Physiological Integrity

A nurse is evaluating a client with severe hepatic cirrhosis who recently underwent a therapeutic bedside paracentesis with the removal of 5 liters of ascitic fluid. Twenty minutes after the procedure, the client reports feeling dizzy and nauseous. The nurse observes that the client's heart rate has increased from 78 to 118 beats per minute, and the blood pressure has decreased from 132/82 mm Hg to 94/56 mm Hg. Which of the following actions should the nurse perform first to mitigate the risk of severe hemodynamic collapse?

A nurse receives a client who has just returned to the medical unit following a percutaneous liver biopsy. To minimize the risk of post-procedure bleeding, which of the following positions should the nurse assist the client into?

A nurse in an orthopedic rehabilitation clinic is providing discharge teaching to a client with a fractured left tibia. The client is prescribed strict non-weight-bearing status for the left leg and is learning to use axillary crutches. When evaluating the client's understanding of how to safely descend a flight of stairs, which statement by the client indicates correct technique?

A client, age 82, with advanced emphysema and cor pulmonale is receiving treatment for hospital-acquired pneumonia. The client is currently prescribed continuous supplemental oxygen at 4 L/min via nasal cannula. During an assessment, the nurse finds the client somnolent, difficult to arouse, and taking 9 shallow breaths per minute. The most recent arterial blood gas analysis reveals a pH of 7.24, PaCO2 of 74 mm Hg, PaO2 of 56 mm Hg, and HCO3 of 32 mEq/L. Based on these clinical findings, which immediate intervention should the nurse implement?

A 55-year-old client is 3 days postoperative following an exploratory laparotomy. During a forceful coughing episode, the client reports a sudden "popping" sensation in the abdomen. The nurse inspects the surgical site and observes an abdominal evisceration. Place the following nursing interventions in the correct priority order to minimize the risk of severe physiological complications. (Arrange the steps from first to last.)

A nurse is preparing to administer an intravenous (IV) infusion of amphotericin B deoxycholate to a client diagnosed with a severe systemic fungal infection. Which of the following nursing actions are appropriate when managing this parenteral therapy? Select all that apply.

A nurse is preparing to discontinue a client's peripheral intravenous (IV) catheter. Place the following steps in the correct chronological order from first to last.

A 68-year-old client is admitted to the medical unit with a history of recurrent syncope, dehydration, and the recent initiation of a new antihypertensive medication. The healthcare provider prescribes orthostatic vital sign measurements. To ensure accurate assessment and reduce the risk of a potential fall, arrange the following procedural steps in the correct chronological order.

A nurse is preparing to draw a blood specimen from a client's central venous catheter (CVC). To maintain catheter patency, prevent infection, and ensure accurate laboratory results, arrange the following steps in the correct chronological sequence.

A nurse on a medical-surgical unit is evaluating the status of four assigned clients. Based on the provided clinical data, which client requires the nurse's immediate intervention?

A nurse is planning care for an 82-year-old client admitted with an acute exacerbation of heart failure. The client has marked lower extremity edema, requires continuous supplemental oxygen, and is on strict bed rest. During the night shift, the client becomes increasingly restless and makes repeated attempts to climb out of bed. Which of the following basic care and safety interventions should the nurse include in the client's plan of care? Select all that apply.

A nurse is caring for a client with dysphagia who is preparing to eat breakfast. Which positioning action is most appropriate to prevent aspiration?

A client is receiving low continuous nasogastric suction for a small bowel obstruction. The nurse should monitor the client for which primary acid-base imbalance resulting from this therapy?

A nurse is directing the basic care and comfort measures for an 82-year-old client admitted to the medical-surgical unit with severe bilateral pneumonia. The client has a history of mild dementia and is currently experiencing significant dyspnea, generalized fatigue, and an oxygen saturation of 88% on room air. Which of the following nursing actions should the nurse include in the client's plan of care? (Select all that apply)

A nurse is preparing to administer a newly prescribed intravenous (IV) antibiotic as a secondary infusion (piggyback) to a client who is currently receiving a continuous primary IV infusion of 0.9% sodium chloride. Which of the following is the priority nursing action before initiating the secondary infusion?

A 68-year-old client is 2 hours post-percutaneous coronary intervention (PCI) utilizing a right femoral artery approach. The arterial sheath was removed 45 minutes ago, and a mechanical compression device is currently in place. The client reports a new onset of vague right lower back and flank pain, accompanied by mild nausea. Over the past 45 minutes, the client's heart rate has progressively increased from 72 to 110 bpm, and the blood pressure has trended from 134/82 mm Hg down to 112/74 mm Hg. The right femoral insertion site is dry, intact, and free of any superficial bleeding or palpable hematoma. Which of the following actions is the priority for the nurse to perform to reduce the risk of severe physiological deterioration?

Following a percutaneous liver biopsy, a client remains on bed rest for post-procedure monitoring. Which specific clinical findings should immediately alert the nurse that this client is developing early hemorrhagic shock? Select all that apply.

A critical care nurse is evaluating a client with a history of acute severe asthma who is undergoing a spontaneous breathing trial (SBT) via a T-piece. Thirty minutes into the trial, the client becomes restless and diaphoretic. The nurse draws an arterial blood gas (ABG) sample, which reveals the following results: pH 7.28, PaCO2 56 mm Hg, PaO2 62 mm Hg, and HCO3- 24 mEq/L. To mitigate the risk of physiological decompensation, which action should the nurse take immediately?

A nurse is monitoring a client admitted with blunt abdominal trauma. The nurse suspects the client is actively bleeding internally. Which assessment findings should the nurse recognize as early compensatory signs of hypovolemic shock? (Select all that apply.)

A client is recovering on the medical-surgical unit two hours after a diagnostic lumbar puncture. The nurse enters the room and observes the client sitting upright on the edge of the bed. The client reports a severe, throbbing headache that began shortly after sitting up. Vital signs are within baseline limits. Which of the following is the most appropriate initial nursing action to reduce the client's risk for further physiological decompensation?