Physiological Integrity

A nurse is developing a plan of care for a 76-year-old client with advanced Alzheimer's disease who is hospitalized for dehydration and receiving continuous intravenous (IV) fluids. The client is restless, repeatedly attempts to pull out the IV catheter, and has a healing stage 2 pressure injury on the sacrum. Which intervention is the most appropriate for the nurse to implement to promote client comfort and safety?

A client is admitted to the neuro-intensive care unit following a severe traumatic brain injury and has an external ventricular drain (EVD) in place. During the current assessment, the nurse notes the client's Glasgow Coma Scale (GCS) score has decreased from $13$ to $9$. The vital signs are: blood pressure $190/60$ mm Hg, heart rate $48$ beats/minute, and irregular respirations. The most recent arterial blood gas (ABG) analysis reveals a pH of $7.30$, PaCO $_2$ of $54$ mm Hg, and HCO $_3^-$ of $25$ mEq/L. Which of the following immediate interventions should the nurse implement to reduce the risk of secondary brain injury? Select all that apply.

A nurse is caring for a client who is 4 hours postoperative following an abdominal hysterectomy. The client reports feeling slightly nauseous. The most recent vital signs are: temperature 37.2°C (99.0°F), heart rate 118 beats/min, respiratory rate 22 breaths/min, and blood pressure 104/78 mm Hg. The client's baseline blood pressure upon arrival at the surgical unit was 126/82 mm Hg. The abdominal surgical dressing is intact with a 2 cm area of serosanguineous drainage. Which of the following is the priority nursing action?

An accidental disconnection of intravenous tubing from a subclavian central venous access device occurs while a patient is resting in bed. Immediately following the disconnection, the patient demonstrates acute respiratory distress, profound cyanosis, and a distinct churning, 'mill-wheel' murmur upon precordial auscultation. To mitigate the risk of fatal obstructive shock, what is the most critical immediate intervention?

A nurse is preparing to administer an intermittent bolus enteral feeding to a client via a nasogastric (NG) tube. The client is currently resting in a supine position. Arrange the following nursing actions in the correct sequence from first to last.

A nurse is preparing to remove a non-tunneled central venous catheter (CVC) from a client's right subclavian vein. Arrange the following nursing actions in the correct sequential order to safely remove the catheter and reduce the risk of an air embolism. (Place the first action at the top and the final action at the bottom.)

A nurse is preparing to administer an intravenous (IV) push dose of furosemide to a client who is receiving a continuous IV infusion of amiodarone. The client has only one patent peripheral IV line. Amiodarone and furosemide are physically incompatible. Arrange the following steps for safely administering the IV push medication in the correct sequential order.

A nurse evaluates a client admitted with severe acute pancreatitis. The client is lethargic and exhibits carpopedal spasm when the blood pressure cuff is inflated. Current vital signs include a heart rate of 128 beats/min, blood pressure of 98/84 mm Hg, and respiratory rate of 28 breaths/min with an SpO2 of 96% on room air. The central venous pressure (CVP) is 1 mm Hg. Arterial blood gas results show a pH of 7.29, PaCO2 of 28 mm Hg, and HCO3- of 14 mEq/L. Which is the priority nursing action?

An older adult client is admitted to the medical-surgical unit following an acute ischemic stroke that has resulted in left-sided hemiparesis and severe dysphagia. The nurse is planning the client's basic care and comfort measures. Which intervention is most appropriate for the nurse to implement?

A nurse is caring for a client with a history of left-sided heart failure who just underwent a bedside thoracentesis. During the procedure, $1,800\text{ mL}$ of pleural fluid was rapidly removed. One hour later, the client develops severe dyspnea, a violent cough, and expectorates pink, frothy sputum. The client's vital signs are: blood pressure $88/54\text{ mmHg}$, heart rate $122\text{ bpm}$, respiratory rate $32\text{ breaths/min}$, and $SpO_2$ $86\%$ on a $2\text{ L/min}$ nasal cannula. An arterial blood gas (ABG) analysis reveals:

- $pH$: $7.26$
- $PaCO_2$: $55\text{ mmHg}$
- $HCO_3^-$: $23\text{ mEq/L}$
- $PaO_2$: $52\text{ mmHg}$

Which of the following actions should the nurse perform FIRST to reduce the client's risk of imminent physiological collapse?

