Physiological Integrity

A nurse evaluates a client experiencing a severe asthma exacerbation. Upon admission, the client was visibly struggling to breathe with a respiratory rate of 38 breaths per minute, and an initial arterial blood gas (ABG) analysis showed a PaCO2 of 28 mm Hg. Two hours later, the client's respiratory rate has decreased to 16 breaths per minute, and breath sounds are significantly diminished bilaterally. A repeat ABG reveals a pH of 7.36, PaCO2 of 43 mm Hg, PaO2 of 59 mm Hg, and HCO3 of 23 mEq/L. Which of the following is the most appropriate action for the nurse to take?

A nurse enters the room of a client with a history of asthma. The client is using accessory muscles to breathe, has audible wheezing, and an oxygen saturation of 88% on room air. In which order should the nurse perform the following actions? Arrange the actions in order of priority from first to last.

Following a subtotal thyroidectomy to treat hyperthyroidism, a client is transferred to the surgical unit for continuous monitoring. The nursing staff is actively observing for potential procedural complications. Which specific assessment findings should prompt the nurse to initiate emergency interventions? Select all that apply.

A client arrives at the urgent care clinic visibly distressed, reporting severe anxiety following a minor vehicle collision. The nurse observes a respiratory rate of 36 breaths per minute. The client states, "I feel dizzy and my fingers are tingling." Based on these assessment findings, which physiological imbalance is the client most likely experiencing?

A nurse is assessing a client on postoperative day 3 following an abdominal laparotomy. The client experiences a sudden, forceful episode of coughing, and the nurse observes loops of intestine protruding through the surgical incision. Arrange the following nursing actions in the correct sequence of priority.

A nurse is preparing to transfer a client who has left-sided hemiparesis from the hospital bed to a wheelchair. In what order should the nurse perform the following actions to ensure a safe transfer? Arrange the steps in the correct chronological sequence.

A nurse is caring for a client with a T4 spinal cord injury. The client suddenly reports a severe, pounding headache and blurred vision. The nurse observes profuse diaphoresis above the level of the injury, a blood pressure of 210/115 mmHg, and a heart rate of 48 beats/min. Arrange the following nursing actions in the correct priority sequence. (Place the most immediate priority action at the top.)

Following an extensive bowel resection with anastomosis, a client is recovering in the surgical step-down unit while receiving a continuous epidural infusion for analgesia. The client currently rates their pain as 2 out of 10 but exhibits increasing restlessness and anxiety. Current assessment findings include:

- Heart rate: 118 beats/minute
- Blood pressure: 106/82 mm Hg (preoperative baseline 128/78 mm Hg)
- Respiratory rate: 26 breaths/minute
- Arterial blood gases: pH 7.48, $PaCO_2$ 30 mm Hg, $HCO_3^-$ 23 mEq/L, $PaO_2$ 85 mm Hg

Based on these clinical indicators, which action should the nurse take first?

A nurse is caring for a client with acute decompensated heart failure who is hemodynamically unstable. The client is receiving a continuous intravenous infusion of milrinone at $0.5 \text{ mcg/kg/min}$. The client weighs $80 \text{ kg}$. The pharmacy has supplied a premixed bag containing $20 \text{ mg}$ of milrinone in $100 \text{ mL}$ of $5\% \text{ Dextrose in Water}$. The client has a single peripheral intravenous catheter. The healthcare provider prescribes a stat dose of intravenous furosemide $40 \text{ mg}$ to treat pulmonary edema. Furosemide and milrinone are visually incompatible and will form a precipitate if mixed.

Which of the following actions is the highest priority for the nurse to take?

A nurse is preparing to administer an intravenous (IV) infusion of potassium chloride to a client diagnosed with severe hypokalemia. Which of the following nursing actions are appropriate to ensure safe administration? Select all that apply.

