Physiological Integrity

A nurse is evaluating a client who underwent a large-volume paracentesis to relieve severe ascites $90$ minutes ago. The client suddenly reports profound dizziness and a feeling of impending doom. Current vital signs reveal a heart rate of $122$ beats per minute, a respiratory rate of $24$ breaths per minute, and a blood pressure of $84/50$ mm Hg. Which immediate action should the nurse perform?

A client with symptomatic anemia requires a transfusion of packed red blood cells (PRBCs). The client's only intravenous (IV) access is a 20-gauge peripheral catheter currently infusing 5% dextrose in water (D5W) at 75 mL/hr. What is the most appropriate action by the nurse?

A client admitted to the intensive care unit with acute decompensated heart failure is prescribed a continuous intravenous infusion of dobutamine at $7.5$ mcg/kg/min. The client weighs $176$ lb. The medication is supplied by the pharmacy as dobutamine $500$ mg in $250$ mL of $5\%$ dextrose in water. At what rate in mL/hr should the nurse set the infusion pump? (Record your answer using a whole number.)

A nurse is evaluating a client who is receiving aggressive intravenous fluid resuscitation for severe dehydration. The client suddenly reports severe orthopnea and a feeling of impending doom. Which of the following clinical assessment findings indicate the development of acute pulmonary edema? (Select all that apply.)

A 42-year-old client is being monitored in the surgical step-down unit 18 hours after a subtotal thyroidectomy for the treatment of Graves' disease. The nurse is evaluating the client's current status to prevent post-operative complications. Which of the following assessment findings indicates the greatest risk for impending physiological decompensation and requires immediate intervention?

A surgical unit nurse is assessing a client who underwent a partial colectomy 8 hours ago. The client reports incisional pain rated as 4 on a 0 to 10 scale. Upon review of the electronic health record, the nurse notes the client's preoperative blood pressure was 128/76 mm Hg with a heart rate of 78 bpm. Current assessment reveals a blood pressure of 106/84 mm Hg, a heart rate of 116 bpm, and a respiratory rate of 22 breaths/min. Which action should the nurse take first?

A nurse is assessing a client who returned to the telemetry unit 2 hours ago following a left heart catheterization performed via the right femoral artery. Which of the following findings require immediate intervention by the nurse? Select all that apply.

A registered nurse is providing care for a client who requires multiple intravenous (IV) therapies, including continuous fluids and scheduled intermittent medications. Which of the following actions indicate that the nurse is safely administering pharmacological and parenteral therapies? Select all that apply.

While performing bedside rounding on a gastroenterology unit, a nurse observes a client who had a percutaneous liver biopsy completed 45 minutes ago. Which finding requires the nurse to take immediate corrective action to prevent physiological decompensation?

A registered nurse is prioritizing care for a group of clients on a medical-surgical unit after receiving the shift handoff report. Which individual's clinical presentation requires the nurse's immediate intervention?

A nurse is preparing to remove a client's non-tunneled central venous catheter (CVC). To minimize the risk of an air embolism and ensure client safety, arrange the following nursing actions in the correct chronological sequence.

While conducting a physiological assessment on a client who experienced an anterior wall myocardial infarction the previous day, the nurse suspects the onset of hemodynamic compromise. Which clinical manifestations indicate the early development of cardiogenic shock? Select all that apply.

A 62-year-old client is transferred to the medical-surgical unit after undergoing an esophagogastroduodenoscopy (EGD) with gastric biopsies. Which of the following assessment findings or situations require immediate intervention by the nurse? Select all that apply.

A nurse is caring for an adult client admitted with a traumatic brain injury who is receiving a continuous intravenous (IV) infusion of 5% dextrose in water (D5W) at 75 mL/hr. Following a brief generalized tonic-clonic seizure, the healthcare provider prescribes a stat loading dose of IV phenytoin. Which of the following is the most appropriate action by the nurse?

A critical care nurse is evaluating a 68-year-old client who is 4 hours post-operative following an open abdominal aortic aneurysm (AAA) repair. The client has a continuous intravenous infusion, an indwelling urinary catheter, and a nasogastric tube to low wall suction. Which clinical findings should the nurse identify as indicators of impending physiological decompensation that require immediate intervention? Select all that apply.

A healthcare provider prescribes a continuous intravenous heparin infusion for a client diagnosed with a deep vein thrombosis. The client weighs $92\text{ kg}$. The facility's weight-based heparin protocol requires an initial infusion rate of $18\text{ units/kg/hr}$. The pharmacy dispenses a premixed intravenous bag containing $25,000\text{ units}$ of heparin in $250\text{ mL}$ of $5\%\text{ Dextrose in Water}$. At what rate, in $\text{mL/hr}$, should the infusion pump be programmed? Record your answer using one decimal place.

Following a left-sided thoracentesis for a massive pleural effusion, a client is now recovering on the respiratory step-down unit. The procedure yielded 1,200 mL of fluid. During the initial post-procedure assessment, which observation demands the most urgent intervention by the nurse?

Following an open laparotomy, a client is receiving pain management via a continuous epidural infusion containing bupivacaine and fentanyl. Upon entering the room, the nurse observes that the client is deeply sedated and unarousable. The client's respiratory rate is 7 breaths per minute. Which action represents the nurse's immediate priority?

A nurse is assessing a client admitted with severe pyelonephritis who is suspected of developing early (hyperdynamic) septic shock. Which of the following clinical manifestations should the nurse expect to find during this initial compensatory stage? Select all that apply.

Following a high-speed collision, an adult client is brought into the trauma bay with a suspected splenic laceration. Initial assessment reveals generalized restlessness, pale mucous membranes, a blood pressure of 96/76 mm Hg, and an apical pulse of 118 beats/min. A stat arterial blood gas panel indicates a pH of 7.29, PaCO2 of 35 mm Hg, and HCO3 of 16 mEq/L. Which intervention should the nurse implement immediately?