Physiological Integrity

A client with a history of early-stage Alzheimer's disease is transferred to the medical unit immediately following a diagnostic lumbar puncture. The client appears highly restless, repeatedly attempts to sit up in bed, and reports generalized back discomfort. Which nursing intervention should be prioritized to promote client safety and comfort?

A 72-year-old client with a history of severe chronic obstructive pulmonary disease (COPD) is evaluated in the emergency department for a suspected respiratory infection. The client appears increasingly restless. Current vital signs are: blood pressure $104/82\text{ mm Hg}$, heart rate $116\text{ beats/min}$, respiratory rate $28\text{ breaths/min}$, temperature $101.8^\circ\text{F}$ ($38.8^\circ\text{C}$), and oxygen saturation $86\%$ on room air. To reduce the risk of further physiological decompensation, which of the following actions should the nurse include in the immediate plan of care? Select all that apply.

During morning rounds on a pulmonary step-down unit, a registered nurse reviews the latest laboratory results for a client with a long-standing history of severe chronic obstructive pulmonary disease (COPD). The client is resting quietly in bed, oriented to person, place, and time, and breathing without the use of accessory muscles. The arterial blood gas (ABG) results on room air are as follows:

* pH: 7.36
* PaCO2: 58 mm Hg
* HCO3: 32 mEq/L
* PaO2: 63 mm Hg

Which of the following is the most appropriate action for the nurse to take based on these clinical findings?

During a shift assessment, a nurse is evaluating a hemodynamically unstable client who is receiving a continuous peripheral intravenous (IV) infusion of norepinephrine for septic shock. The client's current mean arterial pressure (MAP) is $68$ mm Hg. A stat order for IV push pantoprazole is received from the healthcare provider. The nurse consults a drug compatibility resource and notes that pantoprazole will precipitate if mixed with norepinephrine. The client currently has only one working IV access site. What is the most appropriate action by the nurse?

A nurse is caring for a client who underwent a coronary artery bypass graft (CABG) surgery 6 hours ago. During the last 30 minutes, the nurse notes that the client's mediastinal chest tube drainage has abruptly decreased from 100 mL/hr to 5 mL/hr. The client's heart rate has increased from 90 to 128 beats/min, and blood pressure has changed from 120/78 mm Hg to 92/76 mm Hg. The nurse also observes distended neck veins while the head of the bed is elevated at 45 degrees. Which of the following physiological mechanisms is primarily responsible for this client's clinical presentation?

A client is receiving a continuous intravenous infusion of unfractionated heparin for the treatment of a pulmonary embolism. The client reports a new onset of dull, constant lower back pain. Assessment reveals a blood pressure of 106/72 mmHg (decreased from a baseline of 138/84 mmHg) and a heart rate of 114 beats/minute. Which action should the nurse take first?

A nurse is preparing to administer an intermittent bolus enteral feeding via a nasogastric (NG) tube to a client. Arrange the following procedural steps in the correct chronological order from first to last.

During morning rounds, the nurse assesses a client recovering from an anterior wall myocardial infarction sustained two days prior. The client suddenly expresses intense anxiety and a feeling of suffocation. Auscultation reveals bilateral basilar crackles, and the client's skin is cool and diaphoretic.

The most recent clinical parameters are as follows:

Which of the following is the highest priority nursing intervention?

A nurse is preparing to administer a prescribed intravenous (IV) push medication through a client's peripheral intermittent IV access device (saline lock). Arrange the following steps in the correct order from first to last.

A nurse is preparing to administer a large-volume cleansing enema to a client who is experiencing severe constipation following abdominal surgery. In what order should the nurse perform the following actions? Arrange the steps in the correct chronological sequence.

A 28-year-old client is being monitored on the medical-surgical unit 4 hours after an open splenectomy following a motor vehicle collision. The nurse compares the current assessment findings with the baseline taken one hour ago:

Baseline (1 hour ago): Blood pressure 126/78 mm Hg, heart rate 88 bpm, respiratory rate 16 breaths/min.
Current: Blood pressure 114/82 mm Hg, heart rate 106 bpm, respiratory rate 22 breaths/min.

