Physiological Integrity

A nurse is monitoring a client who sustained a closed femur fracture and pelvic contusions following a motor vehicle collision. Serial assessments over a three-hour period reveal the following trends:

Based on the physiological mechanisms underlying these assessment trends, which action should the nurse prioritize?

A triage nurse in the emergency department receives a $45$-year-old client who was rescued from an enclosed structural fire. The client sustained deep partial-thickness and full-thickness burns to the face, anterior chest, and bilateral entire upper extremities.

The nurse assesses the following initial clinical data:

Physical assessment reveals a hoarse voice, singed nasal hairs, and carbonaceous sputum.

Which interventions should the nurse anticipate incorporating into the immediate plan of care? (Select all that apply)

An intensive care nurse evaluates a mechanically ventilated client $24$ hours post-splenectomy who received a massive transfusion protocol for hemorrhagic shock. Over the last two hours, the client's urine output decreased to $10\text{ mL/hr}$, peak inspiratory pressure (PIP) increased from $24\text{ cm H}_2\text{O}$ to $52\text{ cm H}_2\text{O}$, and blood pressure dropped from $118/72\text{ mm Hg}$ to $82/46\text{ mm Hg}$. The current central venous pressure (CVP) is $21\text{ mm Hg}$. Which action should the nurse take first?

A $34$-year-old client with a known history of Graves' disease is admitted to the progressive care unit exhibiting extreme restlessness, profound diaphoresis, and delirium. Current vital signs reveal a heart rate of $188\text{ beats/min}$, blood pressure of $182/104\text{ mmHg}$, and a core temperature of $40.6^\circ\text{C}$ ($105.1^\circ\text{F}$). The client is diagnosed with a thyrotoxic crisis (thyroid storm). The healthcare provider prescribes several emergent interventions. Arrange the following actions in the correct physiological priority order.

An emergency department nurse is caring for a trauma client undergoing aggressive resuscitation for severe hemorrhagic shock. Over the last $120$ minutes, the client has received $10$ units of packed red blood cells (PRBCs) and $6$ units of fresh frozen plasma (FFP). During the ongoing assessment, the nurse notes a core body temperature of $34.2^\circ\text{C}$ ($93.5^\circ\text{F}$) and new-onset facial muscle twitching. The telemetry monitor displays peaked T waves, a widening QRS complex, and a prolonged QT interval. Which of the following physiological adaptations and underlying mechanisms correlate with this client's current presentation? (Select all that apply.)

A rapid response team is called for a client admitted with community-acquired pneumonia who began receiving an initial infusion of intravenous ampicillin-sulbactam $15$ minutes ago. The client presents with acute respiratory distress, audible stridor, and diffuse urticaria. Vital signs are: blood pressure $68/38$ mm Hg, heart rate $52$ bpm, respiratory rate $32$ breaths/min, and SpO2 $86\%$ on room air. The client's medication history includes daily lisinopril, metoprolol succinate, timolol ophthalmic drops, and atorvastatin. The nurse immediately stops the antibiotic infusion and administers $0.5$ mg of intramuscular epinephrine. Five minutes later, the client's blood pressure is $70/40$ mm Hg, heart rate is $54$ bpm, and severe wheezing persists. Which of the following is the most appropriate priority intervention?

A nurse is caring for a client with a complete $T4$ spinal cord injury. The client suddenly reports a severe, pounding headache and blurred vision. The nurse observes profuse diaphoresis and flushing above the level of the spinal lesion, accompanied by marked pallor and piloerection below the lesion. The client's blood pressure is $220/115$ mmHg and heart rate is $48$ bpm. Place the following nursing interventions in the correct sequence of priority to manage this acute complication.

A nurse is caring for a client admitted with severe diabetic ketoacidosis (DKA). The client is receiving a continuous intravenous regular insulin infusion and 0.9% sodium chloride. The nurse observes that the client's deep, rapid breathing has transitioned to shallow, weak respirations over the last $30$ minutes, and the client is now profoundly lethargic and difficult to arouse.

Recent laboratory results:
- Blood glucose: $230$ mg/dL ($12.8$ mmol/L)
- Serum potassium: $2.7$ mEq/L ($2.7$ mmol/L)
- Arterial Blood Gas (room air): pH $7.20$, PaCO $_2$ $49$ mm Hg, HCO $_3^-$ $11$ mEq/L, PaO $_2$ $82$ mm Hg

Which of the following is the priority nursing action?

