Physiological Integrity

A client arrives at the medical-surgical unit for continuous monitoring following a diagnostic lumbar puncture performed 30 minutes ago. Which nursing interventions should be implemented to reduce the risk of physiological complications? Select all that apply.

A nurse is caring for a client receiving mechanical ventilation for acute respiratory distress syndrome (ARDS). The client's most recent arterial blood gas (ABG) analysis reveals the following:

The client is currently receiving a fraction of inspired oxygen ($\text{FiO}_2$) of $0.60$. Which of the following nursing actions are appropriate? Select all that apply.

A nurse is monitoring an adult client who is receiving intravenous antibiotics for acute pyelonephritis. Which assessment finding provides the earliest clinical indication that the client is developing septic shock?

A nurse is assessing a client who returned to the medical-surgical unit 45 minutes ago following a therapeutic thoracentesis for a large right-sided pleural effusion. During the procedure, 1,200 mL of fluid was removed. Which assessment finding is the most critical indicator that the client is developing a severe physiological complication requiring immediate intervention?

Following an exploratory laparotomy, a client is transferred to the surgical unit. Upon admission to the unit, the client's vital signs are blood pressure 132/82 mm Hg, heart rate 82 beats/min, and respiratory rate 16 breaths/min. Two hours later, the client reports feeling 'nervous and unsettled.' The current vital signs are blood pressure 114/92 mm Hg, heart rate 116 beats/min, and respiratory rate 24 breaths/min, with 15 mL of urine output over the past hour. Based on these findings, which of the following actions should the nurse take first?

A nurse is evaluating a client who was admitted with massive hematemesis from ruptured esophageal varices. The client has received 2 liters of 0.9% sodium chloride intravenously over the past hour. Current vital signs are: blood pressure 86/52 mm Hg, heart rate 122/min, respiratory rate 24/min, and oxygen saturation 95% on room air. The client's skin is cool and clammy, and urinary output was 10 mL over the last hour. Arterial blood gas (ABG) results show a pH of 7.29, PaCO2 of 34 mm Hg, and HCO3- of 15 mEq/L. Which of the following is the priority nursing intervention?

A client on a medical-surgical unit is receiving continuous intravenous fluids through a central venous catheter. The client suddenly reports severe chest pain and shortness of breath. The nurse notes that the intravenous tubing has become disconnected from the catheter hub. Arrange the following nursing actions in the most appropriate order of priority to reduce the client's risk of further physiological complications.

A nurse is providing care for a client with a T4 spinal cord injury. The client suddenly reports a severe, pounding headache and blurred vision. Assessment reveals a blood pressure of 210/115 mm Hg, a heart rate of 54 beats/minute, and profuse diaphoresis above the level of the spinal lesion. Arrange the following nursing actions in the correct order of priority.

During a routine hourly check, a client recovering from a right femoral percutaneous coronary intervention (PCI) complains of a newly developed, constant lower back ache. The insertion site dressing remains clean and dry. A review of the continuous vital signs monitor reveals a heart rate of 106 bpm and a blood pressure of 108/84 mm Hg, which is a change from a baseline of 72 bpm and 132/78 mm Hg recorded two hours prior.

Which action should the nurse execute first?

During the second hour of admission to the surgical trauma unit, a client with a closed pelvic fracture begins to exhibit frequent, agitated repositioning and expresses a feeling of intense anxiety. The client's initial admission vital signs were heart rate $86$ beats/min and blood pressure $130/74$ mm Hg. The current vital signs demonstrate a heart rate of $118$ beats/min, a blood pressure of $112/88$ mm Hg, and a respiratory rate of $24$ breaths/min. Which of the following is the priority nursing action?

A nurse is evaluating a client with severe chronic obstructive pulmonary disease (COPD) who was admitted for an acute exacerbation and is currently receiving bilevel positive airway pressure (BiPAP) therapy. Which of the following assessment findings indicate that the client is experiencing acute physiological decompensation requiring immediate transition to invasive mechanical ventilation? Select all that apply.

A nurse is assessing a client who sustained blunt abdominal trauma in a motor vehicle collision 2 hours ago. Which of the following assessment findings should the nurse identify as early compensatory signs of hypovolemic shock? Select all that apply.

A nurse is caring for a 64-year-old client who has just returned to the medical-surgical unit following a flexible bronchoscopy with a tissue biopsy of a suspicious right lung mass. The procedure was performed under moderate sedation. Which of the following nursing actions should the nurse include in the plan of care to reduce the client's risk for potential complications? Select all that apply.

Following a transsphenoidal pituitary tumor resection 14 hours ago, a client develops a sudden, massive increase in urine output, voiding 2,100 mL of pale, odorless urine over a 3-hour period. The client is increasingly restless and reports extreme thirst. Assessment reveals a weak peripheral pulse of 118 beats per minute and a blood pressure reading of 88/50 mm Hg. Which of the following is the priority nursing action?

A client with hepatic cirrhosis and severe ascites has just completed a bedside paracentesis, during which 5 liters of fluid were drained. Shortly after the procedure, the nurse observes that the client's heart rate has increased from a baseline of 82 to 118 beats per minute, and capillary refill time is delayed at 4 seconds. The current blood pressure is 98/64 mm Hg. To address the most likely developing complication, which action should the nurse take?

A nurse is preparing to draw a blood specimen from a client's multi-lumen central venous catheter (CVC). The selected lumen is currently capped and not actively infusing any fluids. In what order should the nurse perform the following actions to safely obtain the specimen, prevent infection, and maintain catheter patency? Arrange the steps in the correct chronological sequence.

A nurse enters the room of a client being treated for a spontaneous pneumothorax and observes that the client's chest tube has accidentally dislodged completely from the pleural space. The client is visibly anxious and tachypneic. Arrange the following nursing actions in the correct priority order from first to last.

The unit nurse is reviewing a new medication prescription for an adult client with a serum potassium level of 2.8 mEq/L. The prescription reads: 'Potassium chloride 40 mEq in 100 mL 0.9% sodium chloride IV piggyback over 2 hours.' The client currently has a continuous normal saline infusion running through a 20-gauge peripheral catheter in the left forearm. What is the priority nursing action?

A nurse is caring for a client who has been experiencing severe, persistent vomiting for the past 48 hours. Which of the following arterial blood gas (ABG) and clinical assessment findings should the nurse anticipate?

A nurse is preparing to administer a unit of packed red blood cells (PRBCs) to a client with severe anemia. In what order should the nurse perform the following actions? Arrange the steps in the correct chronological sequence.