Physiological Integrity

Following a total thyroidectomy, an adult client is admitted to the surgical step-down unit. To minimize the potential for severe postoperative complications, which actions and assessments must the nurse include in the plan of care? Select all that apply.

A nurse is performing a reassessment on a young adult client admitted with an acute asthma exacerbation. The client initially presented with marked tachypnea, use of accessory muscles, and loud bilateral wheezing. Thirty minutes later, the nurse observes that the client's respirations have become shallow, wheezing is no longer audible, and the client appears drowsy. Arterial blood gas (ABG) results reveal a $\text{pH}$ of $7.28$, a $\text{PaCO}_2$ of $58\text{ mm Hg}$, and an $\text{HCO}_3^-$ of $24\text{ mEq/L}$. Which of the following is the priority nursing action?

An older adult client is transferred to the medical-surgical unit after a cardiac catheterization accessed via the right femoral artery. The client is on bed rest, has a history of osteoarthritis, and reports generalized back stiffness. Which of the following nursing actions should be included in the client's basic care and comfort plan? Select all that apply.

An adult weighing $176\text{ lb}$ requires vasopressor support for septic shock. The critical care provider prescribes a norepinephrine infusion to begin at $0.05\text{ mcg/kg/min}$. The available IV bag contains $4\text{ mg}$ of norepinephrine mixed in $250\text{ mL}$ of $5\%$ dextrose in water (D5W). At how many $\text{mL/hr}$ will the infusion pump run? Record your answer using a whole number.

An adult client hospitalized with rapid atrial fibrillation is receiving a continuous intravenous (IV) infusion of diltiazem to maintain ventricular rate control. The client has a single peripheral IV catheter located in the left forearm. The healthcare provider prescribes a scheduled dose of intravenous pantoprazole. The nurse consults the facility's pharmacology reference and notes that pantoprazole is physically incompatible with diltiazem. Which action should the nurse take to safely administer the prescribed medication?

A nurse is caring for a client with a history of adrenal insufficiency who was admitted for management of severe gastroenteritis. During the most recent assessment, the client appears increasingly lethargic. Vital signs show the heart rate has trended from $82$ to $114 \text{ beats/min}$, and the blood pressure has shifted from $118/76 \text{ mm Hg}$ to $102/84 \text{ mm Hg}$. Current laboratory results indicate a serum sodium of $131 \text{ mEq/L}$ ($131 \text{ mmol/L}$), serum potassium of $5.8 \text{ mEq/L}$ ($5.8 \text{ mmol/L}$), and an arterial blood gas (ABG) revealing a $\text{pH}$ of $7.31$, $\text{PaCO}_2$ of $36 \text{ mm Hg}$, and $\text{HCO}_3^-$ of $18 \text{ mEq/L}$ ($18 \text{ mmol/L}$). Which of the following is the priority nursing intervention?

An orthopedic unit nurse assumes care of a client who underwent a right above-the-knee amputation (AKA) twenty-four hours ago. The client's vital signs are currently stable, but they remain at high risk for physiological complications that could impede future rehabilitation. Which of the following nursing actions is most appropriate to reduce the client's risk of adverse physiological outcomes?

A healthcare provider prescribes an intravenous piggyback (IVPB) infusion of cefazolin 1 gram in $50\text{ mL}$ of 0.9% sodium chloride to be administered over $30\text{ minutes}$. The nurse should set the intravenous infusion pump to deliver how many $\text{mL/hr}$? Record your answer using a whole number.

During the night shift, a nurse is monitoring a client admitted with acute decompensated heart failure and rapid atrial fibrillation. The client has a single 22-gauge peripheral intravenous catheter infusing continuous diltiazem. Assessment reveals a blood pressure of 92/60 mmHg, an irregular heart rate of 118 beats/min, and a respiratory rate of 28 breaths/min with audible crackles bilaterally. The provider orders a stat dose of intravenous furosemide. Upon checking the compatibility matrix, the nurse notes that furosemide is physically incompatible with diltiazem. What is the priority nursing action?

