounds on the progressive cardiac care unit, a nurse evaluates a 68-year-old individual who sustained an anterior ST-segment elevation myocardial infarction 36 hours ago. The client is newly restless, diaphoretic, and reports a 'sense of impending doom.' Current vital signs include a blood pressure of 98/82 mm Hg, heart rate of 122 beats per minute, respiratory rate of 26 breaths per minute, and oxygen saturation of 93% on room air. The urinary catheter has drained 15 mL over the previous hour. Which intervention represents the highest priority?

A nurse is preparing to administer an intravenous (IV) push dose of phenytoin to a client. The client has a single peripheral IV line currently infusing 5% dextrose in water (D5W) continuously. Phenytoin is physically incompatible with D5W. The nurse has already verified the client's identity, checked the medication prescription, and donned clean gloves. Arrange the following steps in the correct chronological order to safely administer the medication.

Four hours following an extensive bowel resection, a client reports severe thirst and exhibits new-onset restlessness. The nurse reviews the client's current clinical data:

Recent arterial blood gas (ABG) results show a pH of $7.48$, PaCO $_2$ of $30$ mm Hg, and HCO $_3^-$ of $23$ mEq/L.

Which of the following is the priority nursing action?

A client who is experiencing recurrent seizures is prescribed a 1,000 mg intravenous (IV) loading dose of phenytoin. The client currently has a continuous primary IV infusion of 5% dextrose in water (D5W) running at 75 mL/hr through a peripheral catheter. What is the safest administration sequence for the nurse to implement?

A clinical nurse is preparing to draw a blood specimen for a comprehensive metabolic panel (CMP) from an adult client's triple-lumen central venous access device (CVAD). The client currently has a continuous intravenous infusion of 0.9% sodium chloride with 20 mEq of potassium chloride infusing through the proximal lumen. To ensure accurate laboratory results and reduce the risk of infection, in what order should the nurse perform the following actions? Arrange the steps in the correct sequence.

A nurse is creating a plan of care for an older adult client admitted with acute decompensated heart failure. The client has severe peripheral edema, is experiencing orthopnea, and has become restless, frequently picking at their continuous intravenous (IV) infusion line. Which of the following nursing interventions should be included in the client's basic care and comfort plan? Select all that apply.

A nurse is evaluating a client who is receiving continuous intravenous fluid therapy for severe acute pancreatitis. Which assessment findings indicate the client is developing early hypovolemic shock? Select all that apply.

A nurse is developing a plan of care for an adult client who returned to the surgical unit 4 hours ago following a left-sided pneumonectomy for a pulmonary malignancy. Which intervention is essential to include to reduce the risk of severe physiological complications?

A nurse is caring for a mechanically ventilated client who requires continuous sedation. The healthcare provider prescribes a propofol infusion at $20 \text{ mcg/kg/min}$. The client weighs $176 \text{ lbs}$. The medication is supplied as $10 \text{ mg/mL}$. At what rate in $\text{mL/hr}$ should the nurse set the intravenous pump? (Record your answer to the nearest tenth.)

A nurse is caring for a client with a complete T4 spinal cord injury who suddenly reports a severe, pounding headache. The nurse notes facial flushing, profuse diaphoresis above the nipple line, and a blood pressure of $214/118$ mm Hg. Arrange the following nursing interventions in the correct order of clinical priority.