Physiological Integrity

A young adult client is being monitored on the orthopedic unit 24 hours after sustaining a closed comminuted fracture of the right femur. The client abruptly becomes intensely restless and confused, with a respiratory rate of 34 breaths per minute. Upon physical assessment, the nurse observes a new onset of petechiae over the client's anterior chest and axillae. Which of the following actions is the nurse's priority?

A client recovering from an orthopedic procedure is receiving intravenous morphine via a patient-controlled analgesia (PCA) device. Upon entering the room, the nurse observes that the client is somnolent, difficult to awaken, and has shallow respirations at a rate of 8 breaths per minute. Which of the following arterial blood gas (ABG) values and clinical manifestations should the nurse anticipate? Select all that apply.

A nurse evaluates a client admitted with community-acquired pneumonia and a comorbidity of heart failure. The client is receiving continuous oxygen therapy at $3\text{ L/min}$ via nasal cannula. Over the past hour, the client has become increasingly restless with a respiratory rate of $32\text{ breaths/min}$. Arterial blood gas analysis reveals a pH value of $7.52$, a $PaCO_2$ of $28\text{ mm Hg}$, a $PaO_2$ of $58\text{ mm Hg}$, and a bicarbonate level of $24\text{ mEq/L}$. Which action should the nurse take first?

An adult client who underwent a percutaneous liver biopsy three hours ago is being monitored on the medical-surgical unit. The nurse compares the client's current assessment findings with the baseline data obtained immediately upon arrival to the unit.

Based on these findings, which of the following is the most accurate interpretation of the client's condition?

A nurse is caring for a client who is 2 hours post-procedure following a right femoral cardiac catheterization. The client suddenly reports severe right groin pain. Upon inspection, the nurse notes a rapidly expanding, firm swelling at the catheter insertion site and a heart rate of 118 beats/minute. Which action should the nurse take first?

A nurse is providing care for a client who is receiving total parenteral nutrition (TPN) via a central venous access device. Which of the following nursing actions are necessary to ensure the safe administration of this therapy? Select all that apply.

Following a fall from a roof, a client with a confirmed unstable pelvic fracture experiences a sudden change in condition during the afternoon shift. The client, previously calm, becomes exceedingly restless and reports an intense sensation of thirst. The bedside monitor displays a heart rate of 126 beats/min, a blood pressure reading of 90/54 mm Hg, and a respiratory rate of 26 breaths/min. The indwelling urinary catheter has drained 15 mL of dark urine in the last 60 minutes. Which of the following immediate interventions are required? Select all that apply.

A nurse is caring for a 74-year-old client who is 24 hours postoperative following a right-sided modified radical mastectomy with axillary lymph node dissection. The client reports mild discomfort and a feeling of heaviness in the right arm. Which of the following nursing actions is most appropriate to promote comfort and prevent complications?

A nurse is monitoring a client who is receiving an intravenous infusion of a prescribed antibiotic. Fifteen minutes after the infusion starts, the client becomes restless and reports a feeling of impending doom. Which assessment finding should the nurse identify as the most definitive indicator that the client is developing anaphylactic shock?

A client is admitted to the medical-surgical unit immediately following a lumbar puncture. The client reports a mild, dull headache. Which of the following nursing actions is most appropriate?

While conducting a comprehensive assessment on a client with a systemic infection, the nurse notes several physiological shifts. The nurse suspects the client is entering the early, hyperdynamic phase of septic shock. Which assessment findings indicate this specific stage of clinical deterioration? Select all that apply.

A client with end-stage renal disease is brought to the emergency department with severe weakness and palpitations. The client's serum potassium level is $7.9\text{ mEq/L}$ ($7.9\text{ mmol/L}$), and the cardiac monitor displays widened QRS complexes. The healthcare provider prescribes STAT intravenous (IV) $10\%$ calcium gluconate, IV $8.4\%$ sodium bicarbonate, IV regular insulin, and IV $50\%$ dextrose. The client has a single peripheral IV line infusing $0.9\%$ sodium chloride. Which action by the nurse is the most appropriate?

A nurse is caring for a client who is receiving continuous total parenteral nutrition (TPN) via a single-lumen peripherally inserted central catheter (PICC). The healthcare provider prescribes a scheduled dose of intravenous (IV) ceftriaxone. The drug reference guide indicates that ceftriaxone is chemically incompatible with the TPN formulation. Which of the following is the most appropriate nursing action?

While assessing a client on the first postoperative day following a total thyroidectomy, the nurse observes the client experiencing severe anxiety, visible muscle twitching, and circumoral paresthesia. The rapid response team is activated, and a stat arterial blood gas (ABG) analysis is drawn, reporting the following values: pH $7.54$, $PaCO_2$ $26$ $mm Hg$, $HCO_3^-$ $23$ $mEq/L$, and $PaO_2$ $96$ $mm Hg$. Based on these findings, which initial action is most appropriate to mitigate the risk of impending seizures or tetany?

A nurse is assessing a client who experienced an acute anterior myocardial infarction earlier in the shift. Which of the following assessment findings indicate the client is developing cardiogenic shock? Select all that apply.

A nurse enters the room of a client receiving continuous intravenous fluids through a right subclavian central venous access device (CVAD). The nurse observes that the IV tubing has completely disconnected from the catheter hub. The client is suddenly tachypneic, diaphoretic, and reports severe, sharp chest pain. After immediately clamping the CVAD, which of the following is the nurse's priority action?

A $28$-year-old client is admitted to the trauma unit after sustaining a closed pelvic fracture in a motorcycle collision. The nurse is monitoring the client for potential complications. Which of the following assessment findings suggest early physiological decompensation and require immediate intervention? (Select all that apply.)

An adult client is admitted with community-acquired pneumonia and has a continuous peripheral intravenous (IV) infusion of Lactated Ringer's solution running at $125 \text{ mL/hr}$. The healthcare provider prescribes a scheduled dose of intravenous ceftriaxone. Based on pharmacological safety principles, which action should the nurse perform?

A nurse is caring for a client with a T4 spinal cord injury who suddenly reports a severe, pounding headache. Assessment reveals profuse diaphoresis above the level of the injury, a blood pressure of 210/115 mm Hg, and a heart rate of 54 bpm. Arrange the following nursing interventions in the correct priority sequence, from first to last.

An adult client receiving a continuous $0.9\%$ sodium chloride infusion at $75\text{ mL/hr}$ through a single peripheral venous catheter is prescribed a dose of intravenous amphotericin B for a severe fungal infection. Before hanging the antifungal medication, which action must the nurse prioritize to ensure safe administration?