An older adult client is admitted with a severe urinary tract infection. Over the past hour, the client has become restless and confused. Current vital signs are: blood pressure $84/52\text{ mm Hg}$, heart rate $128\text{ bpm}$, respiratory rate $30\text{ breaths/min}$, and temperature $101.8^\circ\text{F}$ ($38.8^\circ\text{C}$). Oxygen saturation is $93\%$ on room air. An arterial blood gas (ABG) and serum lactate analysis reveal the following:

Which of the following prescribed interventions should the nurse prioritize?

A nurse is caring for a client who is 4 hours postoperative following a coronary artery bypass grafting (CABG) procedure. The client suddenly exhibits profound hypotension, pronounced jugular venous distention, muffled heart sounds, and a precipitous drop in mediastinal chest tube drainage. Arrange the following nursing actions in the priority order they should be executed.

A client is admitted to the medical unit with a history of peptic ulcer disease and reports of passing dark, tarry stools for the past two days. The client is currently resting in a supine position.

Vital signs upon admission (3 hours ago): Blood pressure $138/80$ mm Hg, heart rate $78$ beats/min, respiratory rate $14$ breaths/min.

Current assessment findings:
- Blood pressure $112/84$ mm Hg
- Heart rate $112$ beats/min
- Respiratory rate $24$ breaths/min
- SpO $_2$ $96\%$ on room air
- The client reports feeling restless and slightly lightheaded.
- Arterial Blood Gas (ABG): pH $7.49$, PaCO $_2$ $29$ mm Hg, PaO $_2$ $92$ mm Hg, HCO $_3^-$ $23$ mEq/L

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

A client is receiving care in the intensive care unit four days after a severe subarachnoid hemorrhage. The client, previously alert and oriented, suddenly becomes extremely restless and confused. Current assessment findings include a blood pressure of 82/46 mm Hg, heart rate of 126 beats/minute, and a central venous pressure (CVP) of 1 mm Hg. The client's urine output over the past 4 hours was 1,600 mL.

The nurse reviews the most recent laboratory results:

Based on these findings, which of the following prescribed interventions is the highest priority for the nurse to implement?

A nurse is planning care for a client who is 48 hours post-operative following a right above-the-knee amputation (AKA) due to complications of peripheral arterial disease. Which of the following positioning interventions is most appropriate to include in the client's plan of care?

A nurse is caring for a client who is receiving continuous enteral tube feedings and requires repositioning every 2 hours to prevent pressure injuries. Which of the following actions is the most appropriate for the nurse to take when turning the client?

A nurse is evaluating a client who had an open abdominal surgery 6 hours ago. The client reports feeling dizzy, anxious, and extremely thirsty. The nurse assesses the vital signs: heart rate 124 beats/min, blood pressure 98/74 mm Hg (baseline 130/80 mm Hg), and respiratory rate 24 breaths/min. The client's skin is pale and cool to the touch. Which of the following is the priority nursing action?

A nurse is establishing a plan of care for an older adult client who is recovering from a right-sided modified radical mastectomy with axillary lymph node dissection. Which nursing intervention best addresses the client's basic care and comfort needs while preventing complications?

A nurse is preparing to transfer a client who has bilateral lower extremity weakness from a hospital bed to a wheelchair using a one-person assist technique. Place the following steps in the sequence the nurse should perform them.

A nurse is monitoring a client who is 15 minutes into a packed red blood cell (PRBC) transfusion. The client suddenly reports severe lower back pain, chills, and a feeling of impending doom. The nurse observes that the client's urine in the Foley catheter tubing has become dark red. Arrange the following nursing interventions in the correct order of priority from first to last.

A nurse is developing a plan of care for an 80-year-old client who has right-sided hemiplegia and dysphagia following a recent cerebrovascular accident (CVA). Which interventions should the nurse include in the client's plan of care to promote basic care, comfort, and safety? Select all that apply.

A 68-year-old client is receiving mechanical ventilation in the intensive care unit following a coronary artery bypass graft. The client's oxygen saturation drops to 89%, and auscultation reveals coarse crackles over the mainstem bronchi. The nurse prepares to perform open endotracheal suctioning. To reduce the risk of severe hypoxia and mucosal trauma, arrange the following procedural steps in the correct sequence.