The client's urine output for the past hour was 25 mL. Based on these findings, which action should the nurse take first?

An emergency department nurse receives a client who sustained a C5 spinal cord injury from a diving accident earlier in the day. The healthcare team is monitoring for the development of neurogenic shock. Which assessment findings should the nurse recognize as indicating the onset of this specific complication? Select all that apply.

A nurse is caring for a client who is receiving an infusion of packed red blood cells (PRBCs). Fifteen minutes after the transfusion is initiated, the client develops sudden chills, lower back pain, and a heart rate of 118 beats/min. Place the following nursing interventions in the correct order to reduce the risk of further physiological deterioration. (Arrange the steps from first action to last action)

A client is admitted to the intensive care unit with severe diabetic ketoacidosis (DKA). The initial blood glucose level is 680 mg/dL, and the client exhibits Kussmaul respirations. The nurse prepares to implement the standard DKA treatment protocol. Arrange the following nursing actions in the correct chronological sequence from first to last.

A nurse is providing care for an older adult client who has just returned to the medical-surgical unit following a percutaneous liver biopsy. The client reports mild abdominal discomfort. During the initial interaction, the nurse observes that the client has developed sudden, new-onset confusion. Which nursing action is most appropriate?

A client with end-stage renal disease is recovering in the post-anesthesia care unit (PACU) $2$ hours after the surgical creation of a left upper extremity arteriovenous (AV) fistula. The client suddenly reports profound weakness. The nurse notes deep, rapid respirations at $32$ breaths/minute. STAT laboratory results reveal a serum potassium of $6.8$ mEq/L and an arterial blood gas (ABG) showing pH $7.20$, PaCO $_2$ $29$ mm Hg, and HCO $_3^-$ $10$ mEq/L. Which of the following actions should the nurse prioritize to mitigate the highest risk of mortality for this client?

A nurse in the emergency department is caring for a client admitted with a severe asthma exacerbation. The client exhibits audible wheezing, intercostal retractions, and an oxygen saturation of 88% on room air. Arrange the following nursing actions in the correct order of priority from first to last.

An emergency department nurse receives a client with end-stage renal disease who has missed three consecutive hemodialysis sessions. The client is profoundly lethargic and reports severe, generalized muscle weakness. Assessment reveals a blood pressure of 110/60 mm Hg, heart rate of 48 bpm, and respiratory rate of 24 bpm. Telemetry monitoring shows sinus bradycardia with tall, peaked T waves and significantly widened QRS complexes. Arterial blood gas (ABG) analysis indicates a pH of 7.26, PaCO2 of 31 mm Hg, PaO2 of 94 mm Hg, and HCO3 of 15 mEq/L. Which prescribed intervention should the nurse implement FIRST?

A nurse is preparing to administer a prescribed intermittent intravenous (IV) infusion of amphotericin B deoxycholate. The medication is provided by the pharmacy in a 250 mL bag of 5% dextrose in water (D5W). The client currently has a single peripheral IV line with a continuous infusion of 0.9% sodium chloride (normal saline). Which of the following actions is most appropriate for the nurse to take?

A postoperative client on the surgical unit suddenly develops acute shortness of breath and pleuritic chest discomfort 36 hours after bariatric surgery. Clinical assessment reveals tachypnea at 32 breaths per minute, tachycardia at 115 beats per minute, and an oxygen saturation of $87\%$ on room air. Arterial blood gas analysis displays a pH of $7.54$, a $PaCO_2$ of $29\text{ mm Hg}$, a $PaO_2$ of $55\text{ mm Hg}$, and an $HCO_3^-$ of $22\text{ mEq/L}$. Based on these findings, what is the priority nursing intervention to mitigate the risk of further physiological decline?