Physiological Integrity

A nurse is evaluating the arterial blood gas (ABG) results for a client who is experiencing shallow breathing and lethargy following abdominal surgery. The laboratory report displays a pH of $7.26$, a $\text{PaCO}_2$ of $58\text{ mm Hg}$, and an $\text{HCO}_3^-$ of $24\text{ mEq/L}$. Which of the following acid-base imbalances should the nurse identify to initiate appropriate risk-reduction interventions?

A nurse is caring for a client who is receiving a packed red blood cell (PRBC) transfusion. Fifteen minutes after the transfusion begins, the client reports sudden lower back pain, chills, and shortness of breath. In which order should the nurse perform the following actions? Arrange the actions from first to last.

A nurse is teaching a client with a left tibial fracture, who is prescribed non-weight-bearing status on the left leg, how to safely stand up from a seated position in a chair using axillary crutches. Arrange the following instructional steps in the correct chronological order.

While performing a clinical assessment on a client who underwent an open splenectomy four hours ago, the nurse reviews the electronic health record. The baseline vital signs recorded upon arrival to the surgical unit were: blood pressure 128/72 mm Hg, heart rate 76 beats/min, and respiratory rate 16 breaths/min. Which of the following current clinical findings should the nurse interpret as the earliest sign of impending physiological decompensation that necessitates immediate risk mitigation?

A nurse is caring for an older adult client who is 1 day post-operative following an abdominal surgery. The provider has prescribed knee-high antiembolism stockings to promote venous return. Which of the following actions should the nurse take?

An orthopedic unit nurse is updating the care plan for a geriatric client recovering from a right-sided posterior total hip arthroplasty. The client has developed unexpected episodes of nighttime restlessness and loss of bladder control. Which nursing actions are appropriate to ensure optimal hygiene, comfort, and safety? Select all that apply.

A nurse is preparing to administer a prescribed intravenous (IV) push medication through a client's peripheral saline lock. Place the following steps in the correct chronological order for safe administration.

A nurse is monitoring a client who is receiving a transfusion of packed red blood cells (PRBCs). Fifteen minutes into the transfusion, the client reports sudden lower back pain, chills, and shortness of breath. Arrange the following nursing actions in the correct order of priority, from first to last.

A critical care nurse is removing a non-tunneled central venous catheter (CVC) from a client's right subclavian vein. Immediately after the catheter is withdrawn, the client gasps, reports sudden severe chest pain, and becomes pale and tachycardic. Suspecting a venous air embolism, arrange the following actions in the exact priority sequence the nurse must perform them to reduce the risk of fatal cardiopulmonary collapse.

A client in the trauma intensive care unit is receiving a massive transfusion protocol for severe hemorrhagic shock following a pelvic crush injury. After the rapid administration of 8 units of packed red blood cells and 6 units of fresh frozen plasma, the client's continuous electrocardiogram reveals a newly prolonged QT interval of 0.54 seconds. The nurse observes circumoral tingling and muscle fasciculations. Current vital signs include a heart rate of 112 beats per minute, blood pressure of 86/48 mm Hg, and a central venous pressure (CVP) of 9 mm Hg. Which of the following is the priority nursing action?

A client with septic shock is receiving a continuous intravenous (IV) infusion of norepinephrine via a single-lumen peripherally inserted central catheter (PICC). The client's blood pressure is $88/54 \text{ mmHg}$ and the mean arterial pressure (MAP) is $65 \text{ mmHg}$. The healthcare provider prescribes a stat dose of IV pantoprazole and a continuous IV infusion of regular insulin. The nurse is unable to establish additional peripheral IV access due to severe generalized edema. Which of the following actions should the nurse take? (Select all that apply.)

A multidisciplinary care team prescribes continuous total parenteral nutrition (TPN) alongside a separate $20\%$ intravenous lipid emulsion for a client recovering from an extensive bowel resection. The client currently has a single-lumen peripherally inserted central catheter (PICC). The primary TPN infusion set includes a standard $0.22\text{-micron}$ in-line filter. To safely administer both solutions concurrently, which action must the nurse implement?

During hourly rounding on an orthopedic unit, the nurse evaluates a client recovering from a total hip arthroplasty performed 6 hours ago. The client's pain is being managed with a continuous bupivacaine epidural infusion. The client states, 'My lips feel completely numb, and I have a strange metallic taste in my mouth.' The client also mentions a persistent ringing sound in their ears. Which action should the nurse take first?

Following a right total hip arthroplasty via a posterior approach, an older adult requires assistance with activities of daily living, elimination, and positioning. To ensure safety and promote comfort during the recovery period, which of the following actions should be incorporated into the client's daily care routine? Select all that apply.

While caring for a client who is receiving intravenous antibiotics for acute pyelonephritis, the nurse monitors for systemic complications. Which assessment finding provides the earliest physiological indication that the client is developing septic shock?

During the night shift, a registered nurse is called to the room of an 84-year-old client admitted with community-acquired pneumonia. The client has suddenly become severely agitated, is pulling at the intravenous (IV) tubing, and is attempting to get out of bed unassisted. Which of the following is the most appropriate initial nursing action?

A client admitted with an acute exacerbation of chronic obstructive pulmonary disease (COPD) has the following arterial blood gas (ABG) results: pH 7.26, PaCO₂ 58 mm Hg, and HCO₃⁻ 24 mEq/L. Based on these physiological values, which acid-base imbalance is the client experiencing?

A critical care nurse is monitoring a client admitted with severe acute necrotizing pancreatitis. The client's central venous pressure (CVP) has decreased from 8 mm Hg to 2 mm Hg over the last four hours. Which of the following assessment findings indicate the client is developing hypovolemic shock secondary to massive third-spacing of fluids? Select all that apply.

A client is admitted to the intensive care unit with a severe intra-abdominal infection. The nurse is monitoring the client's hemodynamic parameters to assess for the development of early (hyperdynamic) septic shock. Which clinical and hemodynamic findings indicate that the client is experiencing this specific physiological state? Select all that apply.

A client is receiving care in the intensive care unit 48 hours after sustaining a complete spinal cord transection at the T3 level. The bedside monitor suddenly alarms. Assessment reveals a blood pressure of 72/40 mm Hg, a heart rate of 42 beats/minute, and profoundly warm, flushed skin below the level of the injury. The client is lethargic but maintains a patent airway. Which intervention should the nurse implement first?