Physiological Integrity

A client's recent arterial blood gas (ABG) results are as follows: $\text{pH} = 7.51$, $\text{PaCO}_2 = 42 \text{ mm Hg}$, and $\text{HCO}_3^- = 33 \text{ mEq/L}$. Which of the following underlying conditions or treatments are most likely responsible for this acid-base imbalance? Select all that apply.

A nurse is analyzing the clinical profile of a client who abruptly developed severe dyspnea, pleuritic chest pain, and a feeling of impending doom. A massive pulmonary embolism is confirmed, and the client is currently exhibiting signs of obstructive shock. Which of the following hemodynamic and laboratory findings are consistent with this physiological decompensation? Select all that apply.

An emergency department team is treating a client with advanced chronic obstructive pulmonary disease (COPD) who arrived via ambulance due to worsening lethargy and severe dyspnea. The client is currently on a 2 L/min nasal cannula.

Clinical Data:
* Neurological: Somnolent but rousable to verbal stimuli
* Vital Signs: HR 118 bpm, RR 10 breaths/min and shallow, BP 142/86 mm Hg
* Arterial Blood Gas (ABG): pH 7.24, PaCO2 76 mm Hg, PaO2 54 mm Hg, HCO3 33 mEq/L

Based on the clinical presentation and laboratory results, which action is the priority?

A triage nurse evaluates a client with type 1 diabetes mellitus who presents with a capillary blood glucose of 610 mg/dL, fruity breath odor, and profound lethargy. The client is exhibiting deep, rapid respirations. Arrange the following nursing interventions in the correct chronological order of execution.

An emergency department nurse is preparing to manage a newly admitted client experiencing diabetic ketoacidosis. The treatment plan includes initiating a continuous intravenous infusion of regular insulin. Which of the following interventions should the nurse include in the client's plan of care? Select all that apply.

A nurse is evaluating a client who was brought to the clinic experiencing a severe panic attack. The client has a respiratory rate of 34 breaths per minute and reports tingling in the fingers and lightheadedness. Based on this clinical presentation, which acid-base imbalance should the nurse anticipate?

A nurse is managing the care of a client admitted to the intensive care unit with severe diabetic ketoacidosis (DKA). The client's initial blood glucose is 680 mg/dL (37.7 mmol/L), pH is 7.15, and blood pressure is 88/54 mm Hg. Arrange the following nursing interventions in the correct sequence of execution from first to last.

A client is receiving care 4 hours after a right-sided pneumonectomy. The nurse notes the client has become increasingly restless. Current vital signs include a blood pressure of 138/86 mm Hg, heart rate of 118/min, and respiratory rate of 28/min. Arterial blood gas (ABG) analysis reveals a pH of 7.28, PaCO2 of 56 mm Hg, HCO3 of 24 mEq/L, and PaO2 of 64 mm Hg. Which intervention should the nurse implement immediately to reduce the risk of further physiological deterioration?

A nurse on a medical-surgical unit is evaluating a client with end-stage renal disease who was admitted after missing multiple scheduled hemodialysis sessions. The client appears lethargic and exhibits deep, rapid respirations. Based on this clinical presentation, which of the following arterial blood gas (ABG) results is most expected?

A nurse is caring for a client diagnosed with Guillain-Barré syndrome who reports increasing difficulty swallowing and generalized weakness. The client is restless, has shallow respirations at 28 breaths/min, and an arterial blood gas (ABG) reveals: $\text{pH} = 7.29$, $\text{PaCO}_2 = 58 \text{ mm Hg}$, $\text{HCO}_3^- = 24 \text{ mEq/L}$, and $\text{PaO}_2 = 62 \text{ mm Hg}$. Based on these findings, which of the following is the priority nursing action?

A nurse is preparing to administer a unit of packed red blood cells (PRBCs) to an adult client with symptomatic anemia. Arrange the following actions in the correct chronological order that the nurse should perform them, from first action to last action.

While assessing a client who is 4 hours postoperative following an exploratory laparotomy, the nurse suspects the onset of hypovolemic shock. Which of the following clinical findings are considered early compensatory manifestations of this condition? Select all that apply.

A client who recently underwent a large bowel resection is recovering in the surgical unit. The nurse is actively monitoring the client for postoperative complications, specifically fluid volume deficit. Which of the following assessment findings is the earliest indicator that the client is developing hypovolemic shock?

An older adult client is admitted to the surgical recovery unit immediately following a left eye cataract extraction with intraocular lens implantation. The client reports a mild 'scratchy' sensation in the operated eye and asks the nurse for help getting comfortable. Which nursing intervention regarding positioning and comfort is most appropriate?

A nurse is monitoring a client who is 3 hours post-operative following a radical nephrectomy. Which of the following assessment findings should the nurse identify as early (compensatory) indicators of hemorrhagic shock? Select all that apply.

A nurse is evaluating the arterial blood gas (ABG) results of a client who has severely depressed respirations following a suspected opioid overdose. The nurse determines the client is experiencing uncompensated respiratory acidosis. Which of the following ABG values would confirm this specific finding? Select all that apply.

A client admitted with rapid atrial fibrillation is receiving a continuous intravenous (IV) infusion of diltiazem through a single-lumen peripheral catheter. The healthcare provider prescribes a scheduled dose of IV pantoprazole for stress ulcer prophylaxis. The nurse checks a drug reference guide and notes that pantoprazole is chemically incompatible with diltiazem. Which action is the most appropriate for the nurse to take?

A medical-surgical nurse is developing a plan of care for a client who is 2 hours postoperative following a subtotal thyroidectomy. Which of the following interventions should the nurse include to reduce the risk of physiological complications? (Select all that apply.)

A client with severe chronic obstructive pulmonary disease (COPD) and right-sided heart failure (cor pulmonale) is receiving treatment for acute respiratory distress and massive lower extremity edema. The client requires assistance with all activities of daily living. Which nursing actions appropriately address the client's basic care and comfort needs? Select all that apply.

A nurse is preparing to administer an initial prescribed dose of intravenous amphotericin B deoxycholate $50\text{ mg}$ in $500\text{ mL}$ of $5\%$ dextrose in water (D5W) to a client with a severe systemic fungal infection. The medication is scheduled to infuse over 4 hours. The client currently has a single peripheral intravenous (IV) catheter with a continuous infusion of $0.9\%$ sodium chloride running at $75\text{ mL/hr}$. Which sequence of actions is the safest and most appropriate for the nurse to implement?