Physiological Integrity

A nurse is caring for a 78-year-old client admitted with community-acquired pneumonia and a history of severe chronic obstructive pulmonary disease (COPD). The client suddenly becomes highly restless, disoriented, and repeatedly attempts to remove their nasal cannula. Current vital signs are: Heart Rate 114 bpm, Blood Pressure 148/86 mm Hg, and Respiratory Rate 28 breaths/min. An arterial blood gas (ABG) drawn 15 minutes ago reveals a pH of 7.28, PaCO2 of 65 mm Hg, PaO2 of 57 mm Hg, and HCO3 of 28 mEq/L. To reduce the risk of further physiological deterioration, which action should the nurse take first?

A young adult client with type 1 diabetes mellitus is admitted to the emergency department with a blood glucose level of 450 mg/dL. The nurse suspects the client is experiencing diabetic ketoacidosis (DKA). Which assessment findings and laboratory values should the nurse expect? Select all that apply.

Following a bronchoscopy utilizing topical throat anesthesia, a client is resting in the observation area and requests a glass of water. Which specific nursing assessment must be completed first to ensure the client's safety?

A triage nurse receives a client with type 1 diabetes mellitus who presents with deep, rapid breathing, a fruity breath odor, and increasing lethargy. The initial point-of-care blood glucose is $512$ mg/dL ($28.4$ mmol/L). Arrange the following nursing interventions in the priority order they should be implemented.

A nurse is caring for a $62$-year-old client who returned to the telemetry unit $2$ hours ago following a percutaneous coronary intervention (PCI) via the right femoral artery. Which of the following assessment findings require immediate follow-up by the nurse? Select all that apply.

A nurse is caring for a client with diabetic ketoacidosis (DKA) who is receiving a continuous intravenous (IV) infusion of regular insulin at $0.1\text{ units/kg/hr}$. The client's most recent laboratory results reveal a blood glucose of $215\text{ mg/dL}$ ($11.9\text{ mmol/L}$), a serum potassium of $3.1\text{ mEq/L}$ ($3.1\text{ mmol/L}$), and an anion gap of $18\text{ mEq/L}$. The current maintenance IV fluid is $0.45\%$ sodium chloride infusing at $150\text{ mL/hr}$. Which of the following is the priority nursing action?

A nurse is monitoring a client 4 hours after a complex open abdominal surgery. The client's baseline preoperative vital signs were blood pressure 126/78 mm Hg, heart rate 72 beats/min, and respiratory rate 14 breaths/min. Which combination of current assessment findings provides the most definitive early indication of compensatory hypovolemic shock?

A nurse is caring for a client who has just returned to the medical-surgical unit following a percutaneous liver biopsy. Which of the following interventions should the nurse include in the client's immediate plan of care to reduce the risk of post-procedure complications? Select all that apply.

A nurse is caring for a client receiving a packed red blood cell (PRBC) transfusion. Fifteen minutes after the infusion begins, the client develops sudden chills, severe lower back pain, and dyspnea. Arrange the following nursing actions in the priority order they should be performed, from first action to last.

A nurse is planning hygiene and comfort measures for a client with a severe traumatic brain injury and continuously monitored increased intracranial pressure (ICP). The client is mechanically ventilated and requires a full bed bath, linen change, and repositioning. Which of the following nursing interventions is the most appropriate?

A nurse is caring for an adult client with a serum potassium level of $2.5 \text{ mEq/L}$ who is prescribed $40 \text{ mEq}$ of intravenous (IV) potassium chloride (KCl) to be administered via a peripheral IV line. Which action must the nurse take to ensure safe administration?

A nurse is caring for a client who is $4$ hours post-cardiac catheterization via the right femoral artery. The client begins reporting new, severe discomfort in the lower back and flank area, along with mild dizziness. Current vital signs reveal a blood pressure of $96/54$ mm Hg and a heart rate of $114$ beats per minute. The femoral insertion site dressing is completely dry and intact. Which action should the nurse take first to address the client's risk of physiological decompensation?

A nurse is monitoring an adult client who is receiving a transfusion of packed red blood cells for symptomatic anemia. Twenty minutes after the infusion begins, the client suddenly reports severe lower back pain, chills, and a sensation of chest tightness. In what order should the nurse perform the following interventions to minimize the client's risk of physiological deterioration?

An adult client is transferred to the neurology observation unit following a diagnostic lumbar puncture. Thirty minutes after arrival, the client complains of a severe, throbbing headache that intensifies noticeably whenever they attempt to sit upright. Vital signs reveal a blood pressure of $118/74$ mmHg, a heart rate of $78$ beats/min, and an oxygen saturation of $98\%$ on room air. Which intervention should the nurse prioritize to manage this post-procedure complication?

A nurse is closely monitoring a client who sustained blunt abdominal trauma in a motor vehicle collision 2 hours ago. The client's baseline vital signs upon admission were: blood pressure 138/76 mm Hg, heart rate 80 beats per minute, and respiratory rate 16 breaths per minute. Which of the following current vital sign profiles provides the strongest evidence that the client is experiencing early compensatory hypovolemic shock?

A client admitted with acute decompensated heart failure is receiving a continuous intravenous (IV) infusion of milrinone through a single peripheral IV catheter. The healthcare provider prescribes a stat dose of furosemide via IV push. The nurse consults a drug compatibility reference and notes that furosemide and milrinone are incompatible. Which of the following is the priority nursing action?

A client with a complete spinal cord injury at the $T4$ level suddenly reports a severe, throbbing headache, blurred vision, and profound nasal congestion. The client's blood pressure is $218/114$ mm Hg, and the heart rate is $52$ beats/min. To reduce the immediate risk of a catastrophic cerebrovascular complication, which action must the nurse perform first?

A nurse is instructing a client with a right fractured tibia who is non-weight-bearing on how to ascend stairs using axillary crutches. In what order should the nurse teach the client to perform the following actions? Arrange the steps in the correct sequence from first to last.

While performing an hourly clinical assessment, a critical care nurse evaluates the peripheral intravenous site of a client receiving a continuous norepinephrine infusion. The surrounding skin appears blanched, edematous, and cool to the touch. The client reports intense burning in the arm. Which intervention is the most appropriate initial action?

A nurse is assessing a client who is two days postoperative following a right total knee arthroplasty. The client suddenly becomes severely restless and reports sharp, pleuritic chest pain. Which of the following assessment findings would indicate that the client has developed a pulmonary embolism complicated by obstructive shock? Select all that apply.