Physiological Integrity

An older adult client who underwent a right total hip arthroplasty (posterior approach) 2 days ago has developed acute delirium. The client is restless, frequently attempts to get out of bed unassisted, and requires assistance with activities of daily living. When updating the client's plan of care, what interventions should the nurse implement to safely address the client's basic care and comfort needs? Select all that apply.

A registered nurse is managing the care of a young adult diagnosed with diabetic ketoacidosis. The individual has been receiving a continuous intravenous drip of regular insulin alongside isotonic saline for several hours. A recent metabolic panel and arterial blood gas analysis show a pH of 7.26, PaCO2 of 28 mm Hg, bicarbonate of 14 mEq/L, and a serum potassium level of 3.2 mEq/L. Electrocardiogram monitoring reveals flattened T waves and emerging U waves. Current hemodynamics demonstrate a systolic pressure of 108 mm Hg, diastolic of 70 mm Hg, and a pulse of 110 beats per minute. Which of the following clinical interventions should the nurse prioritize?

A critically ill client is admitted to the intensive care unit with a diagnosis of severe diabetic ketoacidosis. Initial laboratory results reveal a serum glucose of $815$ mg/dL ($45.2$ mmol/L), an arterial pH of $7.08$, and a serum potassium of $3.0$ mEq/L ($3.0$ mmol/L). The client exhibits profound lethargy, deep and rapid respirations, and poor skin turgor. Arrange the following therapeutic interventions in the correct physiological priority sequence to safely manage this client's acute decompensation.

A nurse in the emergency department evaluates the arterial blood gas (ABG) results of a client who intentionally ingested a toxic amount of acetylsalicylic acid 8 hours ago. The client is lethargic, diaphoretic, and breathing deeply at a rate of 34 breaths/minute.

ABG results (on room air):
- pH: 7.42
- PaCO2: 24 mm Hg
- HCO3-: 14 mEq/L
- PaO2: 95 mm Hg

Based on these clinical findings, which conclusion about the client's physiological acid-base status is most accurate?

A nurse is caring for a client experiencing a severe asthma exacerbation. The client is highly agitated, visibly using accessory muscles to breathe, and has a respiratory rate of $34 \text{ breaths/min}$ and a heart rate of $118 \text{ beats/min}$. The most recent arterial blood gas (ABG) results on room air are:

Based on these findings, which of the following is the priority nursing action?

A nurse evaluates a client with severe acute pancreatitis who has become increasingly restless over the last $4$ hours. Current vital signs are: blood pressure $88/46 \text{ mm Hg}$, heart rate $124 \text{ beats/min}$, respiratory rate $28 \text{ breaths/min}$, and temperature $101.8^\circ\text{F}$ ($38.8^\circ\text{C}$). The nurse suspects the client is manifesting early distributive shock secondary to systemic inflammatory response syndrome (SIRS). Which of the following clinical and diagnostic findings are consistent with this specific early physiological state? Select all that apply.

A client is being treated in the emergency department for a severe asthma exacerbation. Upon admission, the client was highly anxious, tachypneic, and audibly wheezing. Initial arterial blood gas (ABG) results were: pH 7.52, PaCO2 28 mm Hg, HCO3- 24 mEq/L, and PaO2 68 mm Hg. Two hours later, the nurse notes that the client has become lethargic and the respiratory effort is shallow. A repeat ABG reveals: pH 7.36, PaCO2 44 mm Hg, HCO3- 24 mEq/L, and PaO2 58 mm Hg. Which of the following is the priority nursing action?

Following a complex cystoscopy procedure, a client develops a systemic infection. While performing a reassessment, the nurse notes several changes in the client's clinical presentation. Which assessment findings should alert the nurse that the client is experiencing the early, hyperdynamic phase of septic shock? Select all that apply.

An adult client is admitted to the surgical step-down unit following a motor vehicle collision involving blunt abdominal trauma. During the initial shift assessment, the nurse notes the client has become increasingly restless and diaphoretic, and is reporting new-onset pain in the left shoulder. The client's vital signs are heart rate $118$ bpm, blood pressure $98/62$ mmHg, and respiratory rate $24$/min. Which of the following is the priority nursing action to reduce the client's risk for physiological deterioration?

A telemetry nurse is caring for an older adult client receiving a continuous intravenous infusion of furosemide for severe decompensated heart failure. Over the past $48$ hours, the client has experienced a net fluid loss of $4.5\ \text{L}$. The nurse notes the client is now exhibiting generalized muscle weakness, shallow respirations at $10\ \text{breaths/min}$, and frequent premature ventricular contractions on the cardiac monitor.

Which physiological mechanism best explains the client's current clinical presentation and laboratory results?

