Physiological Integrity

A nurse is conducting a follow-up assessment on a client who underwent a transfemoral cardiac catheterization two hours ago. The client is resting in a supine position and reports the new onset of mild back pain. Which of the following vital sign profiles requires the nurse to activate the rapid response team?

A nurse is caring for a client admitted 6 hours ago with fractures of the left 7th, 8th, and 9th ribs following a motor vehicle crash. The client's admission vital signs were blood pressure 132/74 mmHg, heart rate 78 beats/min, and respiratory rate 16 breaths/min. Which current assessment finding is the highest priority for the nurse to report to the healthcare provider?

An adult client is transferred to the cardiac step-down unit after a percutaneous coronary intervention utilizing the right femoral artery approach. During routine monitoring, the nurse notes the client's blood pressure has trended downward from 134/82 mm Hg to 106/64 mm Hg within the past hour. Simultaneously, the client complains of sudden, deep pain in the lower back. Which initial action should the nurse perform?

A nurse is caring for a client receiving an intravenous infusion of a cephalosporin antibiotic. The client suddenly reports a feeling of impending doom, throat tightness, and becomes visibly dyspneic with audible wheezing. The client's blood pressure is 85/50 mm Hg, and heart rate is 128 beats/minute. Arrange the following nursing actions in the priority order they should be performed. (Place the first action at the top and the last action at the bottom.)

A client undergoing treatment for gastrointestinal toxicity is receiving total parenteral nutrition (TPN) through a single-lumen peripherally inserted central catheter. The client experiences a sudden onset of severe nausea, and the acute care team prescribes an immediate dose of intravenous ondansetron. Which action represents the safest medication administration practice for this client?

A nurse enters the room of a client receiving total parenteral nutrition via a right subclavian central venous catheter. The nurse discovers that the intravenous tubing has completely disconnected from the catheter hub. The client is suddenly extremely anxious, gasping for air, and cyanotic, with a rapidly dropping blood pressure. Arrange the following emergency nursing actions in the priority sequence they should be performed. (Place the most immediate priority action at the top).

An emergency department nurse is evaluating a young adult client who presented with a severe asthma exacerbation. Upon arrival, the client was highly agitated, using accessory muscles to breathe, and had a respiratory rate of $38$ breaths/min. The initial arterial blood gas (ABG) revealed: pH $7.48$, $\text{PaCO}_2$ $28$ mm Hg, and $\text{PaO}_2$ $68$ mm Hg. After one hour of continuous bronchodilator therapy, the nurse observes that the client has become lethargic and the respiratory rate has decreased to $14$ breaths/min. A repeat ABG reveals: pH $7.29$, $\text{PaCO}_2$ $56$ mm Hg, and $\text{PaO}_2$ $52$ mm Hg. Which of the following is the priority nursing action to reduce the risk of cardiopulmonary arrest?

A nurse enters the room of a client receiving intravenous fluids via a subclavian central venous catheter. The nurse discovers that the intravenous tubing has become inadvertently disconnected from the catheter hub. The client suddenly reports severe chest pain and shortness of breath, and their heart rate increases to 128 beats per minute. Which of the following is the most appropriate initial nursing action?

A nurse is preparing to deliver an intermittent antibiotic infusion into an existing continuous intravenous line utilizing the backpriming technique. Arrange the following actions in the correct chronological sequence.

An adult client presents to the emergency department reporting severe, intractable vomiting for the past four days. The client is lethargic and exhibits shallow respirations, bilateral calf cramping, and tingling around the mouth. An arterial blood gas (ABG) analysis reveals a pH of 7.55, a PaCO2 of 44 mm Hg, and an HCO3- of 36 mEq/L. To prevent the development of a life-threatening complication associated with these clinical findings, which intervention is the highest priority for the nurse to implement?

At 0800, a nurse responds to a monitoring alarm for an adult client who is 36 hours post-operative from an open reduction and internal fixation of a fractured right femur. The client appears highly restless, confused, and is expectorating small amounts of blood-tinged sputum. Vital signs reveal a heart rate of 126 beats/min, a respiratory rate of 34 breaths/min, blood pressure of 148/88 mm Hg, and an oxygen saturation of 84% on room air. An arterial blood gas (ABG) analysis indicates a pH of 7.53, PaCO2 of 27 mm Hg, HCO3 of 23 mEq/L, and PaO2 of 52 mm Hg. Which intervention is the priority for the nurse to implement?

A client admitted with severe lobar pneumonia is receiving targeted intravenous antibiotic therapy. During hourly rounds, the nurse observes that the client has become increasingly agitated and diaphoretic. Current vital signs include a temperature of $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), a heart rate of $126$ beats per minute, a respiratory rate of $30$ breaths per minute, and a blood pressure of $94/68\text{ mm Hg}$.

An arterial blood gas (ABG) analysis is drawn and reveals the following results:

Based on these assessment findings, which physiological alteration is the client most likely experiencing?

A triage nurse is assessing a client with a history of chronic kidney disease who missed their last two hemodialysis sessions. The client reports profound muscle weakness and tingling in the extremities. An immediate electrocardiogram (ECG) reveals a prolonged PR interval, a widened QRS complex, and tall, peaked T waves. The serum potassium level is reported as 7.4 mEq/L. Which of the following prescribed interventions should the nurse implement first?

A client is recovering in the surgical step-down unit $24$ hours after a right-sided pneumonectomy for lung cancer. The client is receiving oxygen at $2$ L/min via nasal cannula. The client reports incisional pain of $6$ on a $0$-$10$ scale and is taking shallow breaths. The nurse evaluates the most recent arterial blood gas (ABG) results:

Based on these clinical findings, which action should the nurse take first to reduce the client's risk of respiratory compromise?

A nurse evaluates the arterial blood gas (ABG) results for a client admitted with acute respiratory distress secondary to severe pneumonia. The laboratory report shows the following values:

Which acid-base imbalance do these findings indicate?

A nurse is reviewing a new prescription for a client with a serum potassium level of 2.8 mEq/L (2.8 mmol/L). The prescription reads: "Potassium chloride 40 mEq in 100 mL 0.9% sodium chloride IV to infuse over 4 hours." The client has a 20-gauge peripheral intravenous catheter in the left cephalic vein. Which of the following is the most appropriate action by the nurse?

A surgical nurse is evaluating a client who is 4 hours post-operative following a total abdominal hysterectomy. Which of the following assessment findings are early clinical indicators of developing hypovolemic shock? Select all that apply.

A nurse is assessing a client who underwent an exploratory laparotomy three days ago. The client suddenly coughs and reports a sensation of 'giving way' in the abdomen. The nurse inspects the surgical site and observes that a loop of bowel is protruding from the incision. Arrange the following nursing interventions in the correct chronological sequence to mitigate the risk of severe complications.

A 64-year-old client is being monitored on the medical-surgical unit 2 hours after a flexible bronchoscopy with transbronchial biopsy. Which assessment findings indicate a developing physiological complication that requires immediate nursing intervention? Select all that apply.

A nurse is assessing a client who has had a nasogastric (NG) tube connected to continuous low wall suction for the past 48 hours due to a small bowel obstruction. Which of the following clinical and laboratory findings indicate that the client is experiencing a primary acid-base imbalance associated with this therapy? Select all that apply.