An older adult client is bedbound and recovering from severe bacterial pneumonia when they develop sudden, acute agitation and confusion. The nursing team is establishing interventions to address the client's basic care, comfort, and safety needs. Which of the following actions should be included in the care plan? Select all that apply.

An older adult client with severe osteoarthritis and mild dementia resides in a long-term care facility. During early morning rounds, the client becomes verbally agitated and physically resists when staff attempt to change the bed linens and assist with dressing. Recognizing that joint stiffness is a primary contributing factor, which action should the nurse take?

A nurse is evaluating a $68$-year-old client who underwent a left-sided thoracentesis $2$ hours ago for the treatment of a large pleural effusion secondary to heart failure. Which of the following assessment findings indicate a potential life-threatening complication and require immediate intervention? Select all that apply.

A client who is admitted with severe gastrointestinal bleeding is receiving a unit of packed red blood cells (PRBCs) through a peripheral intravenous (IV) catheter. Fifteen minutes into the infusion, the client suddenly reports severe lower back pain, chills, and shortness of breath. The nurse suspects an acute hemolytic transfusion reaction. Place the following nursing interventions in the correct chronological order of priority from first to last.

A nurse is monitoring a client who recently underwent endoscopic band ligation for bleeding esophageal varices. Which assessment findings should the nurse identify as early indicators of systemic physiological deterioration and impending hypovolemic shock? (Select all that apply.)

A client recovering from a massive anterior wall myocardial infarction is being monitored with a pulmonary artery catheter. Over the last hour, the client has become increasingly lethargic. The nurse evaluates the following hemodynamic and laboratory parameters:

- Heart rate: $118$ beats/min
- Mean arterial pressure (MAP): $54$ mm Hg
- Central venous pressure (CVP): $16$ mm Hg (Normal: $2$-$8$ mm Hg)
- Pulmonary artery wedge pressure (PAWP): $24$ mm Hg (Normal: $6$-$12$ mm Hg)
- Cardiac index (CI): $1.7$ L/min/m $^2$ (Normal: $2.5$-$4.0$ L/min/m $^2$)
- Systemic vascular resistance (SVR): $2150 \text{ dynes/sec/cm}^{-5}$ (Normal: $800$-$1200 \text{ dynes/sec/cm}^{-5}$)

Arterial blood gas (ABG) results on a $40\%$ Venturi mask reveal: pH $7.24$, PaCO $_2$ $58$ mm Hg, HCO $_3^-$ $25$ mEq/L, and PaO $_2$ $58$ mm Hg.

Based on this physiological presentation, which intervention most accurately addresses the primary pathophysiological failure?

The nurse is preparing to transfer a client with right-sided hemiparesis from the bed to a wheelchair. To promote a safe transfer, where should the nurse position the wheelchair?

A nurse is creating a plan of care for an older adult client who is on strict bed rest and is at high risk for skin breakdown. Which of the following actions are appropriate to promote basic care and comfort? Select all that apply.

A nurse is caring for a 58-year-old client who returned to the unit two hours ago following a percutaneous liver biopsy. The client reports mild right upper quadrant pain. The current vital signs are: blood pressure 98/60 mm Hg, heart rate 112 beats/min, and respiratory rate 20 breaths/min. Which action should the nurse take immediately to minimize the client's physiological risk?

An adult client is receiving care in the emergency department for a severe asthma exacerbation. The initial arterial blood gas (ABG) on room air indicated $\text{pH} = 7.48$, $\text{PaCO}_2 = 28 \text{ mm Hg}$, and $\text{HCO}_3^- = 23 \text{ mEq/L}$. Two hours later, the nurse observes that the client has become extremely lethargic and their respiratory effort has noticeably decreased. A follow-up ABG reveals $\text{pH} = 7.29$, $\text{PaCO}_2 = 56 \text{ mm Hg}$, and $\text{HCO}_3^- = 24 \text{ mEq/L}$. Which action is the highest priority for the nurse to take?

A client with a newly casted right fractured tibia is prescribed non-weight-bearing status for the right leg. The nurse is educating the client on how to safely stand up from a wheelchair using axillary crutches. In which order should the nurse instruct the client to perform the following actions? Arrange the steps from first to last.