Physiological Integrity

A nurse is caring for a client who is 24 hours postoperative following an open bowel resection. The client has an intravenous line and an indwelling urinary catheter. Which change in the client's assessment provides the earliest physiological indication of a developing shock state?

A client recovering from an open femoral fracture reduction abruptly develops profound dyspnea, diaphoresis, and reports a feeling of impending doom. Current vital signs are: blood pressure $85/60$ mmHg, heart rate $132$ bpm, respiratory rate $34$ breaths/min, and oxygen saturation $86\%$ on room air. Arterial blood gas (ABG) analysis reveals: pH $7.52$, PaCO $_2$ $28$ mmHg, PaO $_2$ $54$ mmHg, and HCO $_3^-$ $24$ mEq/L. The nurse notes a rapidly narrowing pulse pressure. Which of the following is the highest priority nursing action?

A nurse is preparing a client with cirrhosis for a bedside paracentesis to relieve severe ascites. Which nursing actions are essential to reduce the client's risk for procedural and post-procedural complications? Select all that apply.

A hospitalized client with severe anemia is receiving a transfusion of packed red blood cells. Fifteen minutes after the procedure begins, the client reports acute lower back pain, sudden chills, and a sensation of chest tightness. The telemetry monitor indicates a rapid onset of sinus tachycardia. The nurse immediately halts the transfusion. What is the most critical subsequent action for the nurse to execute?

A charge nurse is observing a newly licensed nurse care for a 24-year-old client admitted with diabetic ketoacidosis (DKA). The client is lethargic and exhibiting deep, rapid respirations at 32 breaths/minute. Arterial blood gas (ABG) results indicate a pH of 7.23, $PaCO_2$ of 26 mm Hg, and $HCO_3^-$ of 14 mEq/L. Which action by the newly licensed nurse requires immediate intervention by the charge nurse?

A nurse is preparing to administer intravenous (IV) potassium chloride (KCl) $40\text{ mEq}$ in $250\text{ mL}$ of $0.9\%$ sodium chloride to a client with a serum potassium level of $2.6\text{ mEq/L}$. The client is currently receiving a continuous IV infusion of pantoprazole through a single peripheral IV line. Which of the following actions by the nurse are appropriate? Select all that apply.

A nurse is evaluating a client who underwent a percutaneous coronary intervention (PCI) via the right femoral artery 2 hours ago. Which of the following assessment findings require immediate intervention? Select all that apply.

An emergency department nurse is continuously monitoring a client who sustained severe blunt abdominal trauma. The client's baseline vital signs upon arrival were blood pressure 124/76 mm Hg, heart rate 82/min, and respiratory rate 16/min. Which of the following subsequent assessment findings should the nurse identify as the earliest clinical indicator of hemorrhagic shock?

A nurse is caring for an older adult client who recently experienced a cerebrovascular accident (stroke), resulting in right-sided hemiparesis and dysphagia. Which of the following basic care and comfort interventions should the nurse implement? Select all that apply.

A multidisciplinary team is preparing to remove a pleural chest tube from a client whose lung has fully re-expanded. As the nurse assisting with the procedure, arrange the following actions in the correct chronological sequence to minimize the risk of complications. All options must be used.

An adult client admitted with severe diabetic ketoacidosis (DKA) is prescribed a continuous intravenous (IV) infusion of regular insulin. When initiating and managing this high-alert parenteral therapy, which actions should the nurse include in the plan of care? (Select all that apply.)

A nurse is assessing a client who is 4 hours post-operative following an exploratory laparotomy. The nurse is monitoring for complications. Which of the following assessment findings should the nurse identify as early indicators of developing hypovolemic shock? Select all that apply.

A nurse in the emergency department evaluates a client who sustained a complete spinal cord injury at the T6 level in a traumatic incident 2 hours ago. During the assessment, the nurse notes the client's abdomen is firm, distended, and dull to percussion. The client's current vital signs are:

Blood pressure: 84/48 mm Hg
Heart rate: 128 bpm
Respiratory rate: 24/min

Based on the clinical presentation, which physiological complication should the nurse identify?

A nurse is preparing to administer a prescribed oral medication to a client who has a nasogastric (NG) tube connected to low intermittent wall suction. The medication has been appropriately crushed and dissolved in sterile water. Arrange the following nursing actions in the correct chronological order.

A nurse is assessing a client who is 4 hours postoperative following a partial hepatectomy. Which of the following assessment findings should the nurse identify as early indicators of developing hypovolemic shock? Select all that apply.

A client with a severe soft tissue infection is receiving a newly prescribed intravenous antibiotic. Ten minutes after the infusion begins, the client becomes visibly anxious and states, "My throat feels very tight." Which of the following additional assessment findings would indicate the client is developing anaphylactic shock? Select all that apply.

A nurse is caring for a client with a severe intra-abdominal infection who has received $3\text{ L}$ of $0.9\%$ sodium chloride intravenously over the past $2$ hours. The client is lethargic, and the nurse notes the following assessment findings:

Based on these findings, which of the following actions is the nurse's priority?

A nurse is planning care for a client who is 8 hours post-operative following a right total hip arthroplasty utilizing a posterior approach. Which of the following nursing interventions should the nurse implement to reduce the client's risk for postoperative complications? Select all that apply.

A client admitted with cardiogenic shock requires hemodynamic support. The healthcare provider orders a continuous intravenous infusion of dobutamine at a rate of $5\text{ mcg/kg/min}$. The client's current weight is $82\text{ kg}$. The pharmacy dispenses a premixed bag containing $500\text{ mg}$ of dobutamine in $250\text{ mL}$ of $5\%$ dextrose in water ($D_5W$).

At what rate, in $\text{mL/hr}$, should the nurse program the infusion pump? Record your answer as a number with one decimal place.

A nurse in the emergency department is caring for a client who is admitted with severe diabetic ketoacidosis (DKA). The client is lethargic, has a blood glucose of $680\text{ mg/dL}$ ($37.7\text{ mmol/L}$), and an arterial pH of $7.12$. Arrange the following collaborative and nursing interventions in the correct chronological order of implementation.