Physiological Integrity

An adult client is recovering in the surgical observation unit four hours after undergoing a left percutaneous renal biopsy. The client's pre-procedure vital signs were a blood pressure of 134/76 mm Hg, an apical pulse of 72 beats/min, and a respiratory rate of 14 breaths/min. During the current assessment, the client reports a persistent, dull ache in the left lower back that radiates toward the anterior abdomen. The nurse obtains the following data: blood pressure is 112/86 mm Hg, apical pulse is 104 beats/min, and respiratory rate is 22 breaths/min. The client's urine output via Foley catheter is 40 mL over the past hour and appears pink-tinged. An arterial blood gas (ABG) sample drawn 15 minutes ago reveals a pH of 7.44, a $PaCO_2$ of 32 mm Hg, and an $HCO_3^-$ of 21 mEq/L. Based on these assessment findings, which of the following actions should the nurse prioritize?

A registered nurse is preparing to administer an intravenous (IV) push medication through a client's accessed, but currently inactive, implanted venous port (Port-a-Cath). Based on standard facility protocol for a heparin-locked central venous device, arrange the following steps in the correct chronological order.

A nurse is performing a postoperative assessment on a client who underwent a laparotomy a few hours ago. To monitor for the onset of hypovolemic shock from potential internal bleeding, which of the following clinical findings should the nurse identify as the earliest indicator?

A nurse is caring for a client with a history of severe anemia who is receiving a transfusion of packed red blood cells. Fifteen minutes after the transfusion begins, the client reports a sudden onset of lower back pain, chills, and difficulty breathing. Arrange the following nursing interventions in the prioritized sequence from first to last action.

A nurse is preparing to perform open airway suctioning for a client who has a newly established tracheostomy. In what order should the nurse perform the following actions to minimize the risk of complications such as hypoxemia and mucosal trauma?

A 28-year-old client is 4 hours postoperative following an emergency open splenectomy for abdominal trauma. Over the past two hours, the nurse notes the client's heart rate has increased from 88 to 116 beats per minute, and urine output has decreased to 15 mL/hr. The current blood pressure is 104/78 mm Hg. The nurse reviews the most recent arterial blood gas (ABG) results: pH 7.31, PaCO2 36 mm Hg, PaO2 94 mm Hg, and HCO3 16 mEq/L. Based on these findings, which interpretation and corresponding action are the highest priority for the nurse to mitigate impending physiological decompensation?

A client with chronic kidney disease is receiving continuous intravenous fluids. The nurse evaluates the client for physiological manifestations of fluid volume overload. Which of the following assessment findings indicate that the client is experiencing this complication? Select all that apply.

The nurse receives the shift report for four clients on a vascular and pulmonary step-down unit. Which client requires the most immediate assessment by the nurse?

A nurse is planning care for an older adult client who is recovering from a right total hip arthroplasty performed 24 hours ago. The client needs support with comfort measures and daily activities. Which of the following actions is the most appropriate for the nurse to implement?

An adult client admitted with a traumatic brain injury begins to exhibit sustained tonic-clonic seizure activity. The client has one dedicated peripheral intravenous (IV) catheter currently infusing 5% dextrose in 0.45% sodium chloride at 100 mL/hr. The physician orders a 1,000 mg loading dose of intravenous phenytoin. Which of the following actions demonstrates the safest administration technique for this medication?

A nurse is assessing a client who is at risk for developing hypovolemic shock due to excessive postoperative bleeding. Which of the following is typically the earliest clinical manifestation of hypovolemic shock?

The nurse is reviewing assessment findings for several clients recovering from recent supratentorial craniotomies. Which of the following clinical findings indicate impending physiological decompensation and require immediate nursing intervention? (Select all that apply.)

