Physiological Integrity

A nurse is monitoring a client who is at risk for internal hemorrhage following a percutaneous liver biopsy. Which of the following vital sign trends represents the earliest physiological adaptation to intravascular fluid loss?

The nurse receives the shift report for four clients on a medical-surgical unit. Which client should the nurse assess first?

A nurse is preparing to administer a large-volume cleansing enema to an adult client who is experiencing severe constipation. In what order should the nurse perform the following actions? Arrange the steps in the correct sequence.

During the administration of a first dose of intravenous ceftriaxone, the client suddenly grasps their neck, stating their throat is closing, and severe expiratory wheezing is noted. Place the following crisis management actions in the correct priority sequence from first to last.

An adult client with acute decompensated heart failure is admitted to the cardiac intensive care unit. The client is currently receiving a continuous intravenous (IV) infusion of dobutamine at $10 \text{ \mu g/kg/min}$ via a dedicated single-lumen peripheral IV catheter. During the shift, the client suddenly develops severe dyspnea, and the nurse auscultates coarse bilateral crackles. The healthcare provider immediately prescribes a stat dose of furosemide $40 \text{ mg}$ IV push. Which of the following is the most appropriate action by the nurse?

An emergency department nurse is caring for an older adult client who presents with profound lethargy and confusion. The client has a known medical history of heart failure with a severely reduced ejection fraction. The client's family reports a three-day history of dysuria, chills, and fever prior to admission.

Current vital signs:
- Blood pressure: 76/48 mm Hg (MAP 57 mm Hg)
- Heart rate: 134 bpm
- Respiratory rate: 32 breaths/min
- Temperature: 39.2 °C (102.6 °F)
- Oxygen saturation: 88% on 4 L/min via nasal cannula

Physical assessment reveals prominent jugular venous distention at a 45-degree angle, cool and mottled extremities, and coarse crackles auscultated bilaterally up to the mid-lung fields.

Based on the client's clinical presentation and laboratory data, which of the following prescribed interventions is the highest priority for the nurse to implement?

Immediately following a percutaneous liver biopsy, an older adult client is transferred to the medical-surgical unit. The client reports mild discomfort near the insertion site and suddenly exhibits new-onset restlessness. Which intervention is the most appropriate action for the nurse to implement?

A nurse is preparing to administer a scheduled intravenous (IV) push medication into a client's continuous primary IV fluid infusion. To prevent a potentially life-threatening complication, which action must the nurse perform immediately prior to administration?

A client admitted with acute decompensated heart failure is receiving a continuous intravenous infusion of milrinone. The healthcare provider prescribes a one-time dose of intravenous furosemide $40\text{ mg}$ to manage worsening pulmonary edema. The client currently has a single peripheral intravenous access site. After consulting the facility's drug reference, the nurse notes that furosemide and milrinone are incompatible. Which of the following is the most appropriate action for the nurse to take?

A nurse is monitoring a client who is 4 hours post-operative following abdominal surgery. Which clinical finding should the nurse identify as an early indicator of hypovolemic shock?

Following a prolonged transcontinental flight, a traveler is brought to the urgent care clinic reporting sudden, sharp chest pain and severe shortness of breath. Initial assessment reveals a heart rate of 122 beats per minute, a blood pressure of 98/80 mmHg, and a respiratory rate of 32 breaths per minute. Arterial blood gas (ABG) analysis on room air demonstrates a $pH$ of 7.54, $PaCO_2$ of 26 mmHg, $PaO_2$ of 54 mmHg, and $HCO_3^-$ of 23 mEq/L. Which physiological adaptations accurately reflect this client's current presentation? (Select all that apply)

A telemetry unit nurse is monitoring a client who has a long-standing history of chronic obstructive pulmonary disease. The client was admitted yesterday with a severe lower respiratory tract infection. During the current assessment, the nurse observes that the client is somnolent and only responds to painful stimuli. The respiratory rate has dropped from 26 to 9 breaths per minute. The most recent arterial blood gas analysis reveals a pH of $7.21$, a PaCO $_2$ of $78$ mmHg, an HCO $_3^-$ of $29$ mEq/L, and a PaO $_2$ of $54$ mmHg. Based on these findings, which of the following is the most appropriate initial action?

A 42-year-old client is being monitored in the neuro-intensive care unit following a severe traumatic brain injury. The client is sedated and mechanically ventilated. Current assessment findings include an intracranial pressure (ICP) of 26 mm Hg, a blood pressure of 170/65 mm Hg, and a heart rate of 52 beats/min. The latest arterial blood gas (ABG) results are: pH 7.28, PaCO2 58 mm Hg, PaO2 94 mm Hg, and HCO3 24 mEq/L. Which intervention should the nurse prioritize to reduce the client's risk for further neurological deterioration?

While managing the care of a critically ill client diagnosed with severe sepsis, the nurse monitors for the complication of acute respiratory distress syndrome (ARDS). Which specific assessment findings signify that the client has entered the early stages of this pulmonary complication? Select all that apply.

A nurse is managing the care of an older adult client who is receiving continuous enteral nutrition via a nasogastric tube. As part of the client's pressure injury prevention plan, the nurse must reposition the client into a flat, lateral recumbent position. Which action is the most appropriate?

A nurse is caring for a client who is two days postoperative following an open exploratory laparotomy. The client coughs forcefully and reports a sudden "popping" sensation in the abdomen. The nurse assesses the surgical site and observes an evisceration. In which order should the nurse perform the following actions to reduce the client's risk of complications? Arrange the actions in chronological order from first to last.

A client recovering from abdominal surgery requires pain management. The provider orders morphine sulfate $6 \text{ mg}$ IV push every 4 hours as needed for severe pain. The medication is available in a vial containing $10 \text{ mg}/\text{mL}$. How many milliliters should the nurse administer for a single dose?

A 75-year-old client is prescribed prolonged bed rest and has an indwelling urinary catheter in place. The client, who has been previously cooperative and oriented, suddenly becomes severely agitated and repeatedly pulls at the catheter tubing. Which intervention is the most appropriate for the nurse to perform?

A client is recovering on the telemetry unit 4 hours after a percutaneous coronary intervention (PCI) via the right femoral artery. The client reports a new, mild, dull ache in the lower back but denies chest pain or shortness of breath. The nurse notes the following vital sign trends over the past hour:

Which of the following actions should the nurse take FIRST?

An older adult client with moderate Alzheimer's disease is admitted to the medical unit for treatment of bacterial pneumonia. The client is receiving continuous intravenous (IV) fluids. Throughout the morning, the client becomes repeatedly incontinent of urine, appears increasingly restless, and continuously picks at the IV dressing. Which action by the nurse is most appropriate?