Physiological Integrity

A client receiving mechanical ventilation for severe acute respiratory distress syndrome (ARDS) has the following ventilator settings and clinical data:

- Ventilator settings: Assist-control (AC) mode, $\text{FiO}_2$ $0.80$, respiratory rate $18 \text{ breaths/min}$, tidal volume $400 \text{ mL}$, positive end-expiratory pressure (PEEP) $15 \text{ cm H}_2\text{O}$.
- Arterial blood gas (ABG) results: pH $7.27$, $\text{PaCO}_2$ $59 \text{ mm Hg}$, $\text{PaO}_2$ $54 \text{ mm Hg}$, $\text{HCO}_3^-$ $26 \text{ mEq/L}$.
- Vital signs: Blood pressure $82/50 \text{ mm Hg}$, heart rate $128 \text{ beats/min}$.
- Hemodynamic data: Central venous pressure (CVP) $15 \text{ mm Hg}$.
- Physical assessment: Distant breath sounds on the right anterior chest and tracheal deviation to the left.

Which of the following interventions should the nurse anticipate implementing immediately? Select all that apply.

A nurse is evaluating the clinical data and current status of several assigned clients. Which of the following situations indicate a significant risk for physiological complications and require immediate nursing intervention? Select all that apply.

A client is receiving treatment for a hyperosmolar hyperglycemic state (HHS). The initial admission serum glucose was $1,150$ mg/dL. The client is receiving a continuous intravenous regular insulin infusion and aggressive intravenous fluid resuscitation. Three hours into the treatment regimen, the repeat serum glucose is $600$ mg/dL. The nurse notes the client, who was previously alert and oriented, is now increasingly lethargic, reports a severe headache, and exhibits sluggish pupillary light reflexes. Which physiological mechanism best explains this acute neurological deterioration?

A nurse in the emergency department is evaluating a client who has sustained blunt force trauma and is exhibiting signs of early hypovolemic shock. Which of the following clinical findings should the nurse expect to observe? Select all that apply.

A nurse is reviewing the arterial blood gas (ABG) results of a client who has been experiencing severe, frequent diarrhea for the past three days. The ABG results show a pH of $7.31$, a $PaCO_2$ of $39\text{ mm Hg}$, and an $HCO_3^-$ of $18\text{ mEq/L}$. Based on these findings, which of the following acid-base imbalances is the client experiencing?

A nurse is caring for a client with a pulmonary embolism who is receiving a continuous heparin infusion through a single peripheral IV catheter. The healthcare provider has newly prescribed intermittent IV vancomycin to treat a concurrent cellulitis infection. Which of the following actions should the nurse take to safely administer these therapies? Select all that apply.

A nurse is caring for a 75-year-old client with severe bilateral macular degeneration who is struggling to navigate their meal tray due to visual impairment. The client is alert and oriented with no history of swallowing difficulties. Which of the following nursing actions is most appropriate to promote the client's independence and adequate nutritional intake?

A nurse is caring for an oliguric client diagnosed with an acute kidney injury. The laboratory reports a stat serum potassium level of $8.2$ mEq/L ($8.2$ mmol/L). The continuous bedside cardiac monitor suddenly displays widening QRS complexes and absent P waves. Arrange the following collaborative interventions in the priority sequence they should be implemented. (Place the most immediate life-saving action first and the final evaluative action last.)

A nurse is caring for a client who is 2 days postoperative following open abdominal surgery. The client coughs forcefully, and the nurse observes that the surgical incision has completely separated with loops of bowel protruding from the wound. In what order should the nurse perform the following actions? Arrange the actions in the correct sequence from first to last.

A nurse is preparing to administer a continuous intravenous infusion of dobutamine to a client with severe heart failure. The healthcare provider prescribes dobutamine at $5\text{ mcg/kg/min}$. The client weighs $176\text{ lbs}$. The pharmacy supplies a premixed intravenous bag containing $500\text{ mg}$ of dobutamine in $250\text{ mL}$ of $5\%\text{ dextrose in water}$ ($D_5W$). What rate, in $\text{mL/hr}$, should the nurse program into the infusion pump to deliver the prescribed dose?

A nurse is preparing to administer a mixed dose of NPH insulin and regular insulin to a client with diabetes mellitus. Arrange the steps of the medication preparation procedure in the correct chronological order.

A nurse is evaluating a client at 35 weeks of gestation who is receiving a continuous intravenous infusion of magnesium sulfate for severe preeclampsia. During the hourly assessment, the nurse notes a respiratory rate of 10 breaths/min, absent patellar deep tendon reflexes, and a urine output of 12 mL over the past hour. Which of the following actions should the nurse take? (Select all that apply)

A young adult client arrives at the emergency department lethargic and exhibiting shallow breathing at a rate of $7$ breaths per minute following a suspected narcotic overdose. The laboratory reports the following arterial blood gas values: pH $7.26$, $PaCO_2$ $58$ mm Hg, and $HCO_3^-$ $24$ mEq/L. Based on these findings, which acid-base imbalance is the client experiencing?

A nurse is assessing a client who has experienced significant blood loss following a traumatic injury. Which of the following assessment findings should the nurse identify as early indicators of hypovolemic shock? (Select all that apply.)

A 48-year-old client is 12 hours post-transsphenoidal hypophysectomy for a pituitary adenoma. The nurse is evaluating the client's current clinical data and physical assessment. Which of the following findings require immediate follow-up by the nurse? Select all that apply.

A client with a systemic fungal infection is prescribed an intravenous infusion of amphotericin B. The client currently has a continuous intravenous infusion of 0.9% sodium chloride running through a single-lumen central venous catheter. Which of the following actions should the nurse take to safely administer the prescribed medication?

A nurse is caring for a client with severe acute pancreatitis in the intensive care unit. Over the past two hours, the nurse notes the client's heart rate has increased from 92 to 124 bpm, and blood pressure has changed from 120/78 mm Hg to 106/84 mm Hg. Urine output for the past hour was 15 mL. The client's respiratory rate is 28/min. Arterial blood gas (ABG) results are pH 7.29, $PaCO_2$ 30 mm Hg, $HCO_3^-$ 14 mEq/L, and $PaO_2$ 94 mm Hg on room air. Based on these findings, which of the following interventions should the nurse anticipate implementing? Select all that apply.

A nurse is assessing a client who underwent a partial hepatectomy 6 hours ago. Which of the following assessment findings should alert the nurse to the development of early (compensatory) hypovolemic shock? Select all that apply.

A nurse is preparing to administer an intravenous infusion of amphotericin B deoxycholate to a client with a severe systemic fungal infection. Upon reviewing the client's medical record, laboratory results, and the medication preparation, which of the following findings requires the nurse to withhold the infusion and contact the healthcare provider?

A nurse is caring for a client who sustained a complete spinal cord transection at the T2 level 18 hours ago. Which of the following concurrent clinical indicators should alert the nurse that the client is experiencing neurogenic shock? Select all that apply.