Physiological Integrity

A nurse is assessing a client admitted with a severe kidney infection and suspected urosepsis. The client is restless but oriented. Current vital signs are: blood pressure $112/64$ mm Hg, heart rate $118$ beats/min with bounding pulses, respiratory rate $28$ breaths/min, and temperature $39.2^\circ$ C ($102.6^\circ$ F). The client's skin is warm and flushed. Based on this physiological presentation, which of the following arterial blood gas (ABG) results should the nurse anticipate?

An adult client is receiving treatment in the emergency department for status asthmaticus. Upon arrival, the client was highly agitated and exhibited severe intercostal retractions, with an initial arterial blood gas (ABG) reading of pH $7.52$, PaCO $_2$ $26$ mm Hg, and PaO $_2$ $72$ mm Hg on a $100\%$ non-rebreather mask. Two hours later, the nurse notes the client is now drowsy and the wheezing is significantly diminished, though chest excursion is poor. A repeat ABG shows pH $7.37$, PaCO $_2$ $42$ mm Hg, and PaO $_2$ $54$ mm Hg. Which of the following is the priority nursing action?

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

A nurse is evaluating the arterial blood gas (ABG) results for a client who is admitted to the medical-surgical unit with a diagnosis of diabetic ketoacidosis. The laboratory report shows a pH of $7.28$, a $\text{PaCO}_2$ of $38\text{ mm Hg}$, and an $\text{HCO}_3^-$ of $15\text{ mEq/L}$. Based on these values, which of the following acid-base imbalances is this client experiencing?

A nurse is caring for a client who has just arrived at the emergency department with diabetic ketoacidosis (DKA). The client is lethargic, displays deep, rapid respirations, and has a blood glucose level of $650$ mg/dL ($36.1$ mmol/L). Arrange the following collaborative and nursing actions in the correct priority sequence.

A client receiving a packed red blood cell (PRBC) transfusion reports acute lower back pain and sudden shortness of breath. The nurse notes a rapid heart rate and a drop in blood pressure. Arrange the following immediate nursing actions in the correct chronological sequence to manage this severe physiological complication.

A nurse is caring for a client with a spinal cord injury at the T4 level. The client suddenly reports a severe, pounding headache, and the nurse notes profuse diaphoresis and a blood pressure of 210/110 mm Hg. Arrange the following nursing interventions in the correct order of priority.

A nurse is caring for a client who was placed in balanced suspension skeletal traction for a right femur fracture 24 hours ago. The client reports severe lower back discomfort and requests assistance with repositioning. Which of the following is the most appropriate action by the nurse?

A healthcare team is managing the recovery of a 60-year-old client who underwent a right total pneumonectomy yesterday for bronchogenic carcinoma. The client's current continuous intravenous (IV) infusion is 0.9% sodium chloride running at 125 mL/hr. During the morning assessment, the nurse records the following clinical parameters:

- Vital Signs: Blood pressure 146/88 mm Hg, heart rate 116 bpm, respiratory rate 28 breaths/min
- Hemodynamics: Central Venous Pressure (CVP) reading is 15 mm Hg
- Arterial Blood Gas (ABG): pH 7.32, PaCO2 56 mm Hg, PaO2 65 mm Hg, HCO3 27 mEq/L
- Auscultation: Fine crackles present in the dependent lobes of the left lung

Based on these findings, which action should the nurse implement immediately to mitigate the risk of a life-threatening complication?

A young adult client is admitted to the intensive care unit with profound lethargy, deep and rapid respirations, and a capillary blood glucose of 680 mg/dL (37.7 mmol/L). The healthcare provider diagnoses severe diabetic ketoacidosis (DKA). Arrange the following nursing interventions in the correct physiological priority order for managing this acute crisis. (Place the most immediate priority action at the top and the final transition action at the bottom).

An individual with acute necrotizing pancreatitis is currently receiving care on a progressive care unit. The client reports excruciating abdominal pain radiating to the back. A recent rhythm check on the central monitor reveals a newly prolonged QT interval. Current hemodynamics include a mean arterial pressure (MAP) of 62 mmHg, a heart rate of 118 beats per minute, and shallow respirations at 28 breaths per minute. Based on these clinical findings, which of the following interventions are critical for the nurse to implement? Select all that apply.

A nurse is evaluating a client who has just returned to the clinical unit following a percutaneous liver biopsy. The client is awake, oriented, and reports mild tenderness at the puncture site on the right side. Vital signs are currently stable. Which of the following nursing actions is the priority to minimize this client's risk for immediate post-procedure complications?

While evaluating a client recovering from a large anterior myocardial infarction in the intensive care unit, the nurse observes new-onset bilateral crackles extending to the mid-lung fields, severe jugular venous distension, and an audible S3 gallop. The client is restless, and their extremities are cool and mottled. Current vital signs include a blood pressure of 82/52 mm Hg, a heart rate of 124 beats/min, and a respiratory rate of 28 breaths/min. Based on these findings, which of the following prescribed interventions is the priority for the nurse to implement?

A nurse is caring for a client admitted with a severe urinary tract infection who has been receiving intravenous antibiotics. Over the past two hours, the client has become increasingly restless. The nurse notes the following assessment data:

Baseline Data (On Admission):
Blood pressure: 118/76 mm Hg
Heart rate: 88 beats/minute
Skin: Warm and dry

Current Data:
Blood pressure: 84/52 mm Hg
Heart rate: 126 beats/minute (thready)
Respiratory rate: 28 breaths/minute
Skin: Pale, cool, and clammy to the touch
Arterial Blood Gas (ABG) on room air: pH 7.28, PaCO2 31 mm Hg, HCO3 15 mEq/L, PaO2 89 mm Hg

Which of the following actions should the nurse take immediately to reduce the risk of severe physiological decompensation?

A nurse is managing the basic care and comfort of an older adult client who is 48 hours postoperative following a right above-the-knee amputation. The client reports mild discomfort in the residual limb and requests that it be elevated on a soft pillow. Which of the following nursing actions is the most appropriate?

A nurse is evaluating a client who sustained blunt abdominal trauma in a motor vehicle collision. Which of the following assessment findings should the nurse identify as early indicators of compensatory hypovolemic shock? (Select all that apply.)

An older adult client with advanced dementia and impaired physical mobility is admitted to an acute care unit. The client has poor nutritional intake and is at high risk for skin breakdown. Which interventions should the nurse include in the plan of care to promote basic care and comfort? Select all that apply.

A client receiving continuous total parenteral nutrition (TPN) via a single-lumen peripherally inserted central catheter (PICC) suddenly develops acute pulmonary edema. The client's oxygen saturation drops to $84\%$ on room air, and the nurse auscultates bilateral crackles. The healthcare provider prescribes a stat dose of intravenous furosemide $60\text{ mg}$. The available furosemide concentration is $10\text{ mg/mL}$. Which of the following is the most appropriate action by the nurse?

A client is in the intensive care unit 48 hours after sustaining a severe traumatic brain injury. The nurse assesses the following clinical data:

The client is lethargic and responds only to noxious stimuli. Which of the following is the priority nursing action?

A nurse is preparing to perform a routine sterile dressing change for a client's peripherally inserted central catheter (PICC). To minimize the risk of central line-associated bloodstream infection (CLABSI) and prevent catheter dislodgement, place the following nursing actions in the correct sequential order.