An electronic infusion pump is delivering a continuous infusion of 0.9% sodium chloride to a client. The healthcare provider prescribes a scheduled dose of an antibiotic to be given via intermittent intravenous piggyback (IVPB). The two solutions are compatible. Arrange the following nursing actions in the correct sequence to initiate this therapy.

A client presents to the emergency department reporting severe, crushing chest pain. The client's oxygen saturation is 88% on room air. The healthcare provider prescribes supplemental oxygen, chewable aspirin, sublingual nitroglycerin, and intravenous morphine. Arrange these interventions in the correct sequence of administration from first to last.

A nurse is caring for a client who returned to the medical unit 2 hours ago following a cardiac catheterization accessed via the right femoral artery. The client has stable vital signs, no evidence of bleeding at the insertion site, and reports mild lower back stiffness from lying flat. Which of the following nursing actions is the most appropriate to promote comfort?

A nurse is monitoring a client admitted with an acute upper gastrointestinal hemorrhage. The client is increasingly restless. Current vital signs are blood pressure 108/86 mm Hg, heart rate 116 beats/min, and respiratory rate 28 breaths/min. Which of the following arterial blood gas (ABG) results represents the expected physiological adaptation during this specific phase of the client's condition?

A nurse is caring for a client who recently returned to the clinical unit following a flexible bronchoscopy with a transbronchial biopsy under conscious sedation. The client is currently drowsy but opens their eyes to verbal stimuli. The client's pulse oximetry is $96\%$ on room air, and a routine post-procedure arterial blood gas (ABG) analysis reveals a pH of $7.40$, $PaCO_2$ of $40$ mm Hg, and $PaO_2$ of $88$ mm Hg. To effectively reduce the risk of post-procedure complications, which of the following actions should the nurse take first?

A client who sustained a massive anterior wall myocardial infarction 48 hours ago suddenly develops severe dyspnea, diaphoresis, and a cough producing frothy, pink-tinged sputum. Auscultation reveals coarse crackles throughout all lung fields. Current vital signs are: heart rate 132 beats/min, blood pressure 82/54 mm Hg, and respiratory rate 36 breaths/min. Arterial blood gas (ABG) analysis on room air indicates a pH of 7.22, PaCO2 of 64 mm Hg, HCO3 of 24 mEq/L, and PaO2 of 52 mm Hg. Which of the following is the most appropriate initial nursing action?

A nurse is assessing a client admitted with severe acute kidney injury (AKI). During the morning assessment, the client is alert, restless, and exhibiting deep, rapid respirations at a rate of $32$ breaths/minute. The client's oxygen saturation is $96\%$ on room air. The most recent arterial blood gas (ABG) values are: $pH$ $7.31$, $PaCO_2$ $29$ mm Hg, $PaO_2$ $92$ mm Hg, and $HCO_3^-$ $14$ mEq/L. Which of the following is the priority nursing action?

A nurse is caring for a client who is receiving an intravenous infusion of packed red blood cells (PRBCs). Fifteen minutes after the transfusion begins, the client reports a sudden onset of severe lower back pain, chills, and dyspnea. The nurse suspects an acute hemolytic transfusion reaction. Arrange the following nursing interventions in the correct order of priority from first to last.

During interdisciplinary rounds, the healthcare team evaluates a client with a mechanical small bowel obstruction who has been receiving continuous nasogastric decompression for the past 48 hours. The client reports new-onset perioral numbness and tingling in the fingers. Simultaneously, the telemetry monitor displays frequent premature ventricular contractions. Based on these findings, which physiological interpretation correctly identifies the underlying derangement and its consequences?

A client with acute kidney injury is admitted to the progressive care unit. The client's most recent serum potassium level is $8.2 \text{ mEq/L}$ ($8.2 \text{ mmol/L}$). The bedside cardiac monitor suddenly displays a widened QRS complex and absent P waves. Arrange the following actions in the physiological priority order the nurse should perform them.