Physiological Integrity

During the administration of packed red blood cells, a client abruptly reports intense lower back pain, sudden chills, and difficulty breathing. To minimize further physiological injury, arrange the following nursing actions in the correct sequence of execution.

A young adult client with a history of type 1 diabetes mellitus is admitted to the critical care unit with severe lethargy, a fruity breath odor, and deep, rapid respirations at $32\text{/min}$. Current vital signs reveal a heart rate of $128\text{/min}$ and a blood pressure of $88/54\text{ mm Hg}$. Laboratory data show a blood glucose level of $580\text{ mg/dL}$ and a serum potassium of $5.2\text{ mEq/L}$. An arterial blood gas (ABG) analysis indicates a $\text{pH}$ of $7.15$, $\text{PaCO}_2$ of $26\text{ mm Hg}$, $\text{PaO}_2$ of $96\text{ mm Hg}$, and $\text{HCO}_3^-$ of $9\text{ mEq/L}$. What is the nurse's priority intervention?

A nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). The client is lethargic with Kussmaul respirations, a blood glucose of 640 mg/dL, and an arterial blood pH of 7.18. Arrange the following nursing interventions in the priority order they should be implemented.

A client admitted with severe hypotension requires a continuous intravenous (IV) infusion of dopamine. The healthcare provider's prescription is for a dose of $5 \text{ mcg/kg/min}$. The client's current weight is $176 \text{ lbs}$. The pharmacy provides a premixed IV bag containing $400 \text{ mg}$ of dopamine dissolved in $250 \text{ mL}$ of $5\%$ dextrose in water (D5W). At what rate, in $\text{mL/hr}$, should the nurse program the continuous IV infusion pump?

A nurse is caring for a client who has just returned to the medical-surgical unit following a percutaneous liver biopsy. Which of the following nursing actions should the nurse implement to reduce the risk of post-procedure complications? (Select all that apply.)

While rounding on a medical-surgical unit, a nurse assesses a client admitted with chronic heart failure. The client suddenly exhibits profound respiratory distress, orthopnea, and severe anxiety. Assessment reveals an oxygen saturation of 82% on room air, diffuse bilateral crackles, and the expectoration of pink, frothy sputum. Arrange the following collaborative and independent nursing actions in the correct order of priority. All options must be used.

An older adult client is recovering in the cardiac intensive care unit following an acute anterior myocardial infarction. During the morning assessment, the nurse suspects the client is developing early cardiogenic shock. Which of the following clinical findings support this complication? (Select all that apply.)

A nurse is caring for a client who has been receiving continuous gastric suctioning for the past 48 hours to manage a small bowel obstruction. The client reports lightheadedness and a new onset of tingling around the mouth and fingers. The most recent arterial blood gas (ABG) analysis shows a pH of 7.54, a $PaCO_2$ of 41 mm Hg, and an $HCO_3^-$ of 34 mEq/L. Based on these findings, which of the following is the priority nursing action?

During the continuous monitoring of a client admitted with a severe asthma exacerbation, the nurse observes that the client's respiratory rate has abruptly declined from 36 to 10 breaths per minute. The previously auscultated loud wheezes are now markedly diminished, and the client is increasingly somnolent. Recent arterial blood gas (ABG) analysis reveals the following results:

What is the most critical action for the nurse to take?

A nurse is caring for a client who has a right-sided chest tube for the treatment of a spontaneous pneumothorax. The client suddenly exhibits severe dyspnea, tachycardia, and extreme restlessness. The nurse observes that the trachea is deviated to the left and tidaling in the water-seal chamber has abruptly stopped. A stat arterial blood gas (ABG) reveals a pH of $7.24$, a $\text{PaCO}_2$ of $62\text{ mm Hg}$, and a $\text{PaO}_2$ of $52\text{ mm Hg}$. Which action should the nurse take first to reduce the client's risk of physiological deterioration?

A nurse is preparing to care for a postoperative client who will receive intravenous morphine sulfate via a patient-controlled analgesia (PCA) pump. Which of the following nursing actions are appropriate to ensure the safe administration of this parenteral therapy? (Select all that apply.)

A nurse is preparing to administer a mixed dose of regular insulin and NPH insulin in a single syringe for a client with diabetes mellitus. In what order should the nurse perform the following actions? Arrange the steps in the correct chronological order from first to last.

An emergency department nurse assesses a client with a history of severe chronic obstructive pulmonary disease (COPD) who presented with increased work of breathing. After receiving supplemental oxygen for two hours, the client is now profoundly somnolent and responds only to painful stimuli. The respiratory rate is $8\text{ breaths/min}$ and shallow. Recent arterial blood gas (ABG) results are as follows:

* $\text{pH}: 7.18$
* $\text{PaCO}_2: 84\text{ mm Hg}$
* $\text{HCO}_3^-: 32\text{ mEq/L}$
* $\text{PaO}_2: 70\text{ mm Hg}$

Based on the client's current clinical presentation and laboratory results, which action should the nurse prioritize?

While performing a morning assessment on a client who underwent an open bowel resection 48 hours ago, the client experiences a sudden, forceful cough. The client states, "Something just gave way in my stomach." The nurse inspects the surgical site and observes that the wound edges have separated with intestinal loops visible outside the abdominal cavity. In what sequence should the nurse perform the following actions? (Arrange the steps in the correct order of priority.)

A 65-year-old client is receiving a continuous intravenous infusion of furosemide for severe fluid volume overload. During the shift, the client becomes increasingly lethargic and reports profound muscle cramps. The nurse notes the client's blood pressure has dropped from 134/82 mmHg to 86/52 mmHg over the past two hours. An arterial blood gas (ABG) analysis reveals the following values: pH 7.53, PaCO2 43 mmHg, and HCO3 36 mEq/L. Which action should the nurse prioritize to mitigate the risk of further physiological decline?

A clinical unit is monitoring a client admitted for acute pyelonephritis. During the afternoon assessment, the client becomes increasingly restless and confused. The nurse reviews the most recent diagnostic and assessment data:

Based on these clinical findings, which of the following interventions should be implemented? (Select all that apply)

A pediatric client weighing 33 lb is prescribed ampicillin 100 mg/kg/day intravenously, divided into equal doses administered every 6 hours. The pharmacy dispenses ampicillin with a concentration of 250 mg/mL. How many mL will the nurse administer per dose? Record your answer to the nearest tenth.

Two hours after a diagnostic colonoscopy with multiple polypectomies, a client begins to complain of severe, continuous abdominal pain that radiates to the right shoulder. The nurse observes that the client's abdomen is rigid and board-like upon inspection. Vital signs reveal a blood pressure of 88/54 mm Hg and a heart rate of 122 beats per minute. Which intervention is the most critical to implement first?

A nurse is caring for a client with a T4 spinal cord injury who suddenly reports a severe, pounding headache and blurred vision. The client's blood pressure is 215/115 mm Hg, heart rate is 52 bpm, and they have profound diaphoresis above the level of the injury. In what order should the nurse perform the following interventions? Arrange the actions from highest priority (first) to lowest priority (last).

A nurse is assessing a client who is receiving a continuous intravenous (IV) infusion of norepinephrine for the treatment of septic shock. The nurse observes that the tissue surrounding the peripheral IV insertion site is pale, swollen, and cool to the touch. Which action should the nurse take first?