A client in the emergency department is receiving a rapid transfusion of multiple units of packed red blood cells (PRBCs) following a severe pelvic fracture. During the transfusion of the fifth unit, the nurse observes prolonged QT intervals on the cardiac monitor, and the client reports new-onset tingling in their fingers and around their mouth. Which physiological complication should the nurse recognize based on these assessment findings?

An adult client is prescribed a 250 mL intermittent enteral feeding formula via an established nasogastric tube. To minimize the risk of procedural complications, arrange the following nursing actions in the correct chronological sequence.

A nurse is assessing a client admitted 12 hours ago with an acute anterior wall myocardial infarction. The client is receiving a continuous intravenous heparin infusion. The client suddenly reports feeling extremely apprehensive and restless.

Current clinical data:
- Blood pressure: 90/74 mmHg (decreased from 118/76 mmHg two hours ago)
- Heart rate: 116 beats/min
- Respiratory rate: 26 breaths/min
- Jugular venous distention is noted when the head of the bed is elevated to 45 degrees
- Lung fields are clear to auscultation bilaterally
- Urine output was 15 mL over the past hour

Based on these findings, which physiological complication should the nurse suspect the client is developing?

A nurse is caring for a client with a deep vein thrombosis who is receiving a continuous intravenous heparin infusion. The client weighs 198 lb.

The hospital's weight-based heparin protocol includes the following instructions:

The client's current heparin infusion is infusing at a rate of 15 units/kg/hr. The most recent aPTT result is 42 seconds. The available intravenous solution contains heparin 25,000 units in 250 mL of 5% dextrose in water (D5W).

What should the nurse set the new continuous intravenous infusion pump rate to, in mL/hr?

(Record your answer to the nearest tenth. Do not use a trailing zero.)

A nurse is evaluating a client who has a severe exacerbation of chronic obstructive pulmonary disease (COPD). The client's most recent arterial blood gas (ABG) results show a pH of 7.31, PaCO2 of 62 mm Hg, and HCO3- of 34 mEq/L. Which of the following conclusions should the nurse draw regarding the client's physiological state based on these findings? (Select all that apply)

A registered nurse is preparing to collect a routine laboratory blood specimen from a client's multi-lumen central venous catheter (CVC). Arrange the steps for this procedure in the correct chronological order from first to last.

A nurse is admitting a client who has just returned to the clinical unit following a percutaneous liver biopsy. As part of the care plan to ensure optimal comfort and minimize post-procedure complications, which action is most appropriate for the nurse to take?

A nurse is evaluating a 72-year-old client who is 48 hours post-operative following an abdominal aortic aneurysm (AAA) repair. The client is receiving a continuous epidural infusion for pain management. The nurse obtains the following assessment data:

- Neurological: Restless, repeatedly asking for water
- Cardiovascular: Heart rate 118 bpm, Blood pressure 102/76 mmHg (baseline 138/84 mmHg), weak peripheral pulses
- Respiratory: Respiratory rate 28 breaths/min, shallow
- Renal: Urine output 15 mL over the past hour via indwelling catheter (previous output 45 mL/hr)
- ABG (Room Air): pH 7.49, PaCO2 29 mmHg, HCO3 22 mEq/L, PaO2 68 mmHg

Based on the assessment data, which of the following conclusions regarding the client's physiological status are correct? Select all that apply.

A client is brought to the emergency department with severe respiratory depression following an opioid overdose. The client's respiratory rate is 8 breaths per minute. Which primary acid-base imbalance should the nurse anticipate?

During a routine tubing replacement for a continuous total parenteral nutrition (TPN) infusion, a client's central venous catheter (CVC) accidentally disconnects at the hub. The client immediately exhibits air hunger, profound cyanosis, and reports sharp, severe chest pain. Hemodynamic monitoring reveals a sudden tachycardic rate of $135 \text{ beats/min}$ and a blood pressure plummeting to $82/48 \text{ mmHg}$. Which action should the nurse execute first?