A critical care nurse evaluates a client with severe sepsis who is receiving a continuous intravenous infusion of norepinephrine. The client has become increasingly restless and confused over the past hour, with new-onset mottling of the lower extremities. Current assessment data include:

- Blood pressure: $102/82$ mm Hg
- Heart rate: $128$ beats/min
- Respiratory rate: $32$ breaths/min
- Arterial blood gas (ABG): pH $7.28$, PaCO $_2$ $30$ mm Hg, HCO $_3^-$ $14$ mEq/L, PaO $_2$ $85$ mm Hg
- Central venous oxygen saturation (ScvO $_2$): $48\%$
- Serum lactate: $6.8$ mmol/L

Based on these findings, which action should the nurse prioritize?

A nurse is evaluating a client who sustained a high-grade splenic laceration following blunt torso trauma. The client is currently being managed with non-operative, conservative therapy. Which clinical finding provides the most definitive evidence that the client's physiological status has transitioned from a compensatory state into a progressive state of hypovolemic shock?

A nurse in the neuro-intensive care unit is assessing a client who sustained a complete spinal cord injury at the T3 level $24$ hours ago. The nurse is evaluating the client for potential complications. Which of the following clinical findings specifically indicate that the client is experiencing neurogenic shock rather than spinal shock or hypovolemic shock? Select all that apply.

A client with severe emphysema requires mechanical ventilation via an endotracheal tube following acute respiratory failure. During continuous monitoring, the expiratory flow waveform fails to reach the zero baseline prior to the initiation of the next breath. Over the past fifteen minutes, the client's systolic blood pressure has trended down to 78 mmHg, and the heart rate is steady at 132 beats per minute with weak peripheral pulses. What is the immediate priority action for this client?

A nurse is evaluating a client who was admitted with a mechanical small bowel obstruction. For the past 48 hours, the client has been treated with a nasogastric (NG) tube set to continuous low wall suction, yielding high outputs of gastric drainage. The nurse notes the client is becoming lethargic with a respiratory rate of 10 breaths/min and shallow chest excursion. Based on these clinical findings, which of the following arterial blood gas (ABG) results should the nurse anticipate?

A triage nurse in the emergency department receives a client with acute kidney injury secondary to severe rhabdomyolysis. The client reports profound muscle weakness. A STAT 12-lead electrocardiogram reveals absent P waves, a heart rate of $42\text{ bpm}$, and markedly widened QRS complexes. Arrange the following nursing actions in the most appropriate priority order from first to last.

A nurse is evaluating a client who is $3$ days post-operative following an exploratory laparotomy for a perforated appendix. The client appears restless and has warm, flushed skin.

Based on these findings, which intervention should the nurse perform first?

During bedside rounds in the intensive care unit, the nurse assesses a client admitted $24$ hours ago with acute necrotizing pancreatitis. The client is now profoundly lethargic. Current vital signs reveal a blood pressure of $82/48$ mm Hg, a heart rate of $136$ beats/minute, and a respiratory rate of $36$ breaths/minute. Auscultation identifies diffuse coarse crackles bilaterally. Arterial blood gas (ABG) results while receiving $100\%$ oxygen via a non-rebreather mask are: pH $7.28$, PaCO $_2$ $54$ mm Hg, PaO $_2$ $48$ mm Hg, and HCO $_3^-$ $20$ mEq/L. Based on this client's physiological decompensation, which of the following actions should the nurse anticipate? Select all that apply.

A client is receiving care in the neuroscience unit on the second day following surgical clipping of a ruptured cerebral aneurysm. Assessment reveals increasing lethargy, a heart rate of 118 beats/min, a blood pressure of 88/54 mm Hg, and a central venous pressure (CVP) of 2 mm Hg. Laboratory results show a serum sodium of 122 mEq/L, serum osmolality of 258 mOsm/kg, and a urine sodium of 150 mEq/L. Which of the following is the priority nursing action?

A client is 6 hours post-coronary artery bypass graft (CABG) surgery and is receiving mechanical ventilation. The intensive care nurse notes that the mediastinal chest tube drainage, which had been steadily draining $100\text{ mL/hr}$, has abruptly ceased over the past 45 minutes. The client's blood pressure drops from $115/75\text{ mmHg}$ to $82/64\text{ mmHg}$, heart rate increases from $85\text{ bpm}$ to $128\text{ bpm}$, and central venous pressure (CVP) rapidly rises from $8\text{ mmHg}$ to $19\text{ mmHg}$. Jugular venous distension is visible. The nurse suspects acute cardiac tamponade. Place the following collaborative and nursing actions in the correct priority sequence.