During a shift in the intensive care unit, the nurse assumes care for a patient in cardiogenic shock whose current weight is $80\text{ kg}$. The patient has a central venous catheter infusing dobutamine at a rate of $24\text{ mL/hr}$. The IV bag is labeled as containing $500\text{ mg}$ of dobutamine mixed in $250\text{ mL}$ of normal saline. Following a hemodynamic assessment, the critical care prescriber instructs the nurse to increase the dobutamine dosage by $2.5\text{ mcg/kg/min}$. Calculate the new rate at which the nurse should program the infusion pump. Record your answer in $\text{mL/hr}$ as a whole number.

A nurse is caring for a client with a T4 spinal cord injury who suddenly reports a severe, pounding headache and exhibits profuse diaphoresis. The client's blood pressure is $210/110 \text{ mm Hg}$. Arrange the following nursing actions in the correct priority sequence.

A nurse is evaluating a client who is being treated for acute peritonitis. Which of the following assessment findings indicate the client is experiencing the early, hyperdynamic phase of septic shock? Select all that apply.

A nurse in the intensive care unit is caring for a client with acute necrotizing pancreatitis who has received massive intravenous fluid resuscitation over the past 24 hours. The client is increasingly restless and dyspneic. The nurse notes the following assessment findings:

- Urine output has decreased from $45\text{ mL/hr}$ to $15\text{ mL/hr}$ over the last two hours.
- The abdomen is tense, markedly distended, and firm to palpation.
- Intra-abdominal pressure (IAP) measured via the urinary catheter is $26\text{ mm Hg}$.
- Vital signs: Blood pressure $88/54\text{ mm Hg}$, heart rate $128\text{ beats/min}$, respiratory rate $28\text{ breaths/min}$.
- Arterial blood gas (ABG) results: pH $7.28$, $\text{PaCO}_2$ $30\text{ mm Hg}$, $\text{PaO}_2$ $76\text{ mm Hg}$, $\text{HCO}_3^-$ $14\text{ mEq/L}$.

Which of the following actions is the highest priority for the nurse to implement to reduce the client's risk for further physiological deterioration?

A nurse is caring for a client who was admitted to the trauma intensive care unit $4$ hours ago following a high-speed motor vehicle collision. The client sustained a complete T2 spinal cord transection and a severe pelvic fracture.

Initial admission vital signs:
- Blood pressure: $94/60 \text{ mmHg}$
- Heart rate: $58 \text{ bpm}$
- Respiratory rate: $18 \text{ breaths/min}$
- The client's skin was warm and dry below the chest.

Current assessment findings ($4$ hours later):
- Blood pressure: $70/40 \text{ mmHg}$
- Heart rate: $64 \text{ bpm}$
- Respiratory rate: $28 \text{ breaths/min}$
- Urine output: $10 \text{ mL}$ over the past $2$ hours
- Skin is now pale and diaphoretic above the level of injury.
- Arterial Blood Gas (ABG): pH $7.26$, $\text{PaCO}_2$ $34 \text{ mmHg}$, $\text{PaO}_2$ $88 \text{ mmHg}$, $\text{HCO}_3^-$ $15 \text{ mEq/L}$

Which of the following is the priority nursing action?

A client with septic shock is receiving a continuous intravenous (IV) infusion of norepinephrine through a single-lumen peripherally inserted central catheter (PICC). The client's current mean arterial pressure (MAP) is $60\text{ mmHg}$. The healthcare provider prescribes a stat IV dose of sodium bicarbonate to treat severe metabolic acidosis. No other IV access is currently established. Which of the following actions by the nurse is the most appropriate?

A nurse is monitoring a client who is receiving an intravenous transfusion of packed red blood cells. Ten minutes after the transfusion begins, the client develops sudden severe lower back pain, tachycardia, and dyspnea. Place the following nursing interventions in the correct order of priority to mitigate further physiological risk to the client. (Arrange the steps from first action to last action.)

A client is recovering from a recent lumbar puncture and has been prescribed strict bed rest. The client is also experiencing generalized weakness, urinary incontinence, and intermittent mild confusion. Which of the following nursing interventions should be included in the care plan to promote comfort, maintain skin integrity, and ensure safety? Select all that apply.