Physiological Integrity

The nurse is caring for a client with a spinal cord injury at the T4 level. The client suddenly reports a severe, pounding headache and profuse diaphoresis above the level of the injury. The blood pressure is 198/104 mm Hg and heart rate is 52 beats per minute. Arrange the following nursing interventions in the correct priority order from first to last.

A 68-year-old client with a history of heart failure is admitted for an acute exacerbation and is receiving high-dose intravenous furosemide. During the afternoon assessment, the client appears increasingly lethargic with shallow respirations at a rate of 10 breaths/min. The latest laboratory results reveal a serum potassium level of 2.6 mEq/L. An arterial blood gas (ABG) analysis on room air shows:

$pH$: 7.53
$PaCO_2$: 49 mm Hg
$HCO_3^-$: 35 mEq/L
$PaO_2$: 82 mm Hg

Which immediate action should the nurse take to reduce the client's risk for a life-threatening physiological complication?

A nurse is assessing a client who has been receiving continuous nasogastric (NG) tube suctioning for 48 hours due to a mechanical small bowel obstruction. The client is now reporting severe muscle cramping and tingling in the extremities. The nurse observes that the client's respirations are shallow at a rate of 10 breaths/min. Based on the client's clinical presentation and the physiological effects of gastric fluid loss, which of the following arterial blood gas (ABG) results should the nurse anticipate?

A clinical protocol for unfractionated heparin is being used to manage a client with a recent pulmonary embolism. The client's admission weight is $75 \text{ kg}$. The intravenous (IV) medication bag contains $25,000 \text{ units}$ of heparin mixed in $250 \text{ mL}$ of 0.9% sodium chloride.

At 10:00, the client's activated partial thromboplastin time (aPTT) is reported as $42$ seconds. The client's heparin infusion is currently running at $15 \text{ units/kg/hr}$.

The facility's heparin nomogram includes the following directives:

After administering the required IV bolus, what is the correct new rate for the continuous infusion pump in $\text{mL/hr}$? (Round to the nearest tenth).

A healthcare team is managing an immobile older adult client who has severe osteoarthritis and frequent urinary incontinence. Which nursing interventions should be incorporated into the plan of care to promote comfort and maintain physiological integrity? Select all that apply.

A nurse is caring for a client who is $6$ hours post-total thyroidectomy. The client becomes increasingly restless and reports a "tight" sensation around the anterior neck. The nurse observes the client swallowing frequently and hears a harsh, high-pitched inspiratory sound. A recent arterial blood gas (ABG) analysis reveals a pH of $7.31$, $PaCO_2$ of $52 \text{ mm Hg}$, $PaO_2$ of $88 \text{ mm Hg}$, and $HCO_3^-$ of $24 \text{ mEq/L}$. Which priority action should the nurse take to reduce the client's risk of an adverse outcome?

During interdisciplinary rounds, the nursing team discusses interventions for a client newly fitted with a halo vest apparatus for a stable cervical fracture. Which specific actions should be incorporated into the client's daily regimen? Select all that apply.

A 42-year-old client is admitted to the trauma unit following a motor vehicle collision. The client is diagnosed with a basilar skull fracture and has clear fluid leaking from the right ear. The client is lethargic but arousable, reporting a severe, throbbing headache. The nurse reviews the client's arterial blood gas (ABG) results obtained on room air:

To reduce the risk of life-threatening physiological decompensation, which of the following is the priority nursing action?

An adult client with a history of epilepsy is admitted to the medical unit and has a continuous intravenous (IV) infusion of $5\%$ dextrose in water (D5W) infusing at $100 \text{ mL/hr}$ through a peripheral catheter. The healthcare provider prescribes a $1,000 \text{ mg}$ loading dose of IV phenytoin to be administered promptly. The client has no other vascular access. Which action is most appropriate for the nurse to take?

A critical care nurse evaluates a client who has been receiving high-dose continuous intravenous furosemide for three days to manage acute decompensated heart failure. The client now exhibits profound muscle weakness, depressed deep tendon reflexes, and shallow respirations at a rate of 9 breaths per minute. A continuous electrocardiogram displays flattened T waves and newly developed prominent U waves. Based on this clinical deterioration, which arterial blood gas (ABG) result should the nurse anticipate?

An individual with an acute exacerbation of rheumatoid arthritis is admitted to the medical-surgical unit. During morning rounds, the client reports significant joint stiffness and bilateral hand pain that makes moving difficult. Which nursing action is most appropriate to promote comfort and facilitate the client's activities of daily living?

A client presents to the emergency department experiencing an acute panic attack with a respiratory rate of 38 breaths per minute. The client reports lightheadedness and tingling in the extremities. Arterial blood gas (ABG) analysis reveals a pH of 7.52, a PaCO2 of 26 mm Hg, and an HCO3- of 24 mEq/L. Based on these findings, which acid-base imbalance is occurring?

A client who sustained a C4 spinal cord injury in a motor vehicle collision earlier today is admitted to the trauma intensive care unit. The nurse suspects the development of a distributive shock state related to the loss of sympathetic vascular tone. Which assessment findings validate this clinical deterioration? Select all that apply.

A night shift nurse evaluates an older adult client who is unable to sleep due to severe, burning discomfort in both feet. The client has a documented medical history of advanced peripheral arterial disease (PAD). Which nursing intervention provides the safest and most effective comfort measure for this condition?

A nurse is performing a tubing change on a client's central venous catheter. The tubing accidentally disconnects, and the client suddenly develops severe dyspnea, tachycardia, and a feeling of impending doom. Suspecting an air embolism, arrange the following nursing interventions in the order they should be performed to minimize client risk. All options must be used.

A critical care registered nurse evaluates a client $4$ hours post-endovascular aneurysm repair (EVAR) of an abdominal aortic aneurysm via bilateral femoral artery access. The client has a documented history of severe emphysema. Which clinical findings or observations demand immediate intervention to mitigate physiological deterioration? Select all that apply.

A nurse is evaluating a client 12 hours after admission for full-thickness burns over 40% of the total body surface area. Which assessment findings indicate that the client is experiencing inadequate physiological adaptation and early hypovolemic (burn) shock? Select all that apply.

A client with severe gastroenteritis and dehydration is being monitored in the emergency department. Assessment reveals a heart rate of 122 beats per minute, a blood pressure of 96/78 mm Hg, and a respiratory rate of 28 breaths per minute. An arterial blood gas (ABG) sample shows a pH of 7.31, PaCO2 of 30 mm Hg, and HCO3 of 16 mEq/L. Which of the following nursing actions is the priority?

A surgical client is transferred to the progressive care unit following a major open abdominal surgery performed earlier in the day. Upon arrival, the client's baseline blood pressure was 132/76 mm Hg with a resting heart rate of 72 bpm. During the mid-shift evaluation, the nurse observes several new findings. Which of the following requires the most urgent clinical intervention?

Upon reviewing morning laboratory results, the registered nurse notes a client's potassium level is $2.6$ mEq/L. The healthcare provider has ordered $40$ mEq of intravenous potassium chloride. Which method represents the correct administration technique for this